Stefano Bambi

Open intensive care units: a global challenge for patients, relatives, and critical care teams.

Aim: The aims of this study were to describe the current status of intensive care unit (ICU) visiting hours policies internationally and to explore the influence of ICUs’ open visiting policies on patients’, visitors’, and staff perceptions, as well as on patients’ outcomes. Methods: A review of the literature was done through MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The following keywords were searched: “visiting,” “hours,” “ICU,” “policy,” and “intensive care unit.” Inclusion criteria for the review were original research paper, adult ICU, articles published in the last 10 years, English or Italian language, and available abstract. Results: Twenty-nine original articles, mainly descriptive studies, were selected and retrieved. In international literature, there is a wide variability about open visiting policies in ICUs. The highest percentage of open ICUs is reported in Sweden (70%), whereas in Italy there is the lowest rate (1%). Visiting hours policies and number of allowed relatives are variable, from limits of short precise segments to 24 hours and usually 2 visitors. Open ICUs policy/guidelines acknowledge concerns with visitor hand washing to prevent the risk of infection transmission to patients. Patients, visitors, and staff seem to be inclined to support open ICU programs, although physicians are more inclined to the enhancement of visiting hours than nurses. Discussion: The percentages of open ICUs are very different among countries. It can be due to local factors, cultural differences, and lack of legislation or hospital policy. There is a need for more studies about the impact of open ICUs programs on patients’ mortality, length of stay, infections’ risk, and the mental health of patients and their relatives.

Lateral hostilities among nurses employed in intensive care units, emergency departments, operating rooms, and emergency medical services: a national survey in Italy

Background:Lateral hostilities (LHs) are “nasty, unkind, aggressive behavior between colleagues working at comparable organizational levels.” When LHs occur “at least once a week for a period of not less than 6 months,” they become “bullying.” The frequency of lateral violence in health care literature varies from 5.7% to 65%. Objectives:The aim of this study was to explore the extent of LH and the effects on the quality of lives of Italian nurses working in prehospital emergency medical system, emergency department, intensive care unit, and operating rooms. Methods:A descriptive study was conducted through an online survey in the Web site of the National Italian Association of Critical Care Nurses (ANIARTI). Results:A total of 1504 nurses filled up the questionnaire, with 1202 valid data entries (79.9%). Of this group, 739 (61.5%) were women and 951 (79.1%) had experienced some form of LH at least once in the last 12 months, whereas 269 (22.4%) felt to be victims of bullying. The number of transfers to other departments/services due to LH was 43 cases (3.6%), and 829 (69%) experienced psychophysical disorders attributed to LH experienced in the span of the year. Discussion:Lateral hostility is a frequent occurrence that calls for implementation of management policies to achieving an overall improvement of the work environment climate.

[Invasive and non-invasive ventilation: impact on nursing workload].

INTRODUCTION Non invasive ventilation (NIV) is increasingly used in intensive and non intensive wards. OBJECTIVE To detect the impact of ventilation modes on nursing workload. METHODS Retrospective observational study of 200 patients admitted to a general Intensive Care Unit (ICU). Nursing Activities Score (NAS) was used to measure the nursing workload. Patients enrolled were treated with the following ventilation modes: oxygen therapy without positive end-expiratory pressure (PEEP), helmet Continuous Positive Airway Pressure (CPAP), controlled mechanical ventilation, Invasive pressure support ventilation (I-PSV). RESULTS The overall mean NAS score of patients was 74.3% (SD ±8.88 - range 39/143) corresponding to an ideal nurse/patient ratio of 0.7 and varied with the different ventilation modes. In the days in oxygen therapy, the average NAS was 64.5% (±11.9), with helmet CPAP 69.7% (±12.7), with controlled mechanical ventilation 86.1% (SD ±15.1) and with invasive assisted ventilation 76.4% (±11.4) [p=0.0001]. In patients with helmet CPAP the NAS increased of 14% when FiO2 >0.6 and PEEP >10 compared to oxygen therapy. The average NAS score of the 15 patients (7.5%) with mask-PSV was 80.2% (±12:5). CONCLUSIONS Overall, the nursing workload of patient with helmet CPAP was lower than with invasive ventilation. In Helmet CPAP, with FiO2 >0.6 and PEEP level >10 cmH2O and mask-PSV, the nursing workload is similar to that of patients with invasive ventilation. NAS scores in patients with Invasive ventilation in the controlled mode is higher than with assisted mode.

Noninvasive positive pressure ventilation: an ABC approach for advanced nursing in emergency departments and acute care settings.

Noninvasive ventilation has become a widespread tool of treatment and support for patients in acute care settings. The treatment is used for various clinical conditions, particularly chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema. The utilization of a simple nursing care checklist allows treatment in a systematic fashion. This article discusses the respiratory features of this topic: criteria for noninvasive ventilation, choice of the interface for acute clinical conditions, ventilators and modes of ventilation in noninvasive ventilation, management of setting parameters, patient/ventilator interactions, and monitoring.

The strange and conflicting world of nursing

Dear Editor, We read with interest the paper by Hartog and Benbenishty published in the October issue of Intensive Care Medicine [1]. We wish to make some points about the conflicts between nurses and physicians during their work-shifts in intensive care units. The issue described by the authors recalls the concept of ‘‘moral distress’’: a challenge that comes up when a nurse gives an ethical or moral judgment about an issue, differing from others who are in charge [2]. Moral distress occurs when one person is aware of the correct actions to be done, but institutional constraints prevent their accomplishment [2]. There is a negative correlation between moral distress and good nurse–physician relationships (r = -0.25, P = 0.03), thus increasing the chance of healthcare staff conflicts [3]. Hartog and Benbenishty address the inter-professional conflicts related to numerous factors: procedural, organizational, relational, and contextual [1]. We think that the anthropological factor, related to the theory of ‘‘oppressive group behaviors’’, may play a role in this scenario [4] (Fig. 1). Roberts [4] stated that doctors and managers (the dominant groups) impose their values upon the oppressed groups (in this case nurses). This fact creates lack of self-esteem and pride, fear, silence, and self-contempt, generating emotional distress and consequent aggressive behaviors and exclusion among the members of the oppressed group [4]. This phenomenon is labeled ‘‘lateral (or horizontal) violence’’ and, when it happens, contributes to worsen the workplace climate, followed by potential negative consequences on inter-professional relationships, quality of care, and patient safety [5]; basically, the disparity of decisional power between doctors and nurses gets wider when the nursing groups are undermined by internal conflicts. On the contrary, we have scarce information about young physicians being overpowered and pressured by older and experienced ICU nurses, at least in our settings. Furthermore the low nurse to patient ratio, which is not always guaranteed to be 1:2, can increase nursing activities and tighten the socalled task time imperatives, thus reducing time for teamwork and increasing possible conflicts in the team. Lastly, in our opinion, the nursing profession carries some unique stigmata, since we have no information about similar levels of intraand inter-professional conflicts amongst other healthcare professionals such as radiographers, biomedical laboratory technologists, or physiotherapists. We believe that an enduring low social recognition of nursing may be more

Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention.

Dear Editor, We read with interest the paper by Choi and Lee (2017) titled ‘Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention’ published in the Journal of Nursing Management. We were impressed by the high rates of workplace violence (WPV) (95.5% of the respondents, in a time frame of 12 months) recorded by the authors, indicating the real importance of this phenomenon. Even if the most frequent kind of WPV is verbal abuse, a consistent percentage of respondents reported threatening behaviours (89.9%). We would like to add some considerations emerging from data recorded in Italy. According to our recent national survey about violence towards emergency nurses, which involved 1,093 respondents, accounting for 6.9% of the 15,618 Italian emergency nurses currently in service (Ramacciati, Ceccagnoli, Addey, & Rasero, 2017), the turnover intention and, the desire to leave the profession are significantly related to being a victim of violence, regardless of the type of violence suffered (whether verbal or physical), even if a formal transfer request is not submitted, as shown in Table 1. This is consistent with a previous Italian study (Becattini, Bambi, Palazzi, & Lumini, 2007). Moreover, an issue studied by Choi and Lee is that of horizontal violence (HV), which is a type of abuse perpetrated among nurses. In two recent Italian studies performed with critical care and emergency department nurses the reported rates of HV experienced in the last year were 81.6% (Bambi, Becattini, Pronti, Lumini, & Rasero, 2013) and 79.1% (Bambi et al., 2014), respectively. Actually, we are talking about reports of abuse that are at least single episodes, while the systematic occurrence of this kind of abuse perpetrated by peers (at least once a week for not less than 6 months) is called horizontal bullying (Tomei et al., 2007). Our data reported that 22.4% of nurses working in critical care units, operating rooms, emergency departments and ambulances were bullied by other nurses (Bambi et al., 2014). Interestingly, the bullied nurses made formal requests to leave their units in rates significantly higher than nurses that experienced HV but not in a consistent way (29.3% vs. 6.1%; χ2 = 110.262; p < .0001) (Bambi et al., 2014). At the same time, this group of nurses have more frequently thought to leave definitively the nursing profession (31.2% vs. 7.8%; χ2 = 98.654; p < .0001) (Bambi et al., 2014). Therefore, we think it is important to distinguish the various kinds of WPV (verbal abuse, physical aggression), and to grade the intensity of the abuse to understand the relationship between the violence and its consequences for nurses. We would like to know if the authors found any results similar to ours. Sharing knowledge can help nursing managers find effective solutions to counteract this phenomenon (Ramacciati, Ceccagnoli, Addey, Lumini, & Rasero, 2016). In our opinion, one of the most important elements to solve these problems is a fundamental commitment, starting from nurse executives and managers. Nurses should not be left alone in the face of violence (Ramacciati, Ceccagnoli, & Addey, 2015).

Pain assessment scales in nonverbal critically ill adult patients: ventilator-related issues

critical points regarding these scales. First, the CPOT and the BPS do not have a specific item for patients who are in a coma (Glasgow Coma Scale ≤8), with artificial airways (eg, tracheostomy tube), who are breathing spontaneously without receiving mechanical ventilation. Other important concerns are items that evaluate patients’ compliance with ventilators. When patients cough we expect to hear the sound of ventilator alarms, which occurs only if alarms have been adequately set up. Consequently, the evaluation of this item is dependent on the variability of clinical settings and health care professionals. Another element that can make it difficult to recognize a patient “fighting with the ventilator” is the use of ventilation modes based on active expiration valves (eg, BIPAP, Drager; DuoPAP, Hamilton; BiVent, Siemens; Bi-Level, Puritan BennettCovidien). These ventilation modes let the patients breathe spontaneously, without activating the ventilator alarms. The identification of patient-ventilator asynchronies is made by the direct observation of patients and the interpretation of ventilator waveforms. A recent European survey has shown a wide variability in ventilator education provided to ICU nurses. Unfortunately we do not know how many nurses are “comfortable” with ventilator graph interpretation, even if 83% consider waveform analysis education “important” or “very important.” Presently, there is a lack of papers published about this issue. Finally, some clinical conditions, not necessarily related to pain, can determine the activation of ventilator alarms due to patients’ dyssynchronies: hiccup and seizures. These conditions can determine false positive results. We hope that our observations can be helpful to improve these pain assessment tools for critically ill patients. CCN

Ostilità laterali nei gruppi infermieristici di area critica.Indagine su cinque presidi ospedalieri della regione Toscana

Le ostilita laterali (LH) sono una delle forme di violenza sul posto di lavoro, costituita da una varieta di interazioni crudeli, scortesi, antagonistiche che avvengono tra persone agli stessi livelli gerarchici nelle organizzazioni. Questo fenomeno, che puo colpire dal 5.7% e il 65% degli infermieri, determina riduzione della motivazione lavorativa, sintomi e disturbi psicofisici e in taluni casi, l’abbandono precoce della professione. Obiettivo. Quantificare in 5 ospedali toscani, la diffusione del fenomeno delle LH tra gli infermieri di pronto soccorso e terapia intensiva, e le sue conseguenze sulla qualita di vita psicofisica e professionale. Metodo. Studio descrittivo-esplorativo, con questionario a risposte chiuse. Risultati. Hanno risposto 360/444 infermieri (81%), di cui 239 femmine (66.4%); 294 (81.6%) sono stati oggetto di LH nell’arco degli ultimi 12 mesi. Chiacchiericci, lamentele fatte alle spalle, e commenti sarcastici, sono le forme di LH piu frequenti. Le LH avvengono maggiormente nei pronto soccorso rispetto alle terapie intensive (rispettivamente 90% e 77%; p=0.0038). Non ci sono differenze statisticamente significative per genere, eta anagrafica, ne anni di servizio. Il 17.7% ha fatto domande di cambio reparto per le LH subite, e nel 6.9% lo ha effettivamente cambiato. Il 6.9% ha pensato di lasciare la professione infermieristica; 235/444 (65.2%) hanno accusato almeno un disturbo attribuito ad LH nell’arco dell’anno. I piu riportati sono morale ridotto, ansia e disturbi del sonno. Conclusioni. La presenza di LH e di disturbi correlati e elevata nei contesti di area critica e comporta una ridotta qualita di vita professionale e psicofisicaLateral hostilities among emergency and critical care nurses. Survey in five hospitals of Tuscany Region. Introduction. Lateral hostilities (LHs) are a kind of workplace violence. They are defined as varieties of cruel, rude, antagonistic interactions between people at the same hierarchical level. Nurses are affected by LH from 5.7% to 65%, leading to reduced work motivation, psycho-physical disorders, and in some cases, drop out of the nursing profession. Objective. To quantify the LHs among nurses in the emergency departments (ED) and intensive care units (ICU) in 5 hospitals of Tuscany (Italy). To show the impact on the quality of their psycho-physical and professional lives. Method. Exploratory-descriptive study, through closed-ended questionnaire. Results. 360/444 nurses (81%); 294 (81.6%) were victims of LHs during the past 12 months. Gossiping, complaints shared with others without discussing with the concerned person, and sarcastic comments were the most reported LHs. LHs occur more in EDs than ICUs (respectively 90% and 77%; p=0.0038). No statistically significant differences were observed for gender, age, or years of experience. The 17.7% of nurses asked to be moved from the ward, and 6.9% left it; 6.9% respondents had thought to leave the nursing profession; 235 (65.2%) experienced at least one LHs related disorder during the last year. Most reported symptoms were low morale, anxiety, and sleep disturbances. Conclusions. The incidence of LH and related disorders is high in EDs and ICUs, determining a low professional and psycho-physical quality of life.

Off-label utilization of a rigid cervical collar during noninvasive positive pressure ventilation of a patient affected by severe kyphoscoliosis.

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Preventing workplace incivility, lateral violence and bullying between nurses A narrative literature review.

Abstract Introduction: according to available literature workplace incivility, lateral violence and bullying among nurses are widely diffused. Their negative consequences and the outcomes on nurses and healthcare organizations have been well described. However, real pro-active and reactive actions to manage these issues, seem to be poorly recognized and investigated. Aim: to summarize the results of international studies regarding the prevention of individual and collective reactions towards workplace incivility, lateral violence, and bullying between nurses. Methods: a narrative literature review was performed. Results: 7 original papers were included in this review. The implementation of zero tolerance policies and passive dissemination of information about these phenomena showed to be clearly ineffective. Conclusions: The limited number of evidence based studies and the typologies of interventions (mainly educational rather than team building programs and assertive communication) show inadequate effectiveness plus a lacking in the scientific evidence-based support. The need to find out innovative and “creative” solutions to face these problems has been suggested by different authors.