Clinical Voices January 2024

Jan 12, 2024

Added to Collection

In this issue, read articles on new red blood cell transfusion guidelines, nursing workload and patient safety in the ICU, reducing nurse educator burnout, and more. Plus, read a New Year's message from AACN President Terry Davis and a Q&A with a grateful NICU nurse.

Nursing Workload Affects Patient Safety in ICUs

Further research is needed to investigate safe workload levels to protect ICU patients.

Heavy workloads for nurses in intensive care settings result in poor patient outcomes, including increased mortality and more adverse events, such as healthcare-associated infections, pressure ulcers and longer hospital stays.

Nursing Workload and Patient-Focused Outcomes in Intensive Care: A Systematic Review,” in Nursing & Health Sciences, reports that various approaches to measure and report workloads make conclusive assessments difficult. Further research is needed to investigate safe workload levels to protect ICU patients.

After screening more than 4,000 articles, researchers selected 32 studies for full review. They were conducted in 14 countries (majority from Brazil) since 2000 and ranged in size from 33 to 29,445 patients. The nursing activities score (NAS) was the most common method of assessing workloads. In general, an NAS score above 100% indicates that more than one nurse is needed to provide care.

Twelve studies revealed a relationship between workloads and higher mortality, with some even identifying a specific NAS cutoff point at which mortality increased with workload scores. In one study, an NAS exceeding 61.6 on the first day of ICU admission indicated a 3.3 times greater probability of death during hospitalization.

Twenty-one studies examined workloads and adverse events, including five that measured collective nursing-related adverse events, such as medication errors, pressure ulcers, falls, and problems involving breathing tubes and placement of catheters. Only one study did not find an association between nursing workloads and adverse events.

While acknowledging a need for more research, the review suggests the findings can be used to inform workforce policy for ICU nursing. “High workload can be a protective factor for AE [adverse events], if the nursing workforce is able to identify those at high risk and adjust levels of support and care accordingly to benefit outcomes in the most critically unwell patients.”

Reducing Nurse Educator Burnout

Incorporate the educator wellness themes, and periodically evaluate their effectiveness.

Workplace strategies that improve well-being and reduce burnout for nurse educators include these themes: mindfulness training, resilience building, workplace opportunities, and leadership and work cultures that emphasize wellness.

Strategies to Promote Nurse Educator Well-Being and Prevent Burnout: An Integrative Review,” in Teaching and Learning in Nursing, notes that wellness initiatives should be a joint initiative since both employees and employers share responsibility and reap mutual benefits.

A search of medical databases identified 32 relevant studies for review. All were published after 2013 with abstracts and titles pertaining to educator wellness programs, supportive cultures and leadership styles that support wellness.

Recommendations listed under the themes include:

  • Mindfulness: Implement programs that increase coping skills and self-efficacy, which can include mindfulness activities, yoga, meditation, music therapy, journaling and diaphragmatic breathing.
  • Resilience: Provide resilience-building training and professional development regarding autonomy, self-esteem, awareness, responsibility, hope, sociability, tolerance and reducing frustration. Pair novice nurse educators with seasoned faculty mentors to help develop professional relationships.
  • Work engagement: Promote professional autonomy, giving nurse educators the freedom to teach their way. It could involve implementing various teaching and learning strategies, teaching in small groups or team teaching. Ensure educators receive timely performance feedback.
  • Workplace culture and leadership: Encourage interpersonal relationships among nurse educators, and establish meaningful interactions with students. A workplace culture should emphasize caring, community, student success and educator retention.

Successful wellness strategies depend on strong participation from nurse educators and buy-in from all levels of leadership, the review notes. In addition, sustaining a wellness culture requires continued investment in the programs.

“By incorporating the four themes of educator wellness and periodically evaluating their effectiveness, nurse educator well-being may be more reliably sustained,” the review adds.

RBC Transfusion Guidelines Include Individualized Approach

The guidelines were issued by the Association for the Advancement of Blood & Biotherapies.

New red blood cell (RBC) transfusion guidelines establish recommendations for adult and pediatric patients, generally favoring a restrictive strategy but encouraging an individualized approach.

Red Blood Cell Transfusion: 2023 AABB International Guidelines,” in JAMA: The Journal of the American Medical Association, presents strong recommendations for a typical threshold of 7 g/dL for both pediatric and adult patients with some exceptions.

“Good transfusion practice should rely not only on hemoglobin concentration thresholds but also incorporation of patients’ symptoms, signs, comorbid conditions, rate of bleeding, values, and preferences,” the guidelines note.

Issued by the Association for the Advancement of Blood & Biotherapies, the guidelines rely on 45 adult clinical trials with 20,599 patients and seven pediatric studies with 2,730 patients. The principal recommendations, backed by evidence summaries and rationales, are as follows:

  • Hemodynamically stable hospitalized adults: Use a restrictive threshold strategy (less than 7 g/dL), unless the patient is undergoing cardiac (7.5 g/dL) or orthopedic (8.0 g/dL) surgery, or has cardiovascular disease (8.0 g/dL)
  • Hospitalized adults with hematologic or oncologic disorders: Use a restrictive strategy (less than 7 g/dL)
  • Critically ill children and those who are at risk of becoming so but are hemodynamically stable: Use a restrictive strategy (less than 7 g/dL), with some exceptions
  • Hemodynamically stable children with congenital heart disease undergoing surgical repair: Use a threshold appropriate to the abnormality and stage of repair

“Alternatively, we urge clinicians to incorporate into the decision to transfuse an assessment of each patient’s co-morbidity, symptoms and signs in addition to hemoglobin concentration,” notes lead author Jeffrey Carson, Rutgers Robert Wood Johnson Medical School, in a related new release.

“Given the findings indicating the safety of restrictive thresholds, new trial designs should focus on the safety of lower transfusion thresholds (eg, 5-6 g/dL), incorporation of physiologic parameters, and the conduct of health economic analyses,” the guidelines add.

Unveiling the ‘Hidden History’ of Black Nurses

Their voices should be heard and not forgotten.

Throughout history, Black nurses have made valuable contributions to the profession, but their contributions have often been minimized, ignored and forgotten by academic researchers, an editorial contends.

The editorial profiles Black nurses who made lasting contributions to nursing from the slavery era to the COVID-19 pandemic, including Mary Jane Seacole (1805-1881), a nurse-hero of the Crimean War and a front-line caregiver during cholera outbreaks in Jamaica (1850) and Panama (1852). And while Harriet Tubman (1820-1913) is known for leading enslaved people to freedom, the nursing care she provided to wounded African American soldiers during the Civil War is often overlooked.

Tribute is also paid to the Black Angels, who from 1928-1960 cared for patients with tuberculosis at Sea View Hospital, the largest sanitarium in New York City. These 300 nurses heroically stepped in when white nurses declined to provide care for a highly infectious and vulnerable population.

The Black Angels are also celebrated in a 2023 book by Maria Smilios that reveals how extraordinary nurses, including Virginia Allen, one of the last living Black Angels, risked their lives treating New York’s poor and sick.

Commenting on today’s nursing workforce, the editorial wonders if more young people from underrepresented backgrounds would choose nursing if they knew about the “hidden figures” of the past.

“We must reclaim the stories of our ancestors, and those past and present who have paved the way for BIPOC nurses to have a place in the nursing profession,” the editorial adds. “Their voices will be heard and never forgotten.”

AACN offers several related nurse stories, including “A Responsibility Deeper Than Family,” “A Win for Our Family” and “A BRAVE Approach to Difficult Discussions.

Care Needs of Families of Patients With Cardiac Arrest

The care needs of survivors and families led to several clinical practice guidelines for nurses.

Families of patients with cardiac arrest have several common priorities during care that emergency nurses can address. “What Are the Care Needs of Families Experiencing Sudden Cardiac Arrest? A Survivor- and Family-Performed Systematic Review, Qualitative Meta-Synthesis, and Clinical Practice Recommendations,” in JEN: Journal of Emergency Nursing, notes five themes that reflect family needs during the prearrest, intra-arrest and postarrest periods, all of which nurses can impact.

“Meeting the priority, high-certainty care needs of families experiencing cardiac arrest requires the action of individual nurses and supportive health systems that allow for the sharing of information, sharing decision making, accommodating family preferences and cultural needs, and aftercare and follow-up,” the review notes.

Based on 39 studies of survivors and families (broadly defined) primarily from Western Europe and North America, the review revealed 18 descriptive themes. The review then developed five analytical themes: “(1) When the crisis begins we must respond; (2) Anguish from uncertainty, we need to understand; (3) Partnering in care, we have much to offer; (4) The crisis surrounding the patient, ignore us the family, no longer; and (5) Our family’s emergency is not over, now is when we need help the most.”

Care needs identified by survivors and families across all three stages of cardiac arrest resulted in several clinical practice guidelines for nurses, including support for decisions on whether families want to be present during resuscitation, the presence of a liaison or support, respect for family traditions and culture, abandonment issues at discharge, quality-of-life concerns, and the psychosocial impact on both survival and bereavement.

“Families want follow-up to address unanswered questions, process grief, and transition to a new normal – whether bereaved or caregiver to a survivor.”

AACN’s resources for family presence include “Increasing Nurses’ Knowledge of and Self-Confidence With Family Presence During Pediatric Resuscitation,” a feature article, and “Critical Care Nurses’ Attitudes About Family Presence During Resuscitation: An Integrative Review,” a CE article, both in Critical Care Nurse.

Patients (With SCI) Successfully Weaned Regardless of Prior Attempts

The review notes that 76% of patients achieved some weaning from daytime ventilator support.

Weaning patients with spinal cord injury (SCI) from ventilation during rehabilitation remains possible regardless of how many attempts are needed.

In “Just Keep Trying: Prior Attempts at Weaning Do Not Determine Eventual Liberation From Tracheostomy and Mechanical Ventilation in High-Level Spinal Cord Patients,” in CHEST, a review of patient data shows that previous weaning attempts, the time since the injury and age did not impact successful removal or reduction of ventilation. “Many patients with SCI who are initially dependent on mechanical ventilation via tracheostomy are able to wean from ventilation and discharge home, even amongst patients with high injuries,” the review notes.

The review of the medical records of 42 patients rehabilitating at the University of Utah from 2015 to 2022 – 79% male and median age 44 – notes that 76% of patients achieved some weaning from daytime ventilator support, 62% were weaned from any support, and 48% were decannulated. Among those with high cervical injuries (C1-4), 48% were weaned from some support, 28% were decannulated, and 28% were discharged home with or without home health assistance.

“One of the things we really want to do is use this to help us create our own weaning protocol going forward because, right now, we base everything off of how the patient’s doing clinically to guide us rather than having a specific algorithm to follow,” study author Casey Fenger, University of Utah, tells Healio in a related article. “Part of this is that we don’t know why some patients don’t meet these weaning milestones.”

Fenger adds that many patients met milestones even at day 45, but the study lacks complete insight into the patients’ varying timetables. “If we have a protocol,” he notes in the article, “we’re hoping we can use that as a way to find where people are getting stuck in this process to overcome those barriers.”

President’s Column: New Beginnings and Great Hope

AACN President Terry Davis wishes you a Happy New Year. She has great hope for 2024 and encourages you to ask yourself, “How can I become more engaged in the transformation our healthcare system is undergoing?”

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Nurse Story: Gratefulness From the NICU

On her long path from CNA to LPN to RN, a Michigan nurse found her way to the NICU and caring for the youngest, most vulnerable patients. She discusses her journey, the reward in seeing her patients go home, and the gratitude of families. “Neonates are truly little fighting angels.”

Read the Q&A