BACKGROUND:Neurological complications are among the most serious adverse events in patients receiving extracorporeal membrane oxygenation (ECMO). Brain injury during ECMO is associated with increased mortality, long-term neurological deficits and impaired quality of life. Current evidence regarding brain function monitoring and management in ECMO patients is scattered, varies in methodological quality and remains controversial in certain areas. Furthermore, standardised recommendations for monitoring and management across different ECMO configurations and patient populations have yet to be established. AIMS:To retrieve, appraise and synthesise the best available evidence on brain function monitoring and management in adult patients receiving ECMO and to provide evidence-based guidance for clinical nursing practice. STUDY DESIGN:An evidence summary was conducted following the 6S evidence pyramid model. Guideline repositories, professional society websites, evidence-based resources and electronic databases were systematically searched from inception to July 2026. Two reviewers independently performed literature screening, quality appraisal, evidence extraction and synthesis. RESULTS:Twenty-eight articles were included, comprising 4 guidelines, 6 expert consensuses, 5 systematic reviews and 13 original studies. Thirty-four evidence-based recommendations were identified, covering five domains: risk factor assessment, brain function monitoring, brain injury prevention, brain injury treatment and prognosis and continuity of care. CONCLUSIONS:The synthesised evidence provides an evidence-based framework for brain function monitoring and management in patients receiving ECMO support. These recommendations may assist healthcare professionals in identifying neurological risks, implementing multimodal neuromonitoring strategies, preventing secondary brain injury and improving neurological outcomes. RELEVANCE TO CLINICAL PRACTICE:This evidence summary provides nurses and critical care teams with practical guidance for the implementation of multimodal neuromonitoring, individualised brain injury prevention and management strategies in ECMO patients. REVIEW REGISTRATION:PROSPERO CRD420261370955 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=261370955).
BACKGROUND:Organ donation in intensive care units (ICU) involves complex, emotional conversations with families during end-of-life care. While literature often examines consent rates, clinical protocols and family experiences, less is known about the factors that shape donation discussions from the perspective of ICU staff. AIMS:To understand ICU staff experiences and perspectives of factors influencing organ donation discussions and family decision-making in New Zealand ICUs. STUDY DESIGN:A qualitative descriptive study using reflexive thematic analysis of focus group data from 11 ICU staff (medical, nursing and health psychology) across three tertiary ICU facilities. FINDINGS:Three key themes were developed: Having a 'Good' Conversation, Acknowledging the Emotional and Mental Weight and Having the Will to Endure and Feeling Equipped to Care. Participants emphasised the importance of trust-based communication with families; culturally and emotionally responsive care tailored to families' individual needs; and regulating the emotional demands of donation work. Staff relied on regular collegial support to maintain emotional resilience and valued structured education, team preparation and access to resources that built their confidence in donation conversations. Participants identified practices and values that fostered a positive unit culture around organ donation, contributing to team resilience and meaningful family interactions. CONCLUSIONS:This study offers insight into the interpersonal, emotional and practical aspects of organ donation work in NZ ICUs from the perspective of staff. Findings show that supportive team culture, underpinned by quality communication, team preparation, emotional safety and adequate resources, enables more meaningful donation conversations with families. These insights highlight opportunities for strengthening practice, education and unit culture in donation work. RELEVANCE TO CLINICAL PRACTICE:Findings support the need for regular, multidisciplinary education; emotional support structures; and clear, standardised team processes to enhance donation conversations. Improving systemic infrastructure, such as robust donor identification pathways and public-facing education, can further prepare staff and families to navigate donation as a normalised aspect of end-of-life care.
BACKGROUND:Management by walking around (MBWA) is a leadership practice in which head nurses maintain a visible presence in clinical settings, interact directly with nurses, promote open communication, observe workflow and foster a supportive work environment. These practices may contribute to building nurses' trust and encouraging them to speak up. AIM:To examine the direct and indirect effects of head nurses' MBWA on nurses' voice behaviour with trust as a single mediating variable. STUDY DESIGN:A cross-sectional correlational design was employed using a convenience sample of nurses working in intensive care units at a tertiary university hospital in Tanta, Egypt. Data were collected using Head Nurses' Management by Walking Around Questionnaire, Nurses' Trust Questionnaire, and Nurses' Voice Behaviour Scale. Structural equation modelling with bootstrapping (5, 000 resamples) was used to test a single-mediator model in which trust mediated the relationship between MBWA and nurses' voice behaviour. RESULTS:MBWA was positively associated with trust (β = 0.620, p < 0.001) and nurses' voice behaviour (β = 0.468, p < 0.001). Trust significantly predicted voice behaviour (β = 0.471, p < 0.001). The indirect effect of MBWA on voice behaviour through trust was statistically significant (β = 0.292, 95% CI [0.115, 0.547]). Approximately 38.4% of the total effect of MBWA on voice behaviour was transmitted through trust, indicating partial mediation. CONCLUSION:MBWA was directly associated with nurses' voice behaviour and indirectly associated with voice behaviour through trust. These findings suggest that head nurses' visible leadership practices may strengthen trust and open communication, particularly in high-risk environments such as ICUs. RELEVANCE TO CLINICAL PRACTICE:The findings of this study highlight the importance of a positive workplace ecology in enhancing nurses' job satisfaction and their intention to leave. Enhancing leadership practices, particularly those that promote effective communication, staff involvement in decision-making and adequate staffing and resources, can directly influence nurses' work experiences and retention. For clinical practice, fostering a positive work environment may improve teamwork, reduce turnover and ultimately contribute to better patient care outcomes. These findings underscore the need for nurse leaders and healthcare administrators to prioritize workplace improvements as part of organizational safety, quality and workforce sustainability initiatives.
BACKGROUND:Shift-based work is a fundamental component of surgical intensive care nursing and has significant effects on health-related behaviours, particularly nutrition. Irregular working hours, high workload and limited access to healthy food options may contribute to unhealthy eating patterns among nurses. AIM:This study aimed to explore food craving, food acceptance and eating behaviours among surgical intensive care nurses during shift work using a mixed-methods approach in two hospitals located in northern Türkiye. STUDY DESIGN:The study employed a concurrent sequential nested quantitative-qualitative mixed-methods design. Quantitative data were collected using a Personal Information Form, the Food Craving Questionnaire, the Acceptance of Food Craving Scale and the Eating Behaviour Scale and were analysed using descriptive and inferential statistics. Subsequently, semi-structured interviews were conducted with a purposively selected group of nurses. The qualitative data were analysed using thematic analysis, and the findings were integrated with the quantitative results through triangulation to provide a more comprehensive understanding of nurses' eating habits during shift work. RESULTS:Quantitative findings from 159 surgical intensive care nurses indicated moderate levels of food acceptance and willingness towards available food options, alongside difficulties in maintaining regular and balanced nutrition during shifts. These patterns were further explained by qualitative findings from 16 nurses, which revealed that irregular meal patterns were commonly experienced due to shift schedules, high workload and fatigue. Limited access to nutritious and affordable food options was also identified as an additional barrier, providing contextual understanding for the quantitative results and explaining the observed eating behaviour patterns. CONCLUSIONS:Shift work is associated with changes in eating behaviours among surgical intensive care nurses. Both environmental and organisational factors play a critical role in shaping nurses' nutritional practices. RELEVANCE TO CLINICAL PRACTICE:Improving access to healthy food options and ensuring structured meal opportunities may support nurses' well-being and contribute to sustainable workforce performance and quality of care.
BACKGROUND:Sleep and circadian disruption are common in critical illness, yet bedside assessment remains difficult. Wearables are unobtrusive and extend observation across 24 h, but their measurement performance in critical illness requires appraisal. AIMS:To map wearable sleep and circadian monitoring during intensive care, its measurement performance, clinical applications and nursing implications. STUDY DESIGN:A scoping review followed JBI and PRISMA-ScR guidance. PubMed, Europe PMC and OpenAlex were searched from inception to 22 July 2026, with citation searching. Eligible primary reports used a body-worn sensor during intensive care to estimate sleep or circadian/rest-activity outcomes at any age. Conventional polysomnography/electroencephalography without an eligible wearable, non-contact systems, staff studies and post-ICU-only monitoring were excluded. No risk-of-bias appraisal was undertaken. RESULTS:Sixty-one reports (43 adult; 18 paediatric/neonatal; 1996-2026) were included. Actigraphy dominated; commercial trackers, smartwatches and one respiratory-belt/heart-rate-variability system were less common. Monitoring was feasible, but performance varied by device, patient state and age group: wake specificity was often poor in ventilated, sedated or immobile patients and agreement with patient or nurse reports was weak to modest. Records showed fragmented and daytime sleep, weak day-night consolidation and attenuated circadian rhythmicity. Nursing bundles, massage, positioning, light and chronotype-informed care changed selected outcomes, but effects were heterogeneous. CONCLUSIONS:Wearables usefully describe rest-activity patterns and support nursing assessment, but agreement with physiological sleep varied by device, patient state and age; movement-derived estimates need clinical context and are not a stand-alone sleep measure. RELEVANCE TO CLINICAL PRACTICE:Nurses should combine wearable trends with patient report, sedation and mobility, delirium screening and care-interaction records; escalation thresholds require prospective validation.
BACKGROUND:Weaning and extubation in neurocritical care are high - risk decisions complicated by impaired consciousness and airway - protection challenges and practice guidance remains fragmented. AIMS:To map, evaluate and synthesize the available evidence on weaning and extubation management for neurocritical care patients receiving mechanical ventilation. STUDY DESIGN:This study was designed as an evidence summary and conducted according to the methodological standards for evidence summaries established by the Fudan University Evidence - Based Nursing Center. Twenty - seven information sources were searched from inception to 7 June 2025, including clinical decision support systems, guideline repositories, professional association websites, evidence-based practice platforms and speciality databases. Eligible evidence included guidelines/manuals, evidence summaries, expert consensus, systematic reviews and randomized controlled trials. The evidence summary was registered with the Fudan University Evidence - Based Nursing Center and guided by the 6S evidence pyramid. Quality appraisal, evidence extraction, synthesis and grading were conducted using evidence type-specific tools and a pre-established evidence grading system. RESULTS:Seventeen studies met the inclusion criteria and quality requirements. Thirty - two pieces of evidence were synthesized into six domains: functional rehabilitation and training interventions; airway protection and secretion management; swallowing and phonation training; weaning/extubation decision - making and peri - extubation management; sedation management and consciousness support; and risk factors and predictors of extubation failure. CONCLUSIONS:This study consolidated 32 pieces of evidence on weaning and extubation in neurocritical care, providing a structured synthesis while highlighting uneven evidence quality and uncertain feasibility in resource - limited settings. RELEVANCE TO CLINICAL PRACTICE:Clinicians should prioritize positioning, early rehabilitation, artificial airway management and secretion clearance, while combining evidence with expert consensus and tailoring implementation to patient status and local resources.
BACKGROUND:ICU survivors frequently experience reduced health-related quality of life (HRQoL); however, recovery trajectories vary considerably, underscoring the need to identify distinct subgroups for targeted follow-up. AIMS:To identify distinct HRQoL trajectory groups among ICU survivors, compare EQ-5D-5L profiles across groups and explore associated factors. STUDY DESIGN:This multicentre prospective study included 19 ICUs in four South Korean university hospitals. Adult survivors with admissions ≥ 24 h were assessed using the EQ-5D-5L over 24 months post-discharge. Trajectory groups were identified via latent-class mixed modelling, and associated factors via multinomial logistic regression. RESULTS:Among 609 survivors, three groups emerged: normative stable (58.3%), suboptimal (31.7%) and persistently low (10.0%). The normative stable group maintained HRQoL near the Korean population norm. The suboptimal group showed persistently reduced HRQoL, with moderate-to-extreme problems in mobility and pain/discomfort at 24 months. The persistently low group exhibited profound, sustained impairment, particularly in mobility, usual activities and pain/discomfort. Older age (aOR 1.72, 95% CI 1.07-2.75), lower educational attainment (aOR 2.11, 95% CI 1.34-3.32) and ICU delirium (aOR 2.14, 95% CI 1.10-4.15) were associated with suboptimal membership, whereas surgical admission showed lower odds (aOR 0.49, 95% CI 0.26-0.94). Multimorbidity (aOR 3.36, 95% CI 1.69-6.69) and discharge to an extended care facility (aOR 4.97, 95% CI 2.40-10.27) were associated with persistently low membership. CONCLUSIONS:Three distinct HRQoL recovery trajectories emerged over 24 months post-discharge. Although most survivors maintained near-normal HRQoL, unfavourable groups experienced sustained impairment in mobility and pain/discomfort. These findings support trajectory-based approaches for identifying high-risk phenotypes and guiding individualised post-ICU care. RELEVANCE TO CLINICAL PRACTICE:The persistent mobility and pain/discomfort problems highlight the importance of repeated assessment during post-ICU follow-up. Critical care nurses may consider them alongside ICU delirium history, multimorbidity and discharge destination; however, prospective validation is required before these trajectories or factors can identify high-risk survivors. TRIAL REGISTRATION:This study was prospectively registered with the Korean Clinical Research Information Service (KCT0004045). Registered 11 June 2019. First recruitment 11 June 2019.
BACKGROUND:Patients hospitalised in coronary intensive care units often experience heightened existential distress, including increased spiritual care needs and death anxiety. Spiritual well-being has been suggested as a key protective factor that may alleviate death-related anxiety in critically ill populations; however, the mechanisms underlying these relationships remain insufficiently explored. AIMS:This study examined the relationships among spiritual care needs, spiritual well-being and death anxiety in patients hospitalised in a coronary intensive care unit and tested whether spiritual well-being mediates the relationship between spiritual care needs and death anxiety. DESIGN:A cross-sectional design was employed. METHODS:The study included a convenience sample of patients hospitalised in a coronary intensive care unit in Eastern Turkey, between September and December 2024. Data were collected using a Sociodemographic and Clinical Variables Form, the Patients' Spiritual Needs Assessment Scale, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale and the Templer Death Anxiety Scale. Data analysis involved descriptive statistics, Pearson correlation analysis and mediation analysis using Hayes's PROCESS macro (Model 4), with age and gender included as control variables. RESULTS:Patients reported moderate levels of spiritual care needs (3.04 ± 0.47), spiritual well-being (30.53 ± 6.87) and death anxiety (8.04 ± 3.00). Spiritual care needs were positively associated with spiritual well-being (r = 0.56, p < 0.001) and its subdimensions (meaning, peace and faith). Death anxiety was negatively correlated with spiritual well-being (r = -0.32, p < 0.001), with the strongest association observed for the peace subdimension (r = -0.39, p < 0.001). Mediation analysis demonstrated a significant indirect effect of spiritual care needs on death anxiety through spiritual well-being (b = -1.46, 95% CI [-2.28, -0.67]). Although higher spiritual care needs were directly associated with greater death anxiety, they were also associated with higher spiritual well-being, which in turn was related to lower death anxiety, suggesting that spiritual well-being may buffer the association between spiritual care needs and death anxiety. CONCLUSIONS:Higher spiritual care needs among coronary intensive care patients are associated with greater spiritual well-being, which in turn relates to lower levels of death anxiety. The significant indirect effect suggests that spiritual well-being plays a buffering role in the relationship between spiritual care needs and death anxiety. Given the cross-sectional design, these findings should be interpreted as associative rather than causal. RELEVANCE TO CLINICAL PRACTICE:Assessing spiritual care needs and supporting spiritual well-being in coronary intensive care settings may be critical for reducing death-related anxiety. Integrating spiritual care interventions-particularly those fostering inner peace and meaning-into routine nursing care may enhance holistic patient support and psychological resilience in critically ill patients.
BACKGROUND:Transfers from the Operating Theatre (OT) to the Paediatric Intensive Care Unit (PICU) represent a high-risk transition for critically ill children. At a Tertiary Paediatric Hospital, the absence of a standardised handover protocol resulted in prolonged recovery waits of up to 120 min, medication errors, haemodynamic instability, and reduced family and staff satisfaction. AIM:To enhance patient safety, reduce handover time, and improve family and staff satisfaction through a structured Operating Theatre-to-PICU handover process. STUDY DESIGN:Single-centre, pre-post quality improvement project in a 23-bed tertiary PICU. A multidisciplinary, co-designed intervention comprising a two-phase telephone checklist, a standardised shared drug library, preloaded infusion pumps delivered to OT, a dedicated receiving nurse and structured pre-arrival family orientation. Training was delivered by link nurses, using Kotter's change model. RESULTS:Handover duration decreased by approximately 50% (15-20 to 8-10 min) following implementation. No transfer-related medication errors occurred across the 77 protocol cases, versus six across 96 baseline transfers and haemodynamic instability attributable to infusion changes was virtually eliminated. Family satisfaction scores were higher in post-implementation cohorts (87% at 3 months; 90% at 6 months) than pre-intervention (72%), as were staff satisfaction scores (80% and 95% vs. 58%). Mean PICU length of stay decreased from 5.2 to 4.6 days. CONCLUSIONS:A structured, multi-component handover process improved patient safety, handover efficiency, and family and staff experience during OT-to-PICU transfers, sustained at 6 months. RELEVANCE TO CLINICAL PRACTICE:The intervention demonstrates that a multidisciplinary handover protocol can reduce transfer‑related risks and enhance family and staff experience during high‑risk transitions from the Operating Theatre-to-PICU.
BACKGROUND:Increasing cultural diversity in healthcare requires intensive care nurses to demonstrate cultural competence and sensitivity in order to provide care that respects the cultural values, beliefs and practices of patients and their relatives. AIMS:This study aimed to determine the levels of cultural competence and sensitivity among intensive care nurses and to examine the cultural care needs of patient relatives. STUDY DESIGN:This study employed a convergent parallel mixed-methods design integrating quantitative and qualitative research approaches. Quantitative data were collected using the Cultural Competence Scale and the Intercultural Sensitivity Scale administered to intensive care nurses. Qualitative data were obtained through semi-structured interviews conducted with patient relatives. RESULTS:In total, 215 intensive care nurses working in six different intensive care units and 30 patient relatives who had family members hospitalized in these units were included in the study. Nurses demonstrated relatively higher scores in the cultural knowledge and skills dimensions, whereas cultural sensitivity scores were comparatively lower. An increase in intercultural sensitivity scores was found to be associated with a parallel increase in cultural competence scores (r: 0.235; p = 0.001). Cultural competence accounted for a modest but statistically significant 6.5% increase in the explained variance in intercultural sensitivity and was independently associated with higher intercultural sensitivity scores (β = 0.265, p < 0.001). Six themes were identified based on the cultural needs and perceptions of care among patients' relatives: (1) culturally appropriate communication; (2) culturally patterned information needs; (3) participating in care with awareness; (4) culturally shaped boundaries of patient privacy; (5) culturally patterned expectations of attentive care; and (6) psychological support across cultural lenses. CONCLUSIONS:Integrated findings indicated that although nurses demonstrated relatively high levels of cultural competence and intercultural sensitivity, patient relatives emphasised respectful communication, attentive care and sensitivity to cultural values as key components of culturally sensitive care. RELEVANCE TO CLINICAL PRACTICE:Findings revealed unmet expectations regarding understandable information, participation in decision-making and care processes, privacy and attention to spiritual needs, suggesting a need for more individualised and participatory approaches in intensive care settings.
BACKGROUND:Alarm fatigue is a critical concern in intensive care units (ICUs), affecting nurse well-being and patient safety. It may reflect interacting conditions within the clinical work system, yet evidence on its severity and associated factors among ICU nurses remains fragmented. AIM:To synthesise evidence on alarm fatigue severity and associated factors among ICU nurses. STUDY DESIGN:Eleven databases were searched from inception to July 2025. Observational studies assessing alarm fatigue among ICU nurses using measurement tools with reported reliability were included. A random-effects meta-analysis was performed for alarm fatigue severity, stratified by instrument; associated factors and adverse outcomes were synthesised narratively using direction-of-association plots. RESULTS:A total of 28 studies involving 6908 ICU nurses were included, of which 27 reported alarm fatigue scores. For the Iranian Alarm Fatigue Questionnaire, the most common instrument, the pooled mean was 26.12 (95% CI: 23.94-28.30). Heterogeneity was extremely high (I2 ≈98%) and was not meaningfully explained by subgroup analyses or meta-regression. Directional evidence suggested that higher alarm fatigue was associated with a greater tendency towards medical errors and higher levels of burnout. Evidence on associated factors was mostly inconsistent or non-significant, with studies focusing mainly on person- and organisation-level factors. Poorer health, secondary traumatic stress, false alarms and lower trust in alarms tended to show adverse directional signals, whereas job satisfaction, resilience, alarm management support and a better nursing work environment showed potentially protective signals. CONCLUSIONS:Alarm fatigue among ICU nurses appeared to show a moderate tendency overall, although findings should be interpreted cautiously because of substantial heterogeneity. Evidence on associated factors remains scattered, with task-, technology- and environment-related factors comparatively underexplored. RELEVANCE TO CLINICAL PRACTICE:Alarm fatigue may be usefully considered from a clinical work-system perspective. Greater attention to task, technology and environmental factors may inform future practice improvement. REVIEW REGISTRATION: Prospero registration number: CRD42024565806.
BACKGROUND:Hyperglycaemia is common in critically ill patients and is associated with increased morbidity and mortality. Continuous intravenous insulin infusion is widely used for glycaemic control in intensive care units; however, its implementation is complex and requires frequent monitoring and substantial nursing involvement. AIMS:To describe reported practices in continuous intravenous insulin infusion management across Italian intensive care units and to explore variability in glycaemic targets, insulin initiation thresholds, glucose measurement methods and monitoring frequency according to healthcare setting. STUDY DESIGN:A national cross-sectional survey. A structured questionnaire was distributed to intensive care unit nurses and nurse coordinators in Italy between September and November 2025. Data were collected on institutional characteristics, insulin infusion protocols, glycaemic targets, initiation thresholds, glucose measurement methods and monitoring practices. Exploratory comparisons by healthcare setting used cross-tabulations and exact tests, as appropriate. RESULTS:A total of 128 valid responses were analysed. Standardised insulin infusion protocols were reported by 119 respondents (93.0%), but considerable variability was observed in reported practice. The most commonly reported insulin initiation threshold was 180 mg/dL (50.0%). Exploratory comparisons suggested differences across healthcare settings in initiation thresholds, glucose measurement methods and monitoring frequency before glycaemic stabilisation. The median reported monitoring interval before stabilisation was 120 min (interquartile range 60-240), exceeding the recommended hourly frequency during glycaemic instability. CONCLUSIONS:Despite widespread reported protocol availability, substantial variability remained in reported continuous intravenous insulin infusion management, particularly in initiation thresholds, glucose measurement methods and monitoring before glycaemic stabilisation. Because workload, staffing and protocol adherence were not directly measured, they should be considered possible explanations rather than study findings. RELEVANCE TO CLINICAL PRACTICE:The findings support review of local insulin infusion protocols, explicit monitoring intervals during glycaemic instability, staff education, audit and feedback and escalation processes when glucose checks are delayed.
BACKGROUND:The paediatric intensive care unit exposes critically ill children to non-physiological environmental stimuli, such as noise, artificial light and thermal instability, which may interfere with physiological regulation and circadian organization. AIM:To examine how environmental conditions in the paediatric intensive care unit (PICU), including noise, lighting and ambient temperature, affect cardiovascular, respiratory and thermoregulatory physiology in paediatric patients admitted after extracorporeal cardiac surgery. STUDY DESIGN:This prospective cohort study used continuous environmental monitoring and repeated physiological measurements in a tertiary-level paediatric intensive care unit. Environmental variables were recorded at 30-s intervals and aggregated to 15-min resolution to align with routinely collected physiological data. Associations between environmental exposures and heart rate, blood pressure, respiratory rate, oxygen saturation and rectal temperature were evaluated using generalized additive mixed models (GAMMs) incorporating cyclic terms to account for circadian variation and patient-level random effects. RESULTS:Twenty-seven paediatric patients aged 0-14 years were analysed. Environmental factors showed consistent non-linear associations with cardiovascular and respiratory parameters. Heart rate and respiratory rate were the most sensitive variables, particularly in relation to visible light exposure, whereas blood pressure, oxygen saturation and rectal temperature showed comparatively attenuated responses. Despite critical illness, several physiological outcomes continued to exhibit significant 24-h temporal variation throughout the observation period. Age influenced baseline physiology but did not substantially modify the direction of environmental associations. Noise levels consistently exceeded recommended thresholds and lighting patterns lacked a structured day-night cycle. CONCLUSIONS:PICU environmental conditions were associated with changes in key physiological systems in paediatrics following extracorporeal cardiac surgery and may contribute to altered temporal physiological organization. RELEVANCE TO CLINICAL PRACTICE:Environmental optimization strategies-particularly structured light-dark cycles and noise reduction warrant further investigation as potential nursing-led interventions to support physiological regulation and circadian organization in paediatric critical care.
BACKGROUND:Artificial intelligence-assisted early warning systems (AI-EWS) are increasingly integrated into critical care, yet little is known about how nurses experience automation bias and negotiate professional autonomy when algorithmic recommendations intersect with bedside judgement. AIM:To explore how critical care nurses experience automation bias and negotiate professional autonomy when using AI-EWS in intensive care. STUDY DESIGN:A qualitative Interpretive Description study was conducted across four hospitals in a regional health cluster in northern Saudi Arabia. Twenty-three purposively sampled critical care nurses with direct experience of a unified electronic health record-integrated AI-EWS participated in virtual semi-structured interviews. Data were analysed using Braun and Clarke's reflexive thematic analysis, and reporting followed the COREQ 32-item checklist. FINDINGS:Four interpretive themes were identified: reading the algorithm through a nursing lens; the architecture of trust and override; responsibility, risk and the weight of disagreement; and autonomy reshaped at the human-algorithm interface. Nurses viewed algorithmic outputs as useful but insufficient, requiring interpretation through bedside assessment and contextual clinical knowledge. Trust was actively calibrated through experience, while override was framed as an accountable exercise of professional judgement. A subset of participants described overriding alerts without formal documentation under workload pressure, highlighting a governance gap at the human-algorithm interface. Disagreement with the algorithm was experienced as professionally exposing yet shaped by relational and organisational conditions, and sustained AI engagement reshaped surveillance practice, clinical authority and professional identity. CONCLUSIONS:AI-EWS reorganise rather than replace nursing judgement. Safe integration depends not only on algorithmic performance but also on governance, training and interprofessional cultures that recognise and protect nurses' interpretive role at the bedside. RELEVANCE TO CLINICAL PRACTICE:Critical care services should establish non-punitive, low-burden pathways for documenting overrides, provide training on trust calibration and discordant alerts, and position nursing leadership centrally in AI governance, implementation and evaluation.
BACKGROUND:Moral resilience is defined as one's capacity to sustain or restore integrity in response to moral complexity, confusion, distress or setbacks. To maintain a healthy and lasting workforce within a system, it is essential to promote moral resilience among employees. AIM:The purpose of this study was to develop a valid and reliable scale to measure moral resilience among Iranian nurses. STUDY DESIGN:This study is part of a sequential, exploratory and mixed method research that was conducted between January 2021 and July 2024. Phase one of this study involved a directed content analysis to explain the concept of moral resilience among ICU nurses. The findings of this phase, which have been reported previously, were used to generate the initial pool of items for the ICU Nurses' Moral Resilience Scale (INMRS). To enrich the pool of items, statements were extracted from the literature review and existing scales. In phase two, the data from 550 nurses were gathered through both paper-based and online questionnaires using a convenience sampling technique. In this phase, the COSMIN checklist was used to evaluate the psychometric properties of INMRS. Consequently, face and content validity, construct validity (using exploratory and confirmatory factor analysis), convergent and divergent validity, reliability (including stability and internal consistency), responsiveness and interpretability of the scale were evaluated. RESULTS:The findings showed that the INMRS with 14 items contains three factors that explain 46.64% of the total variance. These factors include emotion management (3 items), continuous effort (8 items) and moral comfort (3 items). The fit indices indicated that the model has an acceptable goodness of fit (TLI, CFI, IFI > 0.9; PNFI, PCFI > 0.7; RMSEA < 0.057; CMIN/DF = 1.693). The reliability assessment also revealed acceptable internal consistency and stability (> 0.7). CONCLUSIONS:The study revealed that INMRS consists of three key factors that can be used to assess the moral resilience of Iranian nurses. Given the acceptable psychometric properties of INMRS, this scale is a suitable tool to assess moral resilience among ICU nurses. RELEVANCE TO CLINICAL PRACTICE:Nursing managers can utilize these findings to design training and support programmes aimed at enhancing the moral resilience of critical care nurses. Also, the INMRS is a reliable and valid scale for evaluating this concept in future studies.
BACKGROUND:To ensure the adequate nurse staffing levels and retain intensive care unit (ICU) nurses, it is important to understand the impact of nurse staffing policies on nurse outcomes during the COVID-19 pandemic. AIM:This study examined the impact of nurse staffing policies in ICUs on nurse outcomes before and during the COVID-19 pandemic. STUDY DESIGN:We conducted a secondary data analysis of a nationally representative sample of nurses working in ICUs. Data from the 2018 (before COVID-19) and 2022 (during COVID-19) National Sample Surveys of Registered Nurses (NSSRN) in the United States were used. The association between nurse staffing policies and nurse outcomes (job satisfaction, turnover and turnover due to burnout and inadequate staffing) in ICUs was examined using logistic regression analysis. A difference-in-differences analysis using the 2018 and 2022 NSSRN datasets was used to examine the longitudinal effects of the policy. RESULTS:In the state fixed effects model, the nurse staffing policy in ICUs was not significantly associated with the likelihood of job satisfaction. Meanwhile, nurse staffing policy was negatively and significantly associated with nurse turnover. Thus, the presence of a nurse staffing policy may decrease the likelihood of turnover during the COVID-19 pandemic compared to the absence of a nurse staffing policy (β = -0.12, p = 0.013). CONCLUSIONS:The nurse staffing policy in ICUs effectively reduced turnover during the COVID-19 pandemic. However, it was not significantly associated with job satisfaction, turnover due to burnout and turnover due to inadequate staffing. RELEVANCE TO CLINICAL PRACTICE:During the COVID-19 pandemic, nurse staffing policies could improve nurse retention in ICUs. To enhance nurses' job satisfaction and reduce burnout, further staffing policy development is necessary to improve the appropriate staffing levels among nurses.
BACKGROUND:Children exposed to armed violence and crisis-related paediatric intensive care unit (PICU) admission may experience psychological distress, yet many also show resilient recovery. Existing literature has often focused on post-traumatic stress symptoms and risk of poor outcomes, with less attention to how resilience is supported through family, clinical and community relationships. AIM:To explore and compare mothers' and PICU nurses' experiences of supporting children's psychological recovery following exposure to regional armed violence and to develop an empirically grounded model of resilience in crisis-affected paediatric intensive care contexts. STUDY DESIGN:A conventional qualitative content analysis study was conducted with 20 mothers and 15 PICU nurses recruited from a tertiary paediatric hospital and affiliated follow-up networks after a 12-day regional crisis. Semi-structured, in-depth interviews were audio-recorded, transcribed verbatim and analysed iteratively using MAXQDA software. Trustworthiness was supported through triangulation of mothers' and nurses' perspectives, member checking, prolonged engagement, reflexive memoing, peer review of coding and adherence to COREQ and SRQR reporting guidance. FINDINGS:Analysis generated the model Resilience as Negotiated Co-Regulation, comprising three interrelated domains: (1) intrafamilial negotiation, including relational emotion regulation, narrative reframing and child agency; (2) immediate clinical and social transactions, including caregiver mental health, support and monitoring practices and spiritual/narrative scaffolding; and (3) extended socio-cultural ecology, including school routines, community networks and future orientation. A cross-cutting theme showed differences and alignments between nurses' clinical focus on safety, symptom monitoring and referral, and mothers' emphasis on faith, family routines, patience, hope and return to ordinary life. CONCLUSIONS:Children's resilience after crisis-related PICU admission was experienced as a dynamic process shaped through child-caregiver co-regulation, nurse-family communication, culturally meaningful coping and community support. Interventions should strengthen caregiver capacity, support trauma-informed PICU communication, preserve child agency and integrate safe family, spiritual and community resources. RELEVANCE TO CLINICAL PRACTICE:PICU nurses can promote children's recovery by providing trauma-informed communication, coaching parents in emotional regulation and warning signs, involving children in developmentally appropriate choices and linking families with post-discharge psychosocial, school and community support. Culturally respectful care may improve trust, acceptability and continuity of recovery support.
BACKGROUND:Correct use of personal protective equipment (PPE) is essential for infection prevention in intensive care settings; however, deficiencies in donning and doffing techniques remain common among nurses. AIM:To compare the effects of mobile application (app)-based and printed educational materials on intensive care unit nurses' knowledge and skills related to PPE donning and doffing. STUDY DESIGN:This quasi-experimental study included nurses working in the anaesthesia intensive care unit of a university hospital in İzmir, Turkey. RESULTS:A total of 40 nurses participated in the study (printed material group, n = 20; mobile application group, n = 20). Both groups had high baseline knowledge scores (89.00 ± 10.65 vs. 96.33 ± 7.32). Mean PPE skill scores increased from 85.83 ± 6.81 to 97.50 ± 3.14 in the printed material group and from 84.79 ± 7.79 to 94.37 ± 5.61 in the mobile application group immediately after training, but decreased at Week 8 after training (85.62 ± 6.11 and 87.08 ± 6.18, respectively). UV-fluorescent simulation enabled visualization of contamination areas and increased awareness of contamination routes during PPE use. CONCLUSIONS:Both printed educational materials and mobile app-based education improved PPE donning and doffing performance in the short term. However, declining skill levels indicate that one-time training is insufficient to maintain PPE competence. RELEVANCE TO CLINICAL PRACTICE:PPE education in intensive care units should combine structured instruction, repeated practice and visual feedback. UV-fluorescent simulation may strengthen contamination awareness and support infection prevention training.
BACKGROUND:Hope among patients in intensive care units (ICU) supports a 'will to live' and recovery, yet it remains under-investigated. AIM:To explore ICU patients' experiences of trust in nurses and how they are linked to hope during and following ICU stays. STUDY DESIGN:A longitudinal narrative study guided by a constructivist paradigm, focusing on patients' meaning-making and interpretations of their lived experiences. Participants were three women and six men, aged 62-81, with life-threatening events and prolonged ICU stays. Each participant was interviewed upon discharge and again approximately 1 month later. Participants were recruited through snowball sampling. Inclusion criteria included prolonged ICU stays and willingness to participate. Data were analysed using reflexive thematic analysis. FINDINGS:Participants described both compassionate nursing care characterized by emotional presence and sustained efforts to relieve suffering and experiences of direct or indirect nurse aggression. Four states of trust were identified along a continuum ranging from trust to relying on personal agency and self-efficacy. Incidents of humiliation undermined dignity and weakened patients' capacity to trust. Hope emerged as a relational process closely associated with trust in nurses. Levi's profiles of hope were subsequently used as an interpretive framework for understanding variations in patients' experiences of hope. CONCLUSIONS:Trust is a relational process that unfolds within ICU nurse-patient interactions. Participants who described trusting relationships with nurses were more likely to report experiences consistent with hope during and following ICU hospitalization. Nurses play a central role in fostering trust and supporting hope during critical illness. RELEVANCE TO CLINICAL PRACTICE:The findings highlight the importance of nurse training targeting trust-building nursing practices to support hope among ICU patients. Attention to communication and emotional presence may strengthen therapeutic relationships, establish trust and inspire hope.
BACKGROUND:Severe pneumonia is a respiratory disease associated with high morbidity and mortality, often necessitating mechanical ventilation. However, prolonged mechanical ventilation is associated with an increased risk of complications and higher use of healthcare resources. The efficacy of a nursing checklist on airway management during mechanical ventilation in patients with severe pneumonia has not been extensively investigated. AIM:This study aimed to evaluate the effectiveness of a nursing checklist in improving airway management during mechanical ventilation for patients with severe pneumonia. STUDY DESIGN:A prospective, assessor-blind, single-centre, randomized controlled trial was conducted, and 100 patients diagnosed with severe pneumonia who required mechanical ventilation were enrolled in the study. Participants were randomly assigned to either the Nursing Checklist group (NC group) or the Routine Management group (RM group). The primary outcome measures included the duration of mechanical ventilation, length of stay in the intensive care unit, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, tidal volume (TV), respiratory rate (f) and the oxygenation index (the ratio of arterial oxygen partial pressure [PaO2] to fractional inspired oxygen [FiO2] or PaO2/FiO2). RESULTS:The duration of mechanical ventilation was significantly shorter among patients in the NC group compared to those in the RM group (p < 0.001), but the difference in length of stay in the intensive care unit (ICU) between the two groups was not statistically significant (p > 0.05). By Day 14, the APACHE II score in the NC group was significantly lower than that in the RM group (p < 0.001), and improvements in TV, f and PaO2/FiO2 in the NC group were also statistically significant compared to the RM group (p < 0.001). CONCLUSIONS:In this study, it was observed that the implementation of a nursing checklist was associated with significant improvements in the quality of airway care and patient outcomes during mechanical ventilation in patients with severe pneumonia, leading to a significant reduction in the duration of mechanical ventilation and improved oxygenation status and prognosis of patients. RELEVANCE TO CLINICAL PRACTICE:These findings provide valuable insights for future research and clinical practice, and it is recommended that the use of a nursing checklist be integrated into clinical practice to improve the quality and safety of airway management for patients with severe pneumonia on mechanical ventilation.
