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To explore intensive care nurses' perceptions of their work environments at the unit and organisational levels according to the American Association of Critical Care Nurses standards, their impact on care quality, national differences, and demographic associations.
Cross-sectional study using a survey design.
Study conducted between January 2021 and April 2022, using a convenience sample of intensive care unit nurses across Cyprus, Spain, Croatia, and Poland, Romania. The Critical Elements of a Healthy Work Environment Scale (CEHWES) developed by the American Association of Critical Care Nurses and cross-culturally adapted by the authors was used, which included four sections, including sociodemographic data and a total of 50 questions. The core section of the tool comprised 16 questions using Likert-type response (1—strongly disagree—4 strongly agree). Perception of fulfilment of healthy work environment standards was calculated using the aforementioned Likert-type scale.
A total of 1183 nurses participated reporting moderate perception of fulfilment of the standards, with mean scores ranging from 2.6 to 2.8. Skilled communication and effective decision making were the highest rated. 56% (n = 662) reported awareness of some standards and while 25.8% (n = 305) reported full or significant implementation in their unit. Significant differences related to the perception of all standards were observed across countries. Implementation of the standards was significantly associated with higher quality of care having better perception when standards were fully implemented.
This study shows moderate perception of healthy work environment standards among intensive care nurses. Country differences highlight the need for more awareness, training, and further implementation of the standards, which is linked to better care quality.
Work environment still need to improve and needs to be prioritised by organisations, considering local and national particularities. Having a measuring tool available in multiple languages facilitates comparisons and getting a global picture.
The questionnaire used is validated in different languages, allowing results to be compared with other countries. Novel data from countries that were poorly investigated is now available. More evidence points out the need to prioritise work environment for maintaining quality in patient care.
The study has been reported following the STROBE checklist.
This study did not include patient or public involvement in its design, conduct, or reporting.
Glucosamine is a commonly used ‘over the counter’ dietary supplement. Previous research has identified an association between glucosamine use and several positive health outcomes. However, a plausible biological mechanism for these associations has not yet been identified, meaning the causality of these relationships remains unclear. A protective effect of glucosamine on the vascular endothelium has been suggested as one such possible mechanism. Albuminuria is an early marker of endothelial dysfunction within the kidney and is associated with progression of kidney disease and adverse cardiovascular outcomes. In order to provide insights into the potential biological mechanisms underlying a protective association of glucosamine use with health outcomes, we evaluated evidence for an association between glucosamine use and albuminuria in UK Biobank (N=436 200).
Univariable and multivariable ordinal logistic regression were performed to evaluate evidence for an association between self-reported glucosamine use and albuminuria (measured as urine albumin creatinine ratio (uACR) categories). As a secondary analysis, we performed Mendelian randomisation (MR) to demonstrate the difficulties in inferring causality in this relationship using currently available data, using summary genetic data from UK Biobank and CDKGen (N=67 452).
We found that people who used glucosamine were more likely to be in a lower uACR group (OR 0.81, 95% CI 0.80 to 0.83, px10–16). This association was robust to sensitivity analyses and was maintained after adjustment for age, sex and measures of obesity. In our MR analysis, we found little evidence for an association of genetically proxied glucosamine use on albuminuria (change in log uACR (mg/g) per SD change in genetic liability=1.11, 95% CI –3.01 to 5.23, p=0.60).
We found that detectable albuminuria was common in UK Biobank participants and we are the first to show that use of glucosamine supplements was associated with lower levels. Though this fits with a plausible biological role of the vascular endothelium in a potential protective effect of glucosamine use on many health outcomes, whether this relationship is causal or confounded remains unclear. We further discuss the inherent difficulties in using genetic instruments to proxy supplement use in MR analyses and highlight the need for a genome-wide association study of measured circulating glucosamine levels.
In the intensive care unit (ICU), brain-injured patients are frequently exposed to mechanical ventilation to protect the brain and preserve physiology. After intracranial pressure control and sedation withdrawal, this population is prone to residual disorder of consciousness and altered neurological control of respiratory drive, cough and airway protection. Consequently, extubation failure is more frequent than in general ICU patients, and there is no clear evidence-based clinical trigger for extubation. Different risk factors for extubation failure were described in observational trials, and clinical scores were constructed to detect patients at higher risk of extubation failure. Nevertheless, none of these scores were prospectively tested as interventional tools to prevent extubation failure. The Brain-Injured Patients Extubation Readiness (BIPER) study is an ongoing multicentre stepped-wedge cluster-randomised controlled trial aiming to test one of these scores as an intervention protocol to decrease extubation failure in neurocritical care patients with residual disorder of consciousness.
Trial design: Stepped-wedge cluster-randomised controlled trial with five groups of three to six clusters (20 ICUs). Groups of clusters are randomised to five possible sequences of nine periods with crossing from a control condition period (usual care for extubation) to an intervention condition period (BIPER-guided extubation protocol), separated by a 3-month transition period.
Participants: Participants are clinically stable brain-injured patients (18–75 years old), requiring more than 48 hours of invasive mechanical ventilation with residual disorder of consciousness after sedation withdrawal, and who achieved a spontaneous breathing trial.
Interventions: The control condition consists of extubation based on usual care and local practice. The intervention condition consists of extubation triggered by a clinical score evaluating deglutition, gag reflex, cough and visual tracking (Coma Recovery Scale-Revised Visual Scale).
Objective: To determine whether adoption of an extubation protocol based on a clinical score can lessen extubation failure compared with usual care in brain-injured patients with residual disorder of consciousness.
Outcome: The primary outcome measure is extubation failure, defined within 5 days following extubation. The key secondary outcome measure is time to effective extubation.
Randomisation: Clusters are allocated to sequence of treatments using random blocks randomisation. The constitution of groups of clusters was stratified according to planned recruitment of each centre.
Blinding: Investigators and outcome assessors are not blinded to condition allocation.
Number of participants: 660 patients (220 in the control condition and 440 in the intervention condition).
The BIPER trial was approved by an independent ethics committee. The study began on 9 February 2020, and 571 participants are now included. Results will be published in an international peer-reviewed medical journal.
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