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Critical Care Nurses’ Skill Working in B P Koirala Institute of Health Sciences

Mehta RS, Additional Professor

B.P. Koirala Institute of Health Sciences, Nepal

Email: ramsharanmehta@hotmail.com

Abstract:

Introduction: Critical care units, may be thought of as having context (the demographics and characteristics of the kind of work they do), structure (the grouping of people and the allocation of responsibility through specialization, expertise, formalization, and some degree of centralization or decentralization), process (intraorganizational relationships such as the flow of information and coordination), and outcomes (productivity, goal attainment, morale, and satisfaction of the members). B P Koirala Institute of Health Sciences has 700 bedded tertiary care hospital having 8 beded ICU and 6 beded CCU with modern facilities.

Objectives: The objective of this study was to assess the skills to care the critically ill patients by the nurses working in critical care unit (ICU and CCU) of B P Koirala Institute of Health Sciences, Dharan, Nepal. Methodology: It was hospital based descriptive study conducted among the nurses (staff-nurses) involved in the care of critical patients working in ICU and CCU of B. P. Koirala Institute of Health Sciences for more than three months. Using total enumerative sampling technique all the 35 nurses working in ICU and CCU of BPKIHS was selected for study. Informed verbal consent was obtained prior to data collection. Subjects were assured about the confidentiality of the Informations they were provided and used for the study purpose only. Using pre-tested questionnaire the data was collected during the period of 1-7-2010 to 7-7-2010 for a week and special consideration was maintained to avoid the contamination of sample. The collected data was entered in Excel and analyzed using SPSS 11.5 soft ware package.

Results: Total 35 nurses were working in the unit and most of them (68.6%) had work experiences of one year and only 2 nurses (5.7%) had received basic life support (BLS) and advanced life support (ALS) training. It was found that most of the nurses had limited skill (score-0, 1) on the areas like, interpret arrhythmias (60%), intervene for arrhythmias (62.9%), temporary pacing care (82.9%), and patient care on hemodialysis (60%); where as the most of the nurses had adequate skill (score-2,3) on the areas like start peripheral IV (85.7%), assess heart sound and peripheral pulses (81.9%), and care of patient on arterial line (88.6%). The association calculated between the items of skill score (0, 1, 2, 3) with selected variables found significant association between interpret arrhythmia and age (≤ 20, >20) (p= 0.0001), perform defibrillation and age (p=0.002), and interpret arterial blood gas (ABG) and age group (p=0.016).

Conclusions: skill development training for nurses working in ICU is mandatory for quality care.

Key Words: Critical Care, Nurse, Skill

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Introduction: High intensity fields of work, such as the airline industry and the military, already employ checklists to decrease errors of omission, improper implementation of procedures and protocols, and to decrease human error under stressful conditions. Examples include the prediction of successful weaning from mechanical ventilation in ICU patients, adherence to evidence-based best practices and in the improvement of patient safety in many clinical areas.1 Critical care nurses work in a wide variety of settings, filling many roles. They are bedside clinicians, nurse educators, nurse researchers, nurse managers, clinical nurse specialists and nurse practitioners. 2 Much information is available on patients’ satisfaction and perceptions of quality of care, and some information is available on patients’ perceptions of physicians’ skills, little information is available on patients’ perceptions of nurses’ skills. 3 The defining characteristics of good nursing care investigation mostly involved the demeanor of the nurses: gentle, calm, courteous, kind, attentive, available, empathetic, and reassuring. Although researchers have described nurses’ attributes that patients consider when judging nursing quality and good nursing care in general, little is known of patients’ perceptions specifically of the skill of nurses. 4 Rapid advances in healthcare and technology have contributed to keeping more people out of the hospital. As issues relating to patient care become increasingly complex and new technologies and treatments are introduced, critical care nurses will need to become ever more knowledgeable. 4 Objective: The objective of this study was to assess the skills to care the critically ill patients among the nurses working in critical care unit (ICU and CCU) of B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Methodology: It was hospital based descriptive study conducted among the nurses (staff-nurses) involved in the care of patients working in ICU and CCU of B. P. Koirala Institute of Health Sciences for more than three months. Using total enumerative sampling technique all the 35 nurses working in ICU and CCU of BPKIHS was selected for study. Informed verbal consent was obtained prior to data collection. Subjects were assured about the confidentiality of the information they were provided and used for the study purpose only. Using pre-tested questionnaire the data was collected during the period of 1-7-2010 to 7-7-2010 for a week and special consideration was maintained to avoid the contamination of sample. The collected data was entered in Excel and analyzed using SPSS 11.5 software package. Results: Age and experiences of the subjects: it was found that most of the subjects 25(71.4%) were of age group of 21-25 years, with mean age 22.26, SD 2.187 and range 19-30 years. Only 3(5.7%) subjects had the ICU experiences of more than 3 years. The mean ICU experiences were 13.29, with age SD 12.335 and range 3-60 months. Similarly, only 8.6% (3) nurses had total nursing experiences of more than 3 years, with mean 16.66, SD 123.604 and range 3-60 months. It was found that only 2(5.7%) nurses had received BLS as well as ALS training and 11(31.4%) nurses working in PBKIHS was trained from this institute it self. Skill of the critical care nurses: Using four point scale (0, 1, 2, 3), the extent of skill level was assessed among the nurses working in critical care units (ICU/CCU) of BPKIHS, in the different eight areas like, general (6-items), cardiovascular (22-items), pulmonary (15-items), Neurological (8-items), GI/ Renal/Endocrine (6-items), medications (21-items), pain/wound management (8-items) and experiences with age group (3-items). The details of the results are in depicted in table.

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Association between variables: The association calculated between the items of skill score (0, 1, 2, 3) and with other variables found significant association between the interpret arrhythmias and age group (≤ 20, >20) (p=0.0001), intervene for arrhythmias and age group (p=0.001), assist and provide care with S/G insertion with age (p+0.001), temporary pacing patients care and age (p=0.001), perform defibrillation and age (p=0.002), interpret ABG and age group (p=0.016), obtain ICP/CPAP value and age (p= 0.0001), administer IV lidocane and age group (p=0.012), administer amiodarone and age (p=0.012), administer diltiazem and age (p=0.037), similarly ICU experiences (≤ 6 months, > 6months) with identify pacemaker malfunction (p=0.001), intervene arrhythmias (p=0.002), and care of post operative cardiac surgery patients (p=0.012). Discussion: Most of the nurses working in critical care unit were below age 25 years (94.3%). Most of the nurses had job experiences in ICU is up to 3 years (94.3%), and had total job experiences up to 3 years (91.4%). Only 2 nurses (5.7%) had received BLS and ALS training. The nurses had better skill on the areas like, start peripheral IV (85.7%), giving discharge teaching (91.4%), assess heart sound and peripheral pulses (81.9%), and care of arterial line (88.6%). The nurses had limited skills on the areas like, interpret arrhythmias (60%), intervene for arrhythmias (62.9%), temporary pacing care (82.9%), and haemodialysis patient care (60%). Study conducted by Perrie5 among 136 ICU nurses reported, the mean knowledge score was 47.56 (SD 11.61). The differences in knowledge among ICU training staffs (68) and non-ICU trained staffs (68) was statistically significant (P=0.0099). The correlation between knowledge and years of ICU experiences was poor (r=0.137). Similar findings were reported by Eckerball6, and Egerod7. Study conducted by Perrie5 reported pain management, glycemic control and weaning from mechanical ventilation are nursing care areas that can impact on patient outcome and are commonly guided by protocols. However, in order to ensure safe, optimal management of patients even when care is guided by protocols, nurses require a sound knowledge base. Conclusion: Most of the nurses were younger (<25) years and had lesser critical care experiences (<3Yrs) and very limited had received BLS and ALS training. The areas where nurses had more skill were start peripheral IV, giving discharge teaching, assessing heart sound and peripheral pulses, care of arterial line, where as nurses had limited skill scores on interpret arrhythmias, temporary pacing, intervene for arrhythmias and hemodialysis. The skill development training for nurses working in critical care is mandatory for quality care. Recommendations: Skill development training for nurses working in the unit is urgent need for quality nursing service in critical care unit. References:

1. Julian DG. The history of coronary care units. British Heart Journal. 1987; 57:497–502. 2. Wysong PR. Patient’s perceptions of Nurses’ skill. Critical Care Nurse. 2009; 29:24-37 3. Miller RS, Patton M, Graham RM, Hollins D. Outcomes of trauma patients who survive

prolonged lengths of stay in the intensive care unit. J Trauma. 2000; 48(2):229-34. 4. Mehta NJ, Khan IA. Cardiology's 10 greatest discoveries of the 20th century. Texas Heart

Institute Journal. 2002; 29:164-71. 5. Perrie H, Schmollgruber S. Knowledge of ICU nurses regarding selected care areas commonly

guided by protocols. Critical Care. 2010; 14:446. 6. Eckerblad J, Kriksson H, Kamer J, Edeu GU. Nursess’ Conceptions of facilitative strategies of

weaning patients from mechanical ventilation: a phenomenographic study. Intensive Critical Care Nurses. 2009; 25(5): 225-32.

7. Egerod I. Uncertain terms of sedation in ICU. How nurses and physicians manage and describe sedation for mechanically ventilated patients. Journal of Clinical Nurses. 2002; 11(6): 831-40.

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Table 1 Skill/Experiences of Nurses Regarding Critical Care Activities

N= 35

SN Critical Care Skills

Responses in Percentage (%)

Th

eo

ry,

No

Pra

ctic

e

(0

)

Lim

ite

d

(1)

Co

nfi

de

nt

(2)

Ve

ry c

on

fid

en

t

(3)

1 General Critical Care Skills Admit unstable patient 11.4 17.1 54.3 17.1 Transport ICU patient within hospital for testing 17.1 8.6 57.1 17.1 Start peripheral IV 0 14.3 54.3 31.4

2 Cardiovascular Procedures related skills Assess heart sounds and peripheral pulses 0 17.1 48.6 34.3 Interpret arrhythmias 8.6 51.4 37.1 2.9 Provide care to the patient with an arterial line 8.6 2.9 65.7 22.9 Set up and run 12 Lead ECG 8.6 5.7 45.7 40 Provide care for the patient with acute MI 11.4 34.3 31.4 22.9 Provide care for the patient with acute heart failure 8.6 34.3 42.9 14.3 Provide care for the patient requiring temporary pacing 42.9 40 11.4 5.7 Provide care for the post-op cardiac surgery patient 40 48.6 8.6 2.9 Provide care for the patient in shock 20 28.6 45.7 5.7

3 Pulmonary Procedures Related Skills Assess lung sounds 11.4 45.7 34.3 8.6 Set up oxygen devices 8.6 22.9 37.1 31.4 Obtain pulse oximetry reading 2.9 8.6 48.6 40 Interpret ABG 11.4 20 42.9 25.7 Assess ventilator settings 8.6 28.6 51.4 11.4 Troubleshoot ventilator alarms 11.4 40 45.7 2.9 Suction using in-line suction catheter 8.6 8.6 60 22.9 Use Ambu bag 0 0 60 40 Assist with intubation 8.6 5.7 57.1 28.6 Assist with chest tube insertion 20 25.7 42.9 11.4 Provide care for the patient with mechanical ventilation 2.9 11.4 60 25.7 Provide care for the patient with PEEP therapy 20 25.7 42.9 11.4 Provide care for the patient with chest tube 8.6 22.9 42.9 25.7 Provide care for the patient with a tracheostomy 0 5.7 57.1 37.1

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Table 1 (continue) Skill/Experiences of Nurses Regarding Critical Care Activities

N= 35

SN Critical Care Skills

Responses in Percentage (%)

Th

eo

ry,

No

Pra

ctic

e

(0

)

Lim

ite

d

(1)

Co

nfi

de

nt

(2)

Ve

ry c

on

fid

en

t

(3)

4 Neurological Procedures related skills Identify sudden change in loss of consciousness 2.9 25.7 62.9 8.6 Assess sensory, motor, speech 2.9 31.4 57.1 8.6 Assess reflexes (Babinski, Gag) 2.9 28.6 57.1 11.4 Identify and intervene for seizure 8.6 31.4 54.3 5.7 Obtain ICP and CPP values and care 40 37.1 20 2.9 Provide care for the post-op neurosurgical patient 22.9 45.7 31.4 0 Provide care for the patient with acute stroke 17.1 40 42.9 0 Provide care for the patient in a comatose state 20 28.6 45.7 5.7

5 GI, Renal and Endocrine Procedures related Skills Insert NG, duodenal tube 14.3 8.6 54.3 22.9 Provide care for the patient with GI bleed 8.6 31.4 48.6 11.4 Provide care for the patient with hemodialysis 22.9 37.1 25.7 14.3 Provide care for the patient with DKA 14.3 37.1 37.1 11.4 Provide care for the patient with TPN 28.6 17.1 40 14.3 Provide care for the patient with enteral-nutrition 5.7 25.7 51.4 17.1

6 Medication skills Calculate mcg/min and mcg/kg/min 8.6 17.1 48.6 25.7 Use IV infusion pump to calculate drug doses 5.7 11.4 54.3 28.6 Care of epidural catheter 5.7 31.4 45.7 17.1 Administer IV dopamine 5.7 8.6 48.6 37.1 Administer IV nitroglycerine 17.1 14.3 45.7 22.9 Administer IV atropine 11.4 14.3 40 34.3 Administer IV heparin 0 22.9 37.1 40

7 Pain/Wound management related Skills Assess pain level/tolerance 2.9 22.9 60 14.3 Care of patient with anesthesia/analgesia 5.7 22.9 57.1 14.3 Care of patient with sterile dressing changes 0 5.7 60 34.3

8 Experiences with age groups Calculate body weight to verify correct dosing 2.9 42.9 37.1 17.1