Clinical Voices June 2022

Jun 23, 2022

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This month we feature articles on an ECRI report on staffing shortages, concerns for after-hours ICU transfers, transgender men’s healthcare needs, and more. Plus, watch the new President’s Video and read a crucial nurse Q&A.

Staffing Shortages: First on ECRI List of Patient Safety Concerns

Recommendations include flexible staffing, using teleICUs and surveying staff.

Amplified by the pandemic, staffing shortages led the ECRI Institute’s “Top 10 Patient Safety Concerns 2022” for the first time, with nursing shortages an increasing problem. The Ecri report offers actionable approaches for healthcare organizations to address system safety for each of the top concerns, which also include COVID-19’s effects on healthcare workers’ mental health, and bias and racism in addressing patient safety.

“In early January 2022, it was estimated that 24% of US hospitals were critically understaffed, while 100 more facilities anticipated facing critical staff shortages within the following week,” the report notes. Key data related to staffing shortages includes 18.7% hospital turnover among RNs in 2020, the median age of RNs reaching 52 in 2020, and nursing schools turning away over 80,000 qualified applicants in 2019 due to insufficient resources.

Recommendations include flexible staffing models and action plans to deliver safe care during staff shortages, assessing psychological safety, using teleICU capabilities and surveying staff to improve job satisfaction.

In addition, the report notes shortages of critical care physicians, hospitalists, respiratory therapists and pharmacists. “Even before the COVID-19 pandemic, there was a persistent shortage of clinical and nonclinical staff across the continuum.”

AACN advocacy on staffing issues includes resources on policy and ethical issues that impact critical care nurses in their work environments. Staffing-related links focus on strategies to address the crisis, supporting healthcare workers’ mental health, approaches to nurse retention, exploring team nursing as an alternative delivery model, and curated resources on staffing challenges.

An American Journal of Nursing blog briefly highlights the full list, and you can download the full report there or from the ECRI link above.

Panel Establishes Pediatric Definitions of FAST and E-FAST

The study defines five views as important and appropriate for a complete FAST.

An international panel of pediatric experts has developed definitions of Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children with blunt abdominal trauma.

In “Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children,” in JAMA Network Open, the panel used two rounds of surveys and a live webinar to identify what constitutes complete, high-quality imaging to allow for proper interpretation. “These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research,” the study notes.

The qualitative study defines five views as important and appropriate for a complete FAST: “right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view.” For E-FAST, the study includes those five views and the lung or pneumothorax view.

The panel established consensus on what represents completeness, quality and interpretation accuracy in detecting free fluid, which can be challenging to diagnose in children. “Current diagnostic strategies are suboptimal because of the trade-off between missed injury and resource overutilization, including children’s exposure to ionizing radiation from computed tomography (CT) scans,” the study adds.

Because standardized definitions are lacking and clinician experience plays a significant role in achieving complete, high-quality imaging, FAST may be underused as a diagnostic strategy, the study notes, adding that a limitation of the work may be an inability to generalize the findings for non-expert clinicians.

The panel agreed that FAST should be used to detect internal bleeding but not to detect abdominal solid organ injury. “An agreement was reached on the potential use of serial FAST studies; however, the panelists were unclear on how to clinically interpret trace volumes of abdominal free fluid, suggesting a direction for future research.”

COVID-19 Caregivers at Risk for Moral Injury, Burnout

The study calls for more research to evaluate approaches to PMI prevention and intervention.

Due to the pandemic, healthcare workers are experiencing potential moral injury (PMI) at rates similar to those of post-9/11 military veterans, which may present harmful consequences for mental health.

Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers,” in JGIM: Journal of General Internal Medicine, explains that moral injury is the psychological, biological, spiritual, behavioral or social impact of acts that go against a person’s moral beliefs and expectations. It can be self-induced or caused by witnessing immoral acts by others.

A 2020-2021 survey involving 2,099 COVID-19 healthcare workers (HCWs) revealed that 50.7% experienced other-induced PMI, while 18.2% reported self-induced, the study notes. In comparison, 618 post-9/11 combat veterans reported PMI rates of 46.1% other-induced and 24.1% self-induced.

Types of PMI included significant associations with age, race and working in high-risk settings for COVID-19 exposure. “In both samples [veterans and HCWs], participants endorsing either type of PMI self-reported significantly higher levels of depression, lower quality of life, and, among HCWs, higher levels of burnout,” the study adds.

The study notes that other factors contributing to moral injury among HCWs included potential public disregard for preventing transmission of SARS-CoV-2, high patient mortality, staffing shortages, rationed care, lack of personal protective equipment and policies preventing family members from visiting dying patients, adds a related article in Healio.

The study calls for more research to evaluate approaches to PMI prevention and intervention.

An unrelated review notes physical activity may help reduce depression and improve mental health. “Association Between Physical Activity and Risk of Depression: A Systematic Review and Meta-Analysis,” in JAMA Psychiatry, suggests that even low levels of physical activity, such as walking 2.5 hours per week, can make a significant difference. “Health practitioners should therefore encourage any increase in physical activity to improve mental health,” the review adds.

Safety Concerns for After-Hours ICU Transfers

Patient transfers should occur before 4 p.m. when possible.

Transferring patients from the ICU at night is often unsafe and can lead to significant limitations in care, notes a study highlighting ways to make daytime discharges more likely.

Patient Harm and Institutional Avoidability of Out-of-Hours Discharge From Intensive Care: An Analysis Using Mixed Methods,” in Critical Care Medicine, suggests that patient transfers should occur before 4 p.m. when possible. If after-hours discharges are unavoidable, support systems can be implemented to ensure patient safety.

Conducted in the United Kingdom, the study involved 300 retrospective case reviews of ICU discharges who did not survive to hospital discharge. Of these, 20 in-hospital deaths after ICU discharge were determined to be “probably avoidable” and were compared to 20 cases in which patients survived. Interviews with hospital staff, patients and families revealed concerns about the safety of after-hours transfers due to reduced staffing, lower skill mix and other factors.

“Patients described night-time discharge as frightening and unsettling, at a time when they were already vulnerable,” the study notes. “Fewer staff on shift may have contributed to the perception of chaos described by one patient.”

The study suggests five functions to facilitate ICU transfers before 4 p.m.:

  • Holding team meetings during the day to discuss patient readiness for discharge
  • Patient prepared for discharge
  • Bed availability
  • Staffing levels
  • Appropriate handover of documentation

Patient-based preconditions for discharge include not requiring organ support or medications administered only in the ICU.

Once a bed is allocated, the ICU and ward staff negotiate a discharge time and discuss the need for special equipment or other requirements. “The final outcome relies on the timely output of all the key functions, which rely on all preconditions, resources, and inputs being in place.”

The association between out-of-hours discharge and poor outcomes is an international problem, the study notes, adding that the findings are likely to be relevant in countries with healthcare systems similar to the United Kingdom’s.

Reputable or Predatory Journals? Know the Difference

It’s fine to search in Google and Google Scholar, but they don’t verify content accuracy.

Searching online for journal articles is a great way to learn about new practices and approaches to healthcare, but beware of predatory journals that may have errors, misleading information or flawed research.

How to Identify Predatory Journals in a Search: Precautions for Nurses,” in Nursing2022, offers guidance to distinguish between legitimate and predatory journals. With a primary goal of making money, predatory journals often don’t meet editorial standards and may accept articles without peer review.

While it’s OK to search in Google and Google Scholar, neither one verifies the accuracy or completeness of the content, the article notes, adding that it’s important to back up any search with well-established and reputable databases such as PubMed/MEDLINE, CINAHL and Scopus. “By using one of these databases to find information to guide clinical practice, nurses can largely avoid predatory journals and associated low-quality research and evidence by extension,” the article notes.

If a topic is only in Google or Google Scholar, carefully review the information and try to verify that it’s not from a predatory source. Considerations include the following:

  • Visit the journal website. What’s your impression? Does it look amateurish, have spelling errors or distorted images?
  • Consider whether the journal’s name is misleading or confusing. Is it similar to a legitimate journal but with an extra word or two?
  • Is the editor a nurse? Are nurses on the editorial board? Do you recognize any of their affiliations (hospitals, universities)?
  • Read about the peer-review process; it should last more than one to two weeks.
  • Scan some recent articles. Are they nursing-focused? Are they within the scope of the journal?

Nurses should also consult with a health sciences librarian, if available, for answers to clinical questions or information about journals retrieved in a Google search, the article adds.

Transgender Men’s Healthcare Needs

An estimated 1.4 million Americans identify as transgender.

Providing appropriate care for transgender male patients requires nurses to understand the unique complications and postoperative care possibilities, and be sensitive to cultural and psychological aspects.

Nursing Considerations for Transgender Men,” in Nursing2022, aims to minimize the gaps in nursing education about specific types of hormonal therapies and upper- and lower-body surgeries in the female-to-male population to ensure proper care. “Many nursing professionals anecdotally express discomfort with and lack of knowledge and understanding about this patient population, which may result in issues in patient safety and communication, among others,” the article adds.

An estimated 1.4 million Americans identify as transgender, according to the article, with younger adults more likely to transition. Gender transitioning requires counseling, including a letter of recommendation from a mental health professional to undergo hormone therapy or surgical options.

Clinicians should be aware of the impacts on various body systems, as well as the potential adverse effects of testosterone therapy. A variety of breast and urinogenital issues may arise for transgender men, and lower-body surgical interventions can add potential complications. The article also offers guidance on appropriate health measures, privacy issues and cultural sensitivity.

AACN resources include continuing education on providing care for LGBTQ patients and their families: a journal article, an NTI recorded session and a webinar series. AACN also published “A Transition to Find Herself,” a nurse’s first-person story about transitioning from male to female. Ashley Anderson’s story provides insight into her life experiences and the challenges of transitioning, both personally and professionally.

President’s Video: Beginning to Heal

In the final video of her term, AACN President Beth Wathen expresses her gratitude to our nursing community and invites nurses to look forward, rejuvenate their souls and begin to heal.


Nurse Story: A Transition to Find Herself

To celebrate Pride Month, we revisit a crucial conversation with Ashley Anderson, a nurse who is transgender. She discusses her uplifting experience coming out to nurse colleagues and offers insights for providing care to transgender patients.

Learn More