Nursing Workload as a Risk Factor for Healthcare Associated Infections in ICU: A Prospective Study

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Background and Significance:

Many researchers have found that patients who are admitted in the Intensive Care Unit (ICU) and contract healthcare associated infection (HAI) undergo at least one invasive procedure during their course of stay in the hospital. These invasive procedures are considered to be a major cause of healthcare-associated infection like catheter associated urinary tract infection, central line-associated bloodstream infection, surgical site infection etc. On the other hand, inadequate staffing of nurses is being considered as a plausible reason of patient’s HAI (Stone et al 2005). Nurses have a duty to look after the patients they are assigned to, if understaffing is consistent in a hospital unit, patients welfare is compromised leading to adverse effects and HAIs. Although there are extensive guidelines available in the literature regarding prevention of HAIs, their implementation is still vacant in most of the hospital settings. According to the literature available, well backed up prevention guidelines with authentic scientific evidence have shown to be effective in negating the incidence of HAIs in ICU patients.

Nurse understaffing though being a direct risk factor for patient’s Healthcare associated infections, it indirectly leads to over working of the nursing staff and difficulty in managing the health of the patients. Researchers have started to consider that invasive procedures like CVP line insertion, using of unsterile injections and use of mechanical ventilation can contribute to the workload of the nursing staff and this overload of work might be a thinkable reason for the patient’s healthcare associated infection. This concept is still under evaluation and requires a lot of methodological research to back it up; hence, this study intends to fill the research gap by providing relative data on whether nursing staff’s increased workload could be a potential source of patient’s Healthcare associated infection during their course of stay in a hospital (Daud-Galloti et al. 2012).

Research Question:

Does increased nursing workload act as a causing factor for hospital-associated infections in ICU patients?

P: Healthcare associated infections

I: Assessment of nursing staff workload

Co: Patients with HAI and without HAI.

O: Reduced healthcare associated infections

Method

Research design: Prospective cohort study

Sampling criteria: Patients aged 12 and above and every first patient admitted to Medical ICU and a step-down unit.

Sampling method: Convenience sampling

Data collection method: Direct observation of the subjects and questionnaire filling

Data analysis plan: A database using MS Office Excel 2007, statistical analysis by software Stata version 10.0.

Provide the rationale for the choice of the research design (qualitative/ quantitative/mixed method) and its relevance to proposed research project

The quantitative prospective cohort research design has been selected for the proposed research project. The participants taken for a prospective cohort design are free of the ‘effect’ under study, then a one or more variables relevant to the outcome of interest are measured and then the participants are followed over a period of time in order to check the effect of those variables on them. According to (Mann et al. 2003), these type of studies are useful for evaluating the cause and effect relationships between different variables and determine the prognosis of any phenomenon over a period of time. In contrary, these studies can be expensive and time taking due to the unknown time-period that would be required for the respective effect to occur.

Relative to the similar concept, the proposed research design aims at finding out the effect of work overload on nurses on the prevalence of healthcare associated infections among ICU patients. This study will take patients in ICU that are free of any Hospital acquired infection (HAI) and will be followed throughout their course of stay at the hospital for the evaluation of any infection. Therefore, the prospective cohort research design is best suited for this study.

The prospective cohort will add more value to the proposed research project as it is going to follow the patients over a period of time in order to observe the contraction of the HAI. Using this type of design, the researcher will be able to compare more than one variable like increased nursing workload, use of invasive procedures, non-compliance of NPC, severity of the disease and the presence of any adverse effects, in order to distinguish the cause effect relationship. Hence, this cause effect relationship will then allow the researchers to develop a prognosis that whether a certain variable is the relative cause of the effect under study. Another significant reason for choosing this particular design of study is that the subjects of are admitted to the ICU department of a tertiary care hospital so the disadvantage of losing them to the follow up can easily be avoided and thus improve the significance of our outcome (Daud-Galloti et al. 2012).

Provide the rationale for the selection of the participants (sampling criteria), sampling strategies and data collection method and its appropriateness to the proposed research project.

The sampling criterion selected for the study includes every first patient that is admitted to the medical intensive care unit (ICU) specifically the General medicine ward, pneumonology ward and the emergency ward is included in the study. In addition to these wards, every first patient shifted to the step-down was also considered to be a part of the study. The age of the patients eligible to join the study is considered to be 12 years and above. The sampling strategy used to gather participants or patients for the study was through convenience sampling as only the first patient admitted in every designated unit was considered to be the part of the research. This kind of sampling reduced the chance of any sampling bias by the researcher.

As the proposed study design is a prospective cohort, data collection method is the combination of questionnaire filling and observation of the patients. The study evaluates the workload of the on call nurses with the help of a special questionnaire called the Nursing Activities Score (NAS) designed specifically for this purpose (Bruyneel etal. 2019). Everyday workload of the nurses is taken into account using seven categories of NAS. As two patients were assigned to each nurse, the average NAS score of >51% was ultimately considered to be extreme workload (Daud-Galloti et al. 2012). The researchers observed the communication between the different healthcare professionals of the respective unit. The severity of the patient is observed via APACHE II scores while everyday change in severity is observed using the SAPS II and SOFA scores. In addition, demographics of the patients, their presenting complain, total number of days they stayed in the respective unit, performance of any invasive procedure and the non-compliance of the nurses to follow the NPC was also observed directly and through the patient’s charts. Every infection acquired in the first 48 hours of admission was considered as an HAI and the Infection Control nurses noted it. The proposed sampling criteria, sampling strategy and data collection method not only increases the credibility of the research through data triangulation but also fits perfectly with the purpose of the qualitative study.

Provide the rationale for the selection of the data analysis method and why is it appropriate for the proposed research project? (300 words)

Firstly, Microsoft Office Excel 2007 (Microsoft, Redmond WA, USA) was used to create a baseline platform for the data. Then the descriptive analysis of the data was performed determining the mean, frequencies, percentages and standard deviation of different variables. This step helped in formatting large number of the cohort study data in a table or graphical format as determining the occurrence of variables over a certain period of time would be convenient. Since the prospective cohort study design evaluates the effect of certain variables over a period of time, the normality of the data was thus determined. Independent and dependent variables of the study were recognized with the help of the mean and standard deviation, which are the parameters of the normal distribution curve.

Since the proposed research project has a quantitative data, the inferential statistical analysis was thus performed with the help of the software Stata version 10.0 (StataCorp, College Station TX) in order to check the relationship between different variables (Baum, Christopher. 2006). All the determined independent and dependent variables were compared with each other in order to find the cause effect relationship. A variable was considered to be statistically significant when it had a p value <0.05. The confidence interval selected was 95% for all the dichotomous variables. The Categorical and continuous variables were analyzed with the help of chi square and ANOVA test respectively. While multivariate analysis was performed in order to determine various factors that could lead to the desired outcome of interest. Bivariate analysis of numerical data shows the relationship between values of the variables under study (Cooper et al. 1983). In the prospective cohort study, the same analysis was used to determine the factors that were majorly responsible for contracting hospital acquired infections among ICU patients. On the other hand, multivariate analysis showed the definite variables that were associated with contraction of hospital acquired infections (Daud-Galloti et al. 2012).

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