Clinical Voices March 2022

Mar 23, 2022

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This month we feature articles on the nurse staffing crisis, feeding tube best practices for children, and the practice of giving and receiving honest feedback. Plus, watch a new President’s Video.

Think Tank Targets Nurse Staffing Crisis

The team meets virtually to discuss causes of the crisis, workforce trends and other challenges.

A think tank composed of nurses and workforce experts from across the U.S. is striving to develop evidence-based, nursing-led solutions to address the nation’s nurse staffing crisis, which is exacerbated by the pandemic.

The 2022 Nurse Staffing Think Tank gathers virtually every two weeks to discuss what’s causing the crisis, workforce trends and other challenges. Organizers hope to identify strategies with measurable outcomes to implement within a year, according to a media release from the American Nurses Association (ANA).

AACN is partnering with ANA for the six-meeting effort, which began in January and is set to conclude in late March. Other groups involved are the American Organization for Nursing Leadership, the Healthcare Financial Management Association and the Institute for Healthcare Improvement.

The U.S. Bureau of Labor Statistics projects about 194,000 job openings for RNs each year through 2030, the release reports, adding that the average age of RNs is 52, and 19% of the nation’s healthcare workforce is 65 or older. Filling the vacancies will require support for developing early-career nurses and recent graduates.

The think tank is setting the foundation for a nurse staffing task force by providing:

  • Strategic advice on broad ideas and direction for goals based on data that identifies the shortage’s root causes
  • Input on trends, challenges and issues that hinder progress toward staffing solutions
  • Options for action and associated outcomes

Adequate staffing levels benefit nurses and patients, leading to reductions in mortality, length of stay, readmission rates and preventable healthcare-associated injuries, notes the ANA release.

“With appropriate staffing levels and skill mix, nurses can practice to the full extent of their licensure and expertise,” the release adds. “This will reduce nurse fatigue. Hospitals will benefit from decreased turnover, improved retention, and overall improved job satisfaction.”

Feeding Tube Best Practices for Children

The NOVEL project notes some increase in EBP to verify placement since the results of a previous survey.

A nurse-led study to encourage evidence-based practice (EBP) when placing and verifying nasogastric (NG) feeding tubes in hospitalized infants and children finds ongoing use of non-EBP methods.

Evaluation of Methods Used to Verify Nasogastric Feeding Tube Placement in Hospitalized Infants and Children - A Follow-up Study,” in Journal of Pediatric Nursing, notes that only 65% of surveyed nurses indicate that best practices are followed. “This study demonstrates variation within units at the same facility using methods unsupported by the literature, demonstrating that many centers still rely on non-EBP methods of NG placement confirmation, despite cautions issued by many major healthcare organizations.”

The New Opportunities for Verification of Enteral tube Location (NOVEL) project, an initiative of the American Society of Parenteral and Enteral Nutrition, does note some increase in EBP to verify placement since the results of a previous survey.

The 245 respondents (205 nurses) at 166 organizations identified radiograph (64%) or pH measurement (24%) as best practices, but 42% said their organizations use pH, and 23% said they use radiograph.

The NOVEL project study says neonatal ICUs most often use aspiration and direct eye visualization to verify placement, with EBP followed more often in other units. An annual NOVEL newsletter says organizers intend to form a work group of chief nursing officers to address practice concerns; they also formed a group to address tube placement in adults.

A YouTube video posted by the Patient Safety Movement details the case of an 11-day-old baby who died from an incorrectly inserted tube and the parents’ activism to change practice.

The Gift of Feedback Takes Some Practice

Encourage a grace-filled environment to practice giving and receiving feedback.

Honest feedback can be a gift that helps nurses enhance their role, yet feelings of workplace hierarchy can undermine open communication and keep us from speaking up.

In the American Journal of Nursing’s “Off the Charts” blog, Hui-wen (Alina) Sato, a pediatric ICU nurse in Southern California, writes about two personal experiences with feedback, including a time when she was a relief charge nurse.

Toward the end of a busy shift, she asked a care partner for suggestions on how she could do better in that role. “After a few moments of silence, he told me that he was always reluctant to give feedback because he didn’t know if what he said might be misunderstood,” Sato writes.

In the second example, an attending physician asked Sato for her opinion on how he handled a delicate conversation with a trauma patient’s caregiver. Sato realized that “somewhere in my subconscious remained a hesitation — as ‘just a bedside nurse’ — to give him the requested feedback, even if it were positive.

“These two encounters remind me that there is a general mentality of hierarchy I believe we all continue to battle when it comes to providing feedback to one another in our work,” Sato notes. They’re also reminders of how important it is to develop the communication skills to “clearly articulate our thoughts without tripping ourselves up.”

Looking ahead, Sato hopes to ask the care partner for his feedback again, while continuing to build a trusting work relationship. She also wants to be better prepared to offer feedback when it is requested.

“We need practice and we won’t always get it just right,” Sato adds. “All the more reason to cultivate a grace-filled environment in which to practice offering this invaluable gift of feedback.”

Respiratory Drive and Sedation Depth

Sedation depth should not be used as a surrogate for respiratory drive in critical illness.

Respiratory drive measurements, which can be easily quantified at the bedside, may be a better gauge of sedation depth in the mechanically ventilated patient.

Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation,” in Critical Care Medicine, notes that deeply sedated patients often had higher respiratory drive rates than expected, and lightly sedated patients were not consistently preserving respiratory effort.

“Extremes of respiratory drive (high and low) were observed across the range of routinely targeted sedation depth and were independently associated with fewer ventilator-free days,” the study adds.

The small prospective, cohort study included 56 patients from five ICUs at a U.S. academic hospital for two month-long periods in 2016-2017. The median age was 62.5 and 32% were female, with averages of 8.5 days in the ICU and 4.5 days of mechanical ventilation. Patients’ respiratory drive was measured every 12 hours (± 3 hours) a day using P0.1 by trained personnel, and sedation was measured using the Richmond Agitation-Sedation Scale.

Patients in the P0.1 range were considered normally healthy (0.5 to 1.5 cm H2O) in only 38 of the 197 measurements. Patients in the middle tercile of P0.1 rates “had significantly more ventilator-free days than patients in either the lowest tercile … or the highest tercile,” the study notes.

Because respiratory depth can frequently be used as a surrogate measurement for sedation depth without identifiable correlation, the study suggests clinical practice guidelines should instead focus on “whether the intended clinical effect is achieved and to recognize an undesirable side effect when sedation is prescribed for other indications.”

The study observes that many common medications to reduce pain or anxiety may not achieve the goal of minimizing respiratory distress, so whether “measuring respiratory drive to guide clinical decision-making can improve outcomes is unknown and warrants evaluation.”

Spirituality and Better Quality of Life

Spirituality may contribute to well-being and the ability to cope with adverse situations.

Healthy adults (ages 18-64) with high levels of spirituality/religiousness (S/R) may likely have a positive health-related quality of life (HRQoL).

Association Between Spirituality/Religiousness and Quality of Life Among Healthy Adults: A Systematic Review,” in Health and Quality of Life Outcomes, finds that aspects of spirituality that most determine QoL outcomes in this population include hope, optimism, inner strength, peace, happiness and the meaning of life.

The review suggests that spirituality contributes to well-being and the ability to cope with adverse situations, adding that it’s likely the first review to address how S/R influences QoL among adults who don’t have chronic illnesses and are not elderly or caregivers. A search of several databases identified 1,952 topic-related studies, but only 10 met the inclusion criteria of healthy adults ages 18 to 64. Those 10 studies comprised 4,337 individuals, including 3,860 college students or 89% of all participants.

“Nine studies report a positive association between S/R and HRQoL, while one study did not report any significant association,” the review notes. Quality-of-life domains most positively influenced by S/R were psychological aspects, followed by social relationships and environment domains.

“Whether it is linked to a religion or not, intrinsic spirituality seems to be an interesting strategy, even for those young individuals not facing significant health complications,” the review suggests. It adds that this dynamic can have everyday benefits and may help prevent conditions that trigger mental health disorders, such as stress, anxiety and depression.

The review lists several limitations, including that only observational studies were selected for review. For future research, the review suggests adding intervention studies similar to clinical trials conducted with patients who have chronic or terminal illness or other conditions that alter their physical and mental capabilities.

President’s Video: NTI Live Is Back!

In her new video, AACN President Beth Wathen celebrates the return of NTI two ways and better than ever — NTI Live, May 16-18, and NTI Virtual, June 6-8. “NTI will provide a platform for all of us to start looking forward … and to come back to rejuvenate, refuel and reimagine our future together.”

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