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Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Purpose The person-centered care is essential for better patient outcome. This study was conducted to identify the factors affecting to the person-centered care among intensive care unit (ICU) nurses. Method This study was cross sectional survey, and the participants included 107 ICU nurses who provided a written consent to participate in the study. Using a structured survey, nurse’s compassion fatigue, compassion satisfaction, and person-centered care among ICU nurses were assessed. The collected data were analyzed using t-test, ANOVA, and Pearson correlation test with SPSS 23.0 program. The factors affecting patient-centered care were analyzed using multiple regression. Results According to the multiple regression analysis, education level, perceived caregivers need priority and compassion satisfaction were positive affecting factors to the person-centeredness of ICU nurses. Conclusion In conclusion, the compassion satisfaction was an affecting factor to the person-centered care, however compassion fatigue didn’t affect to the person-centered care among ICU nurses. Therefore, the strategy enhancing compassion satisfaction among ICU nurses will be needed to increase person centeredness. Key Words: Care, Compassion fatigue, Intensive care units, Nurse, Satisfaction 주요어: 간호, 공감 피로, 중환자실, 간호사, 만족

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

Background: There is a lack of published, validated questionnaires for evaluating the attitudes toward organ donor advocacy among intensive care unit (ICU) staff. Specific behavior among ICU staff is significantly associated with if there is consent to, or decline of, organ donation. In 2011, Flodén et al. developed the questionnaire “Attitudes towards organ donor advocacy scale” (ATODAS). Through the translation and cross-cultural adaption of the ATODAS into English, the questionnaire was further developed resulting in the “Flodén ATODAI North American version” (Attitudes Toward Organ Donor Advocacy Instrument). Therefore, the Aim of this study is to develop and psychometrically evaluate the instrument Flodén ATODAI into the Swedish version, for measuring intensive and critical-care nurses’ attitudes toward organ donor advocacy. Methods: A cross-sectional study was employed as the study design. Data was collected separately for the two included studies. Study subjects were Swedish nurses who currently worked in a Swedish ICU. For the major data collection (n=715), participants were identified by the Swedish association of health professionals. For the test-retest (n=33), participants were identified at an ICU at a Swedish county hospital. The validation of the Flodén ATODAI was performed in several steps: • Construct validity with Exploratory Factor Analysis, Kaiser-Mayer-Olkin, Bartlett’s test and Scree plot • Internal validity with Discriminant and Convergent validity, Scaling success, and Cronbach’s alpha • External validity with Known-groups validation, and • Reliability testing with test-retest and Intraclass Correlation Coefficient Results: The Exploratory Factor Analysis showed that the previously used five-factor solution of the questionnaire just agreed partially, but not entirely, which motivated this study of instrument development. Internal and external validation was performed. Known-groups validation revealed significant differences between the ICU nurses with a designated role in organ donation and neuro-ICU nurses, compared to the general ICU nurses. The six factors identified of the Flodén ATODAI showed good reliability in the test-retest analysis and the Intraclass Correlation Coefficient. Conclusions: The modified Flodén ATODAI [Swedish version] may be a reliable and valid tool for measure attitudes toward organ donor advocacy among ICU nurses. Anticipated or potential outcomes of this study may include: Evaluation of baseline attitudes of ICU nurses that can lead to tailored professional development; Changes in organizational structure related to organ donation; and Increased understanding of critical care nurses and the barriers to organ donation.

The impact of a liaison nurse on ICU nurses' perceptions of discharge planning

One of the most important conclusions of a research study conducted by the Human Sciences Research Council in the late 1980s was that junior intensive care unit (ICU) nurses bear a heavy burden as a result of staff shortages in the ICU and do not receive sufficient support from nursing service managers. ICU nurses regularly present with work-related problems such as lack of motivation and frustration due to inadequate equipment, and staff turnover is high. Are ICU nurses unhappy because they do not receive enough support? The question arises, 'How do nurses experience the support they receive in the ICU?' The purpose of this study was to describe and explore the support received by ICU nurses in private hospitals in Gauteng. To answer the research question, a qualitative, descriptive, explorative and contextual research design was followed. The target population was qualified ICU nurses working in private hospitals in Gauteng. A purposeful convenience sampling was done. The sample consisted of 6 nurses working in five different ICUs in different private hospitals in the Gauteng area. The research question put forward to the group was 'Tell me about support in the ICU'. Trustworthiness was ensured and the data obtained from the interview were divided into four categories, namely stress and conflict, debriefing, interpersonal skills and communication, and demotivation. From these categories, guidelines were developed to help support ICU nurses better.

Objective To explore the status quo of pain assessment by the nurses in intensive care units (ICU) of Class Ⅲ hospitals, to analyze the factors influencing the implementation of pain assessment by ICU nurses, and to provide evidence for improving the practice of pain assessment by ICU nurses. Methods Totally 410 ICU nurses from 11 ClassⅢ hospitals in Hu'nan, Guangdong, Beijing and Hebei were selected by convenient sampling and investigated with the self-designed pain assessment questionnaire between April and July 2017. SPSS 21.0 was used to conduct the statistical analysis of the data. Results The implementation rate of pain assessment by ICU nurses was 77.6%. The application of subjective pain assessment tools was consistent mainly with the Numeric Rating Scale (NRS) (74.2%) , while objective assessment tools were less used, including the Critical Care Pain Observation Tool (CPOT) (40.6%) and Behavioral Pain Scale (BPS) (29.9%) . The standard rate of the use of pain assessment tools in ICU was 81.8%. The type of ICU and the frequency of continuing education in pain among ICU nurses were the factors that affected pain assessment by ICU nurses. Conclusions ICU nurses have not standardized their pain assessment, applied less objective pain assessment tools, and lacked norms for pain assessment in ICU. It is suggested that hospitals and departments should formulate relevant pain management rules and regulations, strengthen the continuous professional education for ICU nurses, and standardize and promote the clinical pain assessment of ICU nurses so as to improve the quality of pain care in ICU. Key words: Nurses; Intensive care unit; Pain; Assessment; Status quo; Influencing factors

The Challenges Experienced by ICU Nurses in Kuwait during the COVID-19 Pandemic

Background: The intensive care unit (ICU) is a busy and complex workplace, and several work-related and personal factors are known to make ICU nurses more vulnerable to moral distress than other healthcare professionals. It is crucial to identify these factors to guide future studies and preventive strategies. This scoping review explores such factors to present current knowledge on the factors that trigger moral distress and to guide future research by reviewing studies to explore and summarize factors that trigger moral distress in ICU nurses. Methods: The PubMed, EBSCO, and CINAHL Plus databases were searched to identify potentially relevant studies published between 2011 to 2022. Inclusion criteria: peer-reviewed studies published in English that provided results regarding factors causes or correlated to moral distress in ICU nurses. After removing 63 duplicates, 371 papers were excluded after title and abstract screening, leaving 47 articles for full-text screening. A further 30 articles were excluded as their outcomes did not include factors that caused moral distress, or were not specific to ICU nurses, so 17 studies were eventually analysed using qualitative content analysis through an inductive approach. The findings of the articles were extracted and coded independently by two authors, and data were grouped and categorized. Results: The content categories of factors contributing to ICU nurses' moral distress were organized into themes and subthemes. Four major themes were identified: Powerlessness, end-of-life care, ineffective teamwork, and personal characteristics of ICU nurses. Conclusions: This review highlights the factors that contribute to moral distress in critical care nurses, which are mainly attributable to the organizational climate and the nature of the ICU clinical environment. Descriptive and intervention studies (experimental or action research) must investigate causality between identified variables to inform management strategies to improve support for ICU nurses’ coping relative to moral distress.

A cross-sectional study was conducted among intensive care unit (ICU) nurses in private hospitals in India to identify knowledge and practice of ICU nurses in the prevention of ventilator-associated pneumonia (VAP). Knowledge of 135 nurses working in ICU was tested using a questionnaire consisting of 18 questions. Fourteen forms were excluded from the statistical analysis due to incomplete data entry by the participants. The data of 121 filled questionnaires were analyzed. The information letters, consent forms, and questionnaires were handed to ICU nurses by Research assistant. Data were coded and entered into SPSS version for descriptive and inferential statistics. A majority of the participants perceived oral care as a necessity in all critically ill patients. Nurses were generally aware of the most likely mechanism of acquiring pneumonia. The type and frequency of oral care varied widely. Many of them stated that they had adequate supplies to provide oral care. Although a majority of nurses had some formal training in oral care, they would appreciate an opportunity to enhance and improve their knowledge and skills. The methods of oral care provided vary widely. In summary, randomized controlled trial to date has demonstrated that tooth brushing is associated with a trend toward lower rates of VAP in intubated mechanically ventilated critically ill patients. But it is also to be noted that there was no clear difference between electric and manual tooth brushing. In-house training and workshop can provide required skills needed for the betterment of the treatment provided.

End-of-Life Decision Making, Organ Donation, and Critical Care Nurses

Purpose: The present study determines the factors affecting knowledge of the Glasgow Coma Scale (GCS) of emergency room (ER) and intensive care unit (ICU) nurses who work at a tertiary hospital in Riyadh, Saudi Arabia. Methods: A cross-sectional study with self-administered questionnaire was conducted among 149 ICU and ER nurses conveniently selected at a tertiary hospital in Saudi Arabia. A standardized tool was used to assess knowledge of the GCS. The study adhered to the STROBE guideline for cross-sectional studies. Results: Expatriate nurses (p<0.001) and those with a postgraduate degree (p<0.05) were found to have more knowledge of the GCS. Nurses with expertise in ICU services scored significantly higher (p<0.001) than those who work in the ER. Nurses reporting no previous training in the GCS had higher scores (p<0.05) than those who had previous training in the GCS. Conclusion: Some of the demographic characteristics and nurses’ knowledge about the GCS were associated. Expatriate, postgraduate, and ICU nurses were more knowledgeable about the GCS tool. Surprisingly, nurses without GCS additional training had more GCS knowledge than nurses who had attended training. The results provide valuable insights into and guidance for improving GCS knowledge among ICU and ER nurses.

Tracheostomy is a common procedure in intensive care units (ICUs), with a rising number of patients requiring specialised nursing care. Effective tracheostomy management is critical for preventing complications such as tube blockage, infection and bleeding. Critical care nurses play a pivotal role in ensuring patient safety, highlighting the need for innovative approaches to enhance their knowledge and clinical performance. To evaluate the effect of implementing a Tracheal nursing care bundle on critical care nurses' knowledge and performance in the ICU. A quasi-experimental design was conducted involving critically ill adult patients with tracheostomies and ICU nurses. Data were collected using three tools: (i) a self-administered questionnaire to assess nurses' knowledge, (ii) a pre-post observational checklist to evaluate nurses' performance in applying the Tracheal nursing care bundle and (iii) a patient outcome sheet documenting demographic characteristics, adverse events and tracheostomy-related complications. A total of 60 critical care nurses and 60 ICU patients participated in the study. Post-implementation of the Tracheal nursing care bundle, there was a statistically significant improvement in nurses' knowledge and practice, with 81.7% achieving adequate performance levels. The overall complication rate significantly decreased (pre 28.3% (n=17) vs. post 8.3% (n=5), p=0.006). The Tracheal nursing care bundle enhanced ICU nurses' knowledge and performance, leading to a reduction in tracheostomy-related complications and improved patient outcomes. Implementation of structured care bundles, such as the Tracheal nursing care bundle, strengthens evidence-based tracheostomy management in ICUs. By standardising nursing practice, the bundle reduces preventable adverse events, reinforces patient safety and supports high-quality care delivery. Incorporating such interventions into routine ICU practice can optimise patient outcomes and empower nurses with the confidence and competence required for managing tracheostomies effectively.

A research regarding the relationship among intensive care nurses' self-esteem, job satisfaction and subjective well-being

Knowledge, attitude and practice regarding hypoactive delirium among ICU nurses: A nationwide cross-sectional study