Developing Environmental and Patient Safety Guidelines for Nurses in Critical Care Units

Eman Aly Abd Elhamid¹; Nehad Ezz Eldin Abdallah²; Safaa Mohamed Abd Elrahman³

¹ M.sc.Nursing Administration Faculty of Nursing-MInia University;

²Professor of Nursing Administration, Faculty of Nursing, Cairo University,

³ Professor of Nursing Administration, Faculty of nursing – Minia University

Discussion

Safety in healthcare has become a central focus of organizations, legislators, accreditation organizations, as well as individual patient care areas and clinicians.. In critical care unit gravely ill and injured patients are treated. Close monitoring, a highly techno- logical environment and the constant presence of nurses are required when treating patients with life-threatening conditions in order to ensure bodily functions. The highly technological environment and the numerous staff constantly present can result in a strenuous and complex environment. So, safety in health care remains a clear priority for health care providers and organizations (Gilmer et al., 2005)⁽¹⁰⁾.

In the current study, regarding the personal data of jury members it was noted that less than three quarter of them were female and more than half of them aged between 30-39 years old. Otherwise more than half of them have doctorate degree and had experience range from 11-15 years. Regarding the personal data of the nurses it was noted that the majority of nurses who worked in critical care unit aged from (20-30) years, more than two third of them were female, and more than one third of them worked in Minia University Hospital. Concerning the department, it was noted that about one quarter of nurses worked in coronary care unit. As regarded to resident physician, all of them aged less than 30 years, more than half of resident physicians were male, worked in Minia University Hospital, and one quartered work in Cardiothoracic University Hospital, and less than one quartered worked in intensive care unit

Safety guidelines for critical care units after extensive review of literature 

Kredo (2016) mentioned that development of clinical guidelines has greatly assisted in the delineation of good, evidence based practice. World Health Organization (2004) ⁽¹¹⁾ stated that Patient safety improvements demand a complex system-wide effort, involving a broad range of actions in performance improvement and environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice and safe environment of care. State of Victoria (2016)^(!2) added that keeping patients safe in hospital is making sure they get the right treatment, do not pick up infections, do not have falls, do not take the wrong medication and do not develop pressure sores.

Concerning to the first identified dimension of environmental and patient safety guidelines in the current study was the medication administration. Joshi (2012)) ⁽¹³⁾ stated that drugs are the most potent tools in the hands of clinicians for diagnosing the disease and affecting the cure. These medications can also be hazardous to the life of patients if administered incorrectly or negligibility. Ladak et al., (2007)⁽¹⁴⁾ added that a right drug of right quality administered in right dose, at the right time and in right manner may have a lifesaving effect on the patient. Adequate storage space is important for ensuring safety of drugs, and refrigerators are present for storage of cold and cool items. There should be a documented procedure describing medication administration.

In point out to the second dimension identified in the current study, Bedside nurse. Ibrahim (2018)⁽¹⁵⁾ stated that nurses' vigilance at the bedside is essential to their ability to ensure patient safety. There is link between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events, morbidity, and even mortality as the number of patients per nurse increases. Moreover nursing workload is likely linked to patient outcomes as well.

Regarding the third identified dimension related to environmental and patient safety guidelines was work environment. Ulrich et al.,( 2008)⁽¹⁶⁾ explored that the environment can influence patient safety directly or indirectly. For example, when an environment is designed to reduce the transmission of airborne and contact infectious agents, hospital-acquired infections plummet. In addition, Smith et al., (2009)⁽¹⁷⁾ added that the physical design of a setting could hinder communication and teamwork among care providers.

Regarding the fourth identified dimension related to environmental and patient safety guidelines was infection control. Tremblay (2017)⁽¹⁸⁾ stated that infection control occupies a unique position in the field of patient safety since it is universally relevant to health workers and patients at every single health-care encounter.  Further, the fifth dimension related to environmental and patient safety guidelines in critical care units was patient fall.  Preventing falls is difficult and complex (Dykes, 2010)⁽¹⁹⁾. Successful strategies include the use of a standardized assessment tool to identify fall and injury risk factors, assessing an individual patient’s risks that may not have been captured through the tool, and interventions tailored to an individual patient’s identified risks. (Joint Commission, 2015)⁽²⁰⁾.

Following, the sixth identified dimension related to environmental and patient safety guidelines was Personal Protective Equipment (PPE). Leiss (2014) ⁽²¹⁾ mentioned that PPE are the tools that ensure the basic health protection and safety of patients. Also the use PPE and safety medical devices is mandated for healthcare workers to reduce the risk of infection

Looking to the seventh identified dimension related to environmental and patient safety guidelines was the ventilation.  Cho (2019)⁽²²⁾ stated that airflow and ventilation are particularly important in healthcare premises. The air exchanges control the space temperature and humidity; assist the removal of waste anaesthetic gases; and dilute airborne bacterial contamination. The key is to provide movement of clean conditioned air in the area where the operation is to be performed, and where the sterile instrument and drapes are exposed. This can be achieved by means of a down flow of air from an air filter bank or diffuser over the sterile field of the operation. For different countries

In respect to the eighth identified dimension related to environmental and patient safety guidelines was the water. Walker and Moore (2016)⁽²³⁾ mentioned that the availability of hot and cold water supply systems are vital for public health. Healthcare premises are dependent upon water to maintain hygiene and a comfortable environment for patients and staff, and for treatment and diagnostic purposes. Interruptions in water supply can disrupt healthcare activities. The design of systems should ensure that sufficient reserve water storage is available to minimize the consequence of disruption, while at the same time ensuring an adequate turnover of water to prevent stagnation in storage vessels and distribution system.

In the light of the ninth identified dimension related to environmental and patient safety guideline was the equipment and furniture. Moyimane, Matlala, and Kekana (2017)⁽²⁴⁾ asserted that medical equipment is an essential health intervention tool used by nurses for prevention, diagnosis and treatment of disease and for rehabilitation of patients. However, access to functioning medical equipment is a challenge in low- and middle-income countries.

Regarding the tenth identified dimension related to environmental and patient safety guidelines was the handling and storage of materials, Thompson et al., (2012)⁽²⁵⁾ stated that The ICU design should provide adequate storage for all equipment, supplies, reference materials, and other items in current use, and plan for future needs. Storage is needed for personal items be-longing to staff, patients, and visitors. Equipment and supplies should be stored as close as possible to where they are used. Separate storage should be provided for equipment used with patients in isolation, and for clean and soiled supplies and equipment.

In light of the eleventh identified dimension related to environmental and patient safety guidelines was the maintenance. Hamdi, et al., (2012).⁽²⁶⁾ mentioned that medical equipment becomes increasingly more sophisticated and plays a more crucial role in modern healthcare, maintenance and management issues demand ever-increasing attention. Also Powdrill, Cordero, and Srinivasan, (2010)⁽²⁷⁾ added that the primary responsibility for the care and maintenance of equipment rests with the user. Therefore, user's maintenance of equipment improves patient safety.

In respect to the twelfth identified dimension related to environmental and patient safety guidelines were the doors and exits. Ayllón etal., (2014)⁽²⁸⁾ stated that safe, efficient patient care in critical hospital environments requires sliding, swing, and folding ICU doors. With traffic flowing through them 24 hours a day, damage is inevitable, from porters’ trolleys, beds, wheelchairs, staff and patients. Cracks, dents and tears in doors can harbour dirt and bacteria as well as compromising hygiene. As patient safety is of paramount importance, a damaged hospital doors and its frame has to be repaired or replaced as soon as possible.

Concerning the thirteenth identified dimension related to environmental and patient safety guidelines was the fire safety. Medical Facility Fires (2016)⁽²⁹⁾ agreed that hospital fires, and especially those in critical care units, affect patient safety, since most of the patients might be unable to escape because they are dependent on invasive monitoring and organ support. Holla et al., 2016⁽³⁰⁾ stated that all healthcare facilities must have a plan for the protection of all persons on their premises and for their evacuation from the building in case of fire. Written copies of this plan must be available to all supervisory personnel. All employees must periodically be trained and informed of their duties in implementing the plan.

Regarding the fourteenth identified dimension related to environmental and patient safety guidelines was the electrical safety. Reilly and Lee (2010)⁽³¹⁾ mentioned that electrical safety is very important in critical care units as patients may be undergoing a diagnostic or treatment procedure where the protective effect of dry skin is reduced. Also patients may be unconscious or anaesthetised and may not respond normally to an electric current. Further, electrically conductive solutions, such as and saline, are often present in patient treatment areas and may drip or spill on electrical equipment which can affect the patient safety.

In respect to the fifteenth identified dimension related to environmental and patient safety guidelines was waste disposal. Rasheed et al., (2005) ⁽³²⁾ mentioned that all individuals in critical care units are exposed to hazardous waste are potentially at risk. Waste management is crucial to promote high quality of healthcare and safe environment within hospital. Dixit, et al., (2017) ⁽³³⁾ mentioned thatplastic bags were used for many types of solid or semisolid infectious waste, bottles, flasks, or tanks can be used for liquid, use of packaging that maintains its integrity during storage and transport, closing the top of each bag by folding or tying as appropriate for the treatment or transport, placing liquid wastes in capped/ tightly stopped bottles, do not compact infectious wastes before treatment. 

Housekeepers identified as one of environmental and patient safety guidelines. It was the sixteenth dimension in current study. Mathur (2014) ⁽³⁴⁾ stated that housekeeper help make sure that hospital wards and other units are clean, safe and attractive places for patient care. The role of housekeeping is to create a peaceful, infection free and pleasant atmosphere required for the speedy recovery of the patients. A hospital has to be clean in order to prevent infection and provide quality service. Managerial staff, including head housekeepers, must communicate the importance of safety to each worker to promote the best possible environment for everybody.

Bed sores is the dimension that added by jury members as a dimension of environmental and patient safety guidelines. This was consistent with (González et al.,2017)⁽³⁵⁾ who mentioned that pressure ulcers constitute a health problem with significant impact on patient morbidity and mortality, and the quality of life of those affected and their families. Patients admitted to ICU are at particularly high risk of developing a bed sores.

The result of Validity and reliability of the proposed Environmental and Patient Safety Guidelines for Nurses in Critical Care Units

The psychometric properties of psychological test are related to the data that have been collected on the test to determine how well it measures the construct of interest (Salters, 2018) ⁽³⁶⁾.  In order to develop a good psychological test, the new test is subject to statistical analysis to ensure that it has good psychometric properties. There are two broad types of psychometric properties that a test must have in order to be considered a good measure of a particular construct: reliability and validity. In simple word psychometric properties refer to reliability and validity of the instrument (Alvior, 2013) ⁽³⁷⁾.

In the initial phase of the proposed, guidelines, the general opinionnaire with two scale of agree and disagree, and the proposed environmental and patient safety guidelines with two point scale of agree and disagree were formulated. The guidelines were sent by hand to the jury group including 8 members from medicine faculty – Minia University, 8 members from Nursing Faculty from Mina and Assuit University, 9 members of infection control supervisors in selected hospital, 2 nurse managers and 4 members worked as head nurses in critical care units.

The jury experts were requested to specify whether an item was necessary for operating a construct in a set of items or not be carefully reading the proposed guidelines and evaluating the content in terms of whether it appears to reflect the environmental and patient safety guidelines. They were also requested to assess the overall guidelines in terms of relevancy, clarity and simplicity criteria and to added their suggestion and recommendations. The first finding of the general opinionnaire recommended some suggestion about clarity of the proposed guidelines and adding one dimension to 16 dimensions.

The current result found that the "Administrating medication"   factor was the main factor of environmental and patient safety guidelines in critical care units explained with (53.81%) of the variance followed by " Bedside nurse" factor was explained with "7.36%" of variance, then the "work environment" factor explained  with "5.74%" of the variance. 

Alshammari (2016) ⁽³⁸⁾ mentioned that drug safety is one of the hottest topics in daily medical practice, All drugs have side effects, but the extent of their impact and severity varies from mild to severe However, the serious problem is that some of the drugs’ side effects are not previously known or have not been noticed, and the real risk here is whether they would exert a severe deleterious impact on the patients who are using them. AbdAlla (2017)⁽³⁹⁾ added that nurses are vital for patient safety and there is a focus of recent efforts on keeping patients safe can also be viewed as a public health problem and a human rights issue.

The next phase was the reliability one, the reliability estimated used in the current study was the internal consistency reliability guided by Crronach's Alpha coefficient to assess the consistency of the results across items within a test. In internal consistency reliability estimation, the proposed guidelines of environmental and patient safety in critical care units were administered to staff nurse and resident physicians to analyze its reliability.

Cronbach's alpha coefficient is the most frequently used statistic to show internal consistency reliability, especially by nurse researchers (Polit & Beck, 2004) ⁽⁴⁰⁾. Cronbach's alpha's reliability coefficient normally ranges between (0 and 1); however there is actually no lower limit to the coefficient. The closer Cronbach's alpha coefficient is to 1.0, the greater the internal consistency of the items in the scale. (Cronbach's, 1951)⁽⁴¹⁾. George and Mallery (2003)⁽⁴²⁾ provided the following rules of thumb for Cronbach's Alpha interpretation as : α 0f  ≥0.9 considered excellent, 0.9 > α  ≥ 0.8 is considered good, 0.8 > α  ≥ 0.7 is considered acceptable, , 0.7 > α  ≥ 0.6 is considered questionable, , 0.6 > α  ≥ 0.5 is considered poor,  and , α  ≤ 0.5 is considered unacceptable.

In the current study's finding, the Cronbach's alpha value of the revised scale was 0.991 the result revealed that the final guidelines constantly   assess what intended to measure as indicated by (Copper & Phillips, 2004)⁽⁴³⁾  where the reliability coefficients of the dimensions consider excellent ≥0.90.The current value was relatively more than  the reported by Assefa etal., (2012)⁽⁴⁴⁾ about Patient safety practices and medical errors, where, their alpha value for the overall tool was 0.70. 

On the other hand and due to the absolute correspondence of the tool, the indicators applied in a competent strategic analysis were: Goodness of Fit Index (GFI) and the Index of Corresponding Values and Approximate Error Expressed as in the Root mean Square Error of Approximation (RMSEA). In GFI, the higher value is the higher one with correspondence where the (GFI) value is between 0 to 1 and closeness to indicate a very good fit (Bartholomew & Tzamourani, 1999) ⁽⁴⁵⁾.

Accordingly in the current findings, the obtained value for the modified tool guidelines the modified guidelines was satisfactory [X2 (415) = 1287, P ˂ 0.01]. The (CFI) and (IFI) increase slightly, but (RMSEA) decreased to 0.04

RMSEA is an indicator based on an appreciative error that occurs due to the expected degree of freedom within the population. The lower the indicator is, the higher the correspondence is. Acceptable correspondence is under the value of 0.08, but some authors the value as even under 0.10( Sivo, et al., 2006)⁽⁴⁶⁾. In the current study the modified tool had value of (0.04) which according to (Siva, et al., 2006)⁽⁴⁶⁾ was considered as an indicator of good correspondence.

After application of all needed statistical test and further modifications, the finalized guidelines was sent again to the jury members to read it, evaluate the content in terms of whether it appear to reflect the guideline of environmental and patient safety and assess the overall guidelines in terms of relevance, clarity, and simplicity criteria using two point scale of agree and disagree. The finding of finalized tool's percentage of agreement / disagreement were supported by most of jury members' agreement as the most of jury staff agreed with all items of environmental and patient safety guidelines in the final phase.

Conclusion:

Overall, the current study concluded that the validity and the reliability of the developed guidelines were satisfactory. The guidelines were developed in response to a need for environmental and patient safety in critical care units.

Recommendations:

• Use the developed environmental and patient safety guidelines in different critical care units in the selected hospitals.
• Establish a safety committee to facilitate the application of environmental and patient safety committee.
• Ensuring that the organization’s annual budget includes adequate resources to implement and evaluate health and safety activities.
• Ensuring the implementation of accident/injury reporting system in order to analyze the causes and set a plan for improvement.