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ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION

ICU Nurses Beliefs and Values Towards an Innovative ICU Risk Assessment Application

Jane Foley

Doctor of Nursing Practice

Simmons College

School of Nursing and Health Sciences

Boston, Massachusetts

@ 2018 Jane Foley

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION ii

Simmons College

Doctor of Nursing Practice Program

Capstone Manuscript Approval Form

Name: Jane Foley

Title of Project: ICU Nurse Beliefs and Values Toward an Innovative Risk Assessment

Application

Date: April 27, 2018

___x_____Capstone Manuscript is approved

_________Capstone Manuscript is approved with the following revisions:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

________Capstone Manuscript is not approved

Committee Signatures:

____________________________________________________________________________

Patricia Reid Ponte RN, DNSc, FAAN, NEA-BC

______________________________________________________________________________

Patricia Folcarelli, RN, PhD

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION iii

Abstract

The aim of this study was to explore the Intensive Care Unit (ICU) Resource Nurses’ beliefs and values regarding an innovative on-line risk assessment tool, ICU Intensity Index (I3), at Beth Israel Deaconess Medical Center (BIDMC). The I3 is an IT application that predicts the risk of a patient harm occurring in the ICU. With the support from the Gordon and Betty Moore Foundation the I3 application was developed in collaboration with ICU leaders at BIDMC and system engineers. A retrospective analysis of environmental factors, such as patient admission, transfers, and discharges within the ICU; staff factors, including level of nursing experience, and patient factors such as the Sequential Organ Failure Assessment Score (SOFA) and nursing intensity as measures of patient acuity, were used to understand the impact they collectively have on actual patient harms. Assessing the intensity of the ICU environment, and how it relates to the likelihood of patient harm as a way to describe risk state of the unit, is a fundamentally different approach that has potential to improve patient safety. The successful adoption and implementation of the I3 application has the potential to change how ICU nurses and physicians assess intensity and subsequent risk in the ICU. Additionally, this application has the potential to change how ICU workflow and resources are deployed. (Stevens, 2017) The ICU Resource Nurses are key stakeholders in the ICU environment and their beliefs and values towards an innovative risk assessment tool will inform the development of the implementation and dissemination plan for the I3.

Method:

Two semi structured focus group interviews were conducted with the ICU Resources Nurses. Twelve of the seventeen ICU resource nurses participated. Using open ended questions, the focus groups were designed to answer the research question “what are the ICU resource nurses’ beliefs and attitudes towards using an electronic tool to assess overall risk in the ICU environment”. The participants were given the opportunity to reflect and respond on how the functionality of the I3 application would influence their decisions in the allocation of nursing resources; the impact the tool would have on nursing workflow; and how could the tool inform strategies to mitigate the risk of patient harm. A Qualitative Analysis of the focus group transcripts was conducted.

Results:

The main thematic finding was the nurses’ descriptions of skepticism. This was reflected by expressed lack of trust in the accuracy of the tool’s ability to in capture the full range of factors that represented risk to a patient, as well as in statements of concern that the tool would result in loss of control/autonomy in staffing decisions currently made by the Resource Nurses. Additionally, there were concerns expressed related to the changing landscape of critical care and general initiative overload. Qualitative data may not be widely generalizable, but this study suggested a lack of readiness by frontline ICU Resource Nurses at BIDMC to adopt the use of an innovative risk assessment tool; and a preference to rely on their clinical experience and nursing intuition for decision making. Findings from this study may be of importance in the future planning and design of innovation and quality improvement initiatives in an ICU at an academic medical center.

Keywords: innovative technology, nurses’ intuition, ICU environment, implementing change

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION iv

Acknowledgments

I first would like to acknowledge and thank Patricia Reid Ponte, RN, DNSc, FAAN, NEA -

BC, and Patricia Folcarelli, RN, PhD, for serving as my Capstone Committee members. It was

their wisdom, support, and encouragement that served as my beacon along the way in this

journey. I feel fortunate that I have had the opportunity to work so closely with both these

nursing leaders who I have come to admire as scholars, and whose work has advanced quality

and safety in the health care industry.

Without the genuine interest of Jennifer Stevens MD, the Director for the Center for

Healthcare Delivery Science at Beth Israel Deaconess Medical Center, who understood the

importance of the nursing voice in implementing sustainable change, the results of this study

may not have had the impact that they did in our Intensive Care Units at Beth Israel Deaconess

Medical Center. In addition I would like to thank Carla Pollack, Anna Johannson PhD, and

Susan Desanto-Madeya PhD, whose wisdom and support was invaluable in bringing this study to

fruition.

I would be remised if I did not also recognize and thank the incredible group of ICU Resource

Nurses at Beth Israel Deaconess Medical Center who participated in focus groups. They shared

their extraordinary knowledge and I thank them for the care and compassion they provide to their

patient every day, I am humbled and proud to call them colleagues.

And finally to Marsha Maurer, Chief Nursing Officer at Beth Israel Deaconess Medical

Center, for having a vision of nursing excellence at BIDMC that supports this amazing

opportunity that I have had to receive a Doctrine of Nursing Practice from Simmons College.

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION v

Table of Contents

Capstone Manuscript Approval Form…………………………………………………………….ii

Abstract…………………………………………………………………………………………...iii

Acknowledgements……………………………………………………………………………….iv

Table of Contents……………………………………………………………………………….…v

CHAPTER 1

Introduction and Background…………………………………………………………………….1

Purpose of Study and Research Question……………………………………………………..…10

Significance of Study…………………………………………………………………………….11

CHAPTER 2

Literature Review………………………………………………………………….……………..12

CHAPTER 3

Theoretical Model………………………………………………………………………………..16

Method and Design………………………………………………………………………………17

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION vi

Study Participants……………………………………………………………………….....…….18

Setting……………………………………………………………………………………………18

Source of Collection Data…………………………………………………………….………….19

Data Processing and Analysis……………………………………………………………………20

Ethical Considerations…………………………………………………………………………...21

Plan for Dissemination……………………………………………………………..….…………21

CHAPTER 4

Findings………………………………………………………………………………………….23

Introduction………………………………………………………………………………………23

Theme One: “Lack of trust and accuracy of the I3 tool” …………………………………..........26

Theme Two: “Clinical experience and intuition is more reliable”………………….…………...27

Theme Three: “Loss of control/autonomy”………………………………………….……..……28

Theme Four: “Changing landscape of critical care environment”………………………….……30

Theme Five: “Risk is accepted as normal”………………………………………………………31

Chapter Summary……………………………………………………………………………..…33

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION vii

Chapter 5

Discussion and Implications……………………………………………………………………..34

Study Limitations………………………………………………………………………………...40

TABLES

Table 1: Focus Group Demographics…........................................................................................41

Table 2: Harms/ Definition…........................................................................................................42

Table 3: Environmental Drivers….................................................................................................43

APPENDIX

APPENDIX A: Intensive Care Intensity Index Dashboard…......................................................44

APPENDIX B: Rogers Innovation Bell Curve………………………………………………….45

APPENDIX C: Rogers Diffusion of Innovation…………………………………………………46

APPENDIX D: Focus Group Discussion Guideline……………………………………………..47

APPENDIX E: Focus Group Demographic Form…………………………………….………....49

APPENDIX F: Participants Study Information Summary…………………………………...….50

APPENDIX G: Focus Group Categories / Notable Quotes……………………………………..52

APPENDIX H: Focus Group Themes and Definitions……………………………………….…55

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION viii

APPENDIX I: Institutional Board Review Certification…………………………………….…..57

REFERENCES………………………………………………………………………………….59

ICU NURSES BELIEFS AND VALUES TOWARD AN INNOVATIVE RISK ASSESSMENT APPLICATION 1

CHAPTER ONE

Introduction and Background

Patient safety moved to the forefront in health care with the release in 1999 of the Institute of

Medicine (IOM) landmark report, To Err is Human which estimated that annually in the United

States up to one million people were injured, and 98,000 died as a result of medical error (Kohn,

2000). The IOM report caught the attention of not only the health care community, but also of

the general public and the media. Accordingly, many organizations, including the federal

government, began to focus on defining what a medical error is, and then on developing

supporting systems and practices to prevent patient harm. In 2001 the IOM published Crossing

the Quality Chasm further detailing the changes needed to ensure patient safety as well as

looking at other quality issues (Ulrich, 2014). Following the Quality Chasm publication

clinicians began evaluating their practices; researchers initiated evaluations of practice changes

and health care organizations began to focus efforts on patient safety (Ulrich, 2014). The IOM

published another landmark report in 2004, Keeping Patients Safe: Transforming the Work

Environment of Nurses, which recognized the value of nurses and the impact of the care

environment, and discussed how the design of nursing work environments influenced safe

patient care. All three of these reports from the IOM have contributed to the transformation of

the healthcare systems and have resulted in a focus on how the environments in which clinicians

work can influence outcomes.

The 1999 IOM report To Err Is Human: Building a Safer Health System, encouraged the use

of incident reporting systems, maintaining that hospitals can address patient safety problem only

if events are identified and adequately described by caregivers (Levinson, 2012). Despite


widespread computerization, underreporting of medical errors by nurse and other medical staff

persists (Lederman, 2013). Studies in the United States and the United Kingdom illustrate that

underreporting of adverse events may be as high as 96% and that even in hospitals that use

electronic incident reporting systems; they likely capture only 10% of errors (Richter, 2015).

Hession-Laband et.al. (Hession-Laband, 2011) also found from a web-based survey sent to 675

nurses at Boston Children’s Hospital, that 68% of nurse reported that they had filed less than 5

incident reports in a 4-year period which suggested underreporting (Hession-Laband, 2011).

Lucian Leape (Leape L., 2002) in his landmark work on patient safety discussed the importance

of reporting for the monitoring progress in the prevention of errors (Leape L. , 2002). Leape

(Leape L. , 2002) also cited the reasons for the lack of reporting including: the voluntary nature

of reporting; lack of agreement on a standardized definition of a reportable event; perceived lack

of benefit; apathy; lack of feedback; time constraints; and unfamiliarity with the process (Leape

L. , 2002). More current research has shown similar findings linking a number of factors to

underreporting of medical errors such as: fear of repercussion; belief that error reporting will not

lead to safety improvements; lack of confidentiality and legal concerns (Zaheer, 2015). Despite

the best efforts of hospital leaders, underreporting of errors continues to be a significant problem.

Medical errors continue to influence levels of morbidity and mortality. In a study by Richter et

al. (Richter, 2015) found that hospital error reporting can be influenced by non-punitive error

feedback; leadership that demonstrates safety is a priority; and an environment that inspires

organizational learning (Richter, 2015).

Regardless of the many improvements in safety processes and clinical systems design, errors

occur more frequently in the intensive care unit (ICU) than other areas of the hospital due to the

acuity of illness and the frequency and complexity of interventions (Pronovost, 2003). Studies


have found that in a medical – surgical ICU there will be 1.7 errors per patient per day and

extrapolation of these results to all ICUs in the United States suggests approximately 85,000

errors a day, of which 24,650 are potentially life –threatening (Wu, 2002).

The Beth Israel Deaconess Medical Center (BIDMC) has been attentive to health care quality

and safety in its ICUs. The BIDMC ICU’s include 7 specialty units totaling 77 beds. In January

2014, BIDMC launched a project, funded by the Gordon and Betty Moore Foundation, which

focused on eliminating preventable harm in the ICU. The Gordon and Betty Moore Foundation

is a private philanthropic organization established by Intel co –founder Gordon and his wife

Betty to “create positive change for future generations.” BIDMC’s project, “Optimizing ICU

Safety through Patient Engagement, System Science and Information Technology”, proposed a

body of work aimed at reducing the burden of harm in the ICU by leveraging patient-family

engagement, enhanced workflow management, information technology (IT), and system science

(Moore Foundation, 2017). A part of the Moore Foundation body of work was the development

of the ICU Intensity Index (I3), a tool that measures the overall risk of patient harm in the ICU or

in other words identifies “risky states”. Such high risk conditions or “risky states” can be

defined as situations that occur when a combination of environmental, clinical, and staffing

conditions put the entire clinical care setting at increased risk for patient harm. (Stevens, 2017)

The I3 application was developed in collaboration with system engineers who analyzed

retrospective data elements representing components of the environment, staff, and patient

factors within the ICU’s at BIDMC that could potentially create conditions that would contribute

to increased risk of actual patient harms. The data used in this analysis included both those harms

that were submitted voluntarily by ICU staff in the patient safety reporting system as well as

those harms not reported but evident in a standardized review of the documentation in the

http://www.moore.org/programs/patient-care/learn-more-about-the-patient-care-program


electronic medical record. (Ma, 2008) The analyses of these data from the BIDMC ICUs lead to

the development of the I3 application. The harms that were considered in the analyses are listed

below in table 2.

Table 2

Harm Definition

Arrest Cardiac Arrest or Code Blue

Code Purple Shifts on which hospital police was dispatched to the unit

Fall A patient falls, or nearly falls in the ICU

Hemoglobin A shift with an abrupt drop in hematocrit greater than 4 within 24 hours, given it happens after 2 hours of admission to the ward

Identification Errors or near misses in which the wrong patient was given an intervention

Lab Errors or near misses related to lost, misunderstood, or preprocessed lab procedures

Medication Errors or near misses related to wrong dose, or wrong medication

Safety Errors or near misses related to safety disturbances in the unit

(Traina A, 2015)

In the analyses of these data it was found that 38% of ICU shifts were classified as low risk

for harm states; and 13 % of shifts in the ICU were classified as significantly high risk for harm

states. (Traina A, 2015) Additionally, the study drew four major conclusions regarding

environmental conditions in the ICU that influenced the risk for patient harm:

1. The root indicator for most elevated risk states was nursing workload as measured by the

modified Nursing Intensity Score (TISS). Levels of nursing workload that are even

slightly above the mean are a precursor to higher risk states.


2. Groups of newly hired nurses, in combination with elevated workload as reflected on the

TISS, were strongly associated with elevated risk.

3. When multiple risks factors were high, so were the risks for harm.

4. Shifts with low average workloads as measured by the TISS were relatively safe (i.e. had

lower risk for patient harm) and remained low risk even when perturbed by a single

environmental factor that stressed the system. (Traina A, 2015)

It was also found that the patient Sequential Organ Failure Assessment (SOFA) acuity score,

had less impact in some units, and in some circumstances had no impact on the unit risk level.

(Hu Y, 2017) In general, the day shifts had a higher harm rate than night shifts. This made

sense as there are more activities occurring during the day shifts adding complexity to the unit,

as compared to the night shift. (Hu Y, 2017) The environmental factors that were shown to

influence the overall risky state of the unit are characterized below in table 3.

Table 3

Environmental Category Driver

Acuity Patient SOFA (sequential organ failure assessment) scorePatients first 24 hours in the unitLength of stay in the ICU

Unfamiliarity Float Nurse assigned to the unitNovice NurseBoarding patient in ICU (i.e. medical pt in Coronary Care Unit)

Utilization Nurses Workload (TISS 28 acuity tool)Nurse to patient ratioAdmissions activity during a shiftDischarge activity during a shift

Others EU critical (unidentified patient)Night Shift/ Day ShiftWeekendUnit

(Hu Y, 2017)


The ICU environment changes quickly and frequently and individual patient acuity is

generally what is monitored to reflect the changing environment. The reality is that there are

many uncaptured critical events that happen on a regular basis in the ICU. Consider a scenario

where there are multiple critically ill patients, undergoing life threating procedures at the

bedside, simultaneously. At the same time, the nursing skill mix of a particular unit may not be

optimal as unavoidable scheduling issues have left the unit staffed with a disproportioned

number of novices to experienced nurse. Compounding this situation is an additional staffing

dilemma resulting in a float nurse being assigned to the unit and while they are competent in

basic critical care skills, they do not work regularly in the assigned specialty unit. Currently

these constellations of events are highly probable and happen regularly in an ICU, yet the ability

to anticipate and respond to these circumstances is inconsistent due to a lack of credible data.

The I3 application uses environmental, clinical, and staffing drivers to signal that a unit is at risk

for a patient to experience an adverse event or preventable harm. The patient harm data that was

used to build the tool was taken from two years of voluntary patient safety reports, as well as by

looking at patient outcomes in the medical record. For example; a sudden unexpected drop in

hematocrit which may be an indication of unrecognized blood loss or an untoward reaction to a

medication.

The leading environmental factors that were associated with real harm events in the ICU at

BIDMC included: the composition of nurse staffing as it relates to years of experience; the

patient flow in the unit which can be described as the churn, (admissions, discharges, transfers);

and nursing workload as measured by the modified Therapeutic Intervention Scoring System 28

(TISS 28). The TISS 28 is a tool that indirectly classifies the intensity of the nursing

interventions in relationship of severity of illness of patients in ICUs. (Urbanetto, 2014) The


data indicated that these factors collectively have a relationship with a patient safety event

occurring on the unit. The I3 models the environmental factors and is able to predict if the unit is

at a low, medium, or high risk for a patient event to happen. The output of the I3 is displayed on

a dashboard which indicates which drivers are the contributors to the current state of intensity on

the unit. (Appendix A)

The I3 tool is designed to signal that there is a risk for harm in the unit based on the real time

data. The unique feature of the tool is that it is not patient specific; it signals that there are

drivers in the environment (Table 3), that puts the unit at risk for a patient event or a preventable

harm (Table 2). Assessing patient harm at the unit level, as opposed to the individual patient

level, is a fundamental paradigm shift in how ICU nurses and physicians assess for patient safety

(Stevens, 2017). Stevens (Stevens, 2017) also suggested that targeting units that are in risky

states rather than individual harms opens up the powerful possibility of implementing single,

system level intervention to reduce the overall burden of harm. As an example, strategic

decisions such as which unit the next ICU patient will be admitted to, or staffing decisions made

by the ICU Resource Nurses. The retrospective analyses of two years of data from the I3 study

indicated that there are patient level, unit level, and staffing characteristics that when combined

resulted in shifts with a rate of 2.9 preventable harms per shift; while other shifts, dependent on

these contributing factors, had harm rates closer to 0.4 harms per shift on average (Stevens JP et

al., 2017). The I3 dashboard was developed with inputs from clinical data and staffing

information systems and displays the intensity of each of the seven ICUs in real time. (Appendix

A)

While there are studies that look at specific patient harms in the ICU, there are no studies in

the literature that prospectively looked at patient harm considering the overall intensity of the


ICU environment. Patient specific voluntary reporting is the most frequently used tool to identify

adverse events and errors for nursing and despite this, as noted earlier, voluntary reporting is

underutilized. It is estimated that 50% to 96% of errors are underreported. (Barach, 2000) .

The ICU Resource Nurse role at BIDMC is a nursing leadership position that has direct

influence over front line staff. The Resource Nurse role supports the Director of Nursing and

functions as a middle manager. The responsibilities of the ICU Resource Nurse include the

daily operations of their unit, as well as decisions related to the allocation of appropriate staffing,

and coordination of patient care assignments. As mandated by the Commonwealth of

Massachusetts ICU Staffing Law (Massachusetts General Laws, chapter 155,section 231, 2017)

BIDMC has implemented a modified Therapeutic Intervention Scoring System 28 (TISS 28) as a

patient acuity tool which may be used as a guide for nurse patient assignments in the ICU.

The TISS 28 is a tool that indirectly classifies the intensity of the nursing interventions for the

patient (Urbanetto, 2014). TISS was designed to classify nursing workload in relation to the

severity of illness of patients in ICUs; however the relationship between severity of illness and

the use of nursing time is known to be not perfectly linear. Time motion studies to evaluate the

TISS found that the TISS -28 explained only 43% of nursing time across all patient severity

levels. (Miranda, 2003) In general, acuity tools are imperfect tools for providing a true

assessment of the workload intensity of the unit; or of the nursing resources that are needed in

the ICU on any shift. Acuity tools that are based on time/motion studies do not consider holistic

patient care (Harper, 2007). In addition, time/motion studies do not consider (a) transfers,

admissions, or discharges; (b) interruptions in work fluency; (c) family dynamics; and (d)

ethical, social or psychologic factors. (Harper, 2007) Therefore, in current state, the ICU


Resource Nurse must also rely on their best clinical judgement and experience to determine

appropriate nursing resources.

Since the publications of IOM reports from 1999-2006, there has been considerable literature

published on patient safety with a focus on human error, system designs, and health care

environments. Aiken et al. have published research on the impact that nurse staffing and work

environments have on patient mortality and failure to rescue. There are detectable differences in

risk-adjusted mortality and failure to rescue rates across hospitals with different registered nurse

staffing ratios (Aiken, 2002). Furthermore results of Aiken et al. studies (Aiken, 2002)

demonstrated that there is an association between nurse staffing levels, and the rescue of

patients with life-threatening conditions, suggesting that nurses contribute importantly to

surveillance, early detection, and timely interventions that save lives (Aiken, 2002). Consistent

with Aiken’s findings that nurses play a key role in the surveillance of early detection of harm,

the successful adoption and implementation of the I3 application has the potential to be a

valuable tool that ICU Resource Nurses can utilize in the assessment of unit risk in the ICU. In

addition, the adoption of the I3 risk assessment tool has the ability to fundamentally change how

critical care workflow and resources are deployed.


Purpose of Study and Research Question

The aim of this study was to explore the ICU Resource Nurses beliefs and values regarding

the I3 tool as an innovative risk assessment application throughout all seven ICUs at BIDMC.

The findings will inform the development of the implementation phase of the I3 applications.

As described previously the I3 is an innovative risk assessment tool that predicts a risky state for

patient harm at the unit level. This fundamentally different approach to the assessment of unit

intensity and subsequent risk for patient harm will require a paradigm shift in how ICU nurses

and physicians currently think about patient safety (Stevens, 2017). Patients in an ICU are on

multiple patient monitoring devices that provide continuous auditory and visual output about the

patient’s physiological status. For this reason, ICU nurses are constantly aware of the

information these devices are delivering at the patient level, but often are unaware of the overall

risk, or of other warning signals that exist or are emerging in the environment. Being able to

predict when an ICU is approaching a risky state has the potential to allow Resource Nurses to

plan and implement mitigation strategies.

Research Question: What are the ICU Resources Nurses’ beliefs and values towards the

Intensive Care Intensity Index (I3) application as an innovative risk assessment application?

It was important to understand what the Resource Nurses perceive as barriers to the

implementation of the I3 as a tool to mitigate risk and patient harm in the ICU. Similarly, the

focus group guidelines (Appendix D) were developed to determine if the I3 provided data that

would be valuable in managing ICU resources, altering clinical workflow, and enhance

situational awareness among staff.


Significance of the Study

There is often a persistent and troubling gap between the inherent value of new technology

and the ability to have it work effectively. (Barton-Leonard D, 2017) Frequently those who are

responsible to shepherd new technical innovation into routine use are not those who are best

equipped to guide the process. Accordingly, adoption of technological solutions capable of

supporting nursing practice, that could potentially improve care delivery and patient safety and

outcomes, requires early contribution and buy –in from nurse end-users. (Kent, 2015) Nursing

managers are often left with distinctive challenges in introducing technology if the frontline staff

do not perceive a value, or understand the utility of new technology. Identifying individuals, or

groups whose acceptance is essential to an innovation’s success is an important strategy in the

process. The ICU Resource Nurses are experienced clinical nurses who have the responsibility

of the day to day operation of the ICU. As influential leaders in their respected units the ICU

Resource Nurses are key stakeholders who can affect the success or failure of the I3 project.

Equally important to adoption of new technology is managing the risk of failure of a new system

by assuring that key stakeholders are on board and believe in the utility of the technology.

The ICU Resource Nurses belief and values in an innovative risk assessment tool for the ICU

will inform the implementation phase of the I3 application. Prior to any innovation taking place

it is important to identify people most affected by the change since fundamental to creating a

change culture, is getting the commitment and involvement of the stakeholders and using their

energy and expertise to generate and sustain the change. (Glenn L, 2010) The ICU Resource

Nurses influence the community culture in the ICU, and given the complexity of the ICU

environment, having input from those who are close to the work is valuable and essential in the

planning phase of innovation and change.


CHAPTER TWO

Literature Review

The literature suggests that middle managers influence innovation implementation by

bridging informational gaps between top managers and frontline employees that might otherwise

impede innovation implementation (Birken S. L., 2012). The Resource Nurses at BIDMC

function in a middle manager role and have direct influence on the culture, and staff in the ICUs.

Such boundary spanning positions allows middle managers to influence their superiors in top

management, as well as frontline employees, and positively impact organizational outcomes such

as effectiveness, competitive position, efficiency, and financial performance (Birken S. L.,

2012). The Resource Nurses at BIDMC are positioned to be transformational leaders with the

ability to bring about sustainable and long-standing change. Readiness for change is perhaps the

most difficult goal to achieve but is essential for successful quality and safety transformation.

The foundation of readiness is willingness to learn, trusting, and a perception of a fair transparent

process where ideas are considered ( Sherwood, 2012).

The literature describes different ways to lead change. Waldersee et al (Waldersee, 2004)

highlighted that in technical and structural change unilateral top to down methods are more

successful, in contrast to behavioral and social change where shared methods with participation

are more promising (Waldersee, 2004). Changing how ICU nurses assess patient risk and the

behaviors that are then adopted to mitigate that risk will depend on a transformational change. It

may be that current methods of assessing risk will be augmented by the I3 application that has

the potential to enhance current methods. For example, ICU Resource Nurses currently plan

staffing based on a twice daily meeting where the decisions are made based on the judgement of


the Resource Nurses with informal inputs from the ICU staff. This informal decision making

may be positively influenced with objective data on the real time intensity of the units.

Implementation of complex innovation in health care is challenging, yet necessary for health

systems to meet the dual challenges of cost containment and effective and safe patient care

(Woiceshyn, 2017). Testing is about learning if the change will result in an improvement and

implementation is about how to make the change an integral part of the system (Langley, 2009).

Implementing even seemingly simple health care innovations has proven to be challenging. The

rate of successfully implemented quality improvement initiatives or innovations is less than 50%

(Alexander, 2008).

The testing phase of the I3 application has been completed, and the next phase of the project

was to plan the implementation strategy. If implementation did not involve people then the

physical, emotional, and logical, challenges that hinder most planned changes might not be an

issue (Langley, 2009). Langley et al (Langley, 2009) further outlined important considerations

when implementing complex changes effectively: (1) managing implementation as a series of

cycles, (2) providing support during and after the implementation to ensure that improvement is

achieved and maintained (3) recognizing and addressing the social aspects of implementing a

change (Langley, 2009). Change often happens in an ad hoc and unplanned way. Balogun et al.

(Balogun, 2008) reported a failure rate of around 70% of all change programs initiated because

of the current tendency of change management to be reactive (Balogun, 2008). Edward Deming,

one of the founders and chief proponents of the total quality movement, asserted that effective

management must be built upon respect and trust in human nature (Braughton, 1999). Deming’s

theory maintained that workers are intrinsically motivated to cooperate, to contribute, and to

succeed within an environment in which they were valued and empowered to do their best.


Furthermore Deming asserted that leaders within the organization support the empowerment of

their employees by providing training and knowledge that allowed workers to be involved in

problem solving. (Braughton, 1999) Armenakis et al. summarized how the perceptions of

individuals in organizations was shaped by the change message; the change strategies; and

dependent variables like the quality of information (Armenakis, 1999).

Lee (Lee, 2005) in a descriptive study with 15 nurses participating in one to one interviews

found that educational programs should be provided, and strategic planning should be done in

the early stage of implementing a policy to adopt new technology. Woiceshyn et al. (Woiceshyn,

2017) also reported from a qualitative comparative case study on the implementation process in

acute health care, that upfront planning and allowance for local customization within the general

principles of standardization was required (Woiceshyn, 2017). Chow et al. (Chow, 2011)

conducted a random sampling of 342 nurses working in a private hospital with a questionnaire

intended to assess perceptions, and attitudes towards hospital information systems. The authors

found that an effective collaboration with the information technology team would enhance a

more efficient exchange of information to understand the complex factors of IT implementation

(Chow, 2011). Birken et.al (Birken S. D., 2016) in a study of 154 nurse managers at the

Cleveland Clinic’s 2014 Nursing Innovation Summit, distributed a self-administered

questionnaire and found that diffusing and synthesizing information was the most important

influence on implementing healthcare innovations (Birken S. D., 2016). Other studies (Kent,

2015), (Brewster, 2013) used qualitative methods of focus groups and mixed method study

review and found that early involvement of nursing staff to understand the potential capabilities

and benefits of novel technology enabled acceptance and adoption (Kent, 2015). Additionally,


it was reported that lack of acceptance of novel technology is a key barrier to successful

implementation (Brewster, 2013).

Throughout the literature it is noted that thoughtful planning and the awareness of key

stakeholder beliefs and values is important for the successful implementation of innovative

technology. The ICU Resource Nurses are key stakeholders, and influential leaders in the ICU.

The literature shows that successful implementation of technology requires buy in from key

stakeholders who are involved early on in the process. Therefore, appreciating the ICU

Resource Nurses beliefs and values toward the I3 as an innovative risk assessment tool, will be

paramount to the successful implementation of the I3 application.

Data Sources: Medline, CINAHL, PubMed, Google Scholar

Search Terms: patient safety, patient harm, innovation, implementation, technology,


CHAPTER THREE

Theoretical Model

Rogers Diffusion of Innovations (DOI) was first described in 1962 and characterizes people

based on their likelihood to adopt technology and categorizes organizations based on their stage

of adoption of a new technology. (Doyle G, 2013) Rogers suggested that there are five types of

adopters based on their relative likelihood to try out new things including: innovators; early

adopters; early majority, late majority; and lagers. (Rogers E, 2003) One of the best-known

components of DOI is its normally distributed adoption curve, and its separation of people into

early innovators and late adopters. (Hornik, 2004) (Appendix B &C) Several authors cite

Rogers’ DOI as a useful framework to guide innovations in nursing, to create a culture of

innovation in originations, and to guide research designs. (Doyle G, 2013)

Rogers’s framework supports the implementation and adoption of innovative technology.

Qualitative researchers’ and participants’ interactions can lead to an understanding of

experiences and generation of data.


Method and Design

This research project is a qualitative study using semi-structured interviews of ICU Resource

Nurses to assess their beliefs and values regarding the I3 application and to identify perceived

barriers to implementation. The ICU Resource Nurses were interviewed in 2 groups by a nurse

facilitator who does not work in the ICU or have any supervisory role in the ICU’s. The

questions were related to the following domains: the role of the resource nurse in mitigating risk

for harm in ICU patients; the current tools and tactics used by resource nurses to assess the safety

risk in their units; the reaction to an innovative risk assessment tool, (the I3 tool) to assist the

resource nurse; the anticipated barriers to implementation of an innovative risk assessment tool

(I3) as a decision aid in the ICU environment. (Appendix D)

Qualitative research is concerned with measuring attributes and relationships; the aim is to

discover meaning and to uncover multiple realities, not to generalize to a target population. In

health design, qualitative research can serve as a valuable method to explore how healthcare

environments can be enhanced to improve outcomes in those receiving and providing care and to

generate new knowledge about evidence-based healthcare design (Malagon-Maldonado, 2014).


Study Participants

The participants for this study were a convenience sample of 2 groups of ICU Resource

Nurses. Nurses represented the CCU, the Cardiovascular ICU, the Neurosurgical ICU, the

Surgical ICU and the Medical ICU’s. This represented a homogeneous sampling and accounted

for individual unit cultures. Homogeneous sampling deliberately reduces variation and permits

more focused inquiry to understand the beliefs and values of the ICU Resource Nurses as a

group. Twelve of the total seventeen ICU resource nurses participated capturing 71% of the

total potential sample of ICU resource nurses. Seven of the twelve participants had between 31-

45 years of nursing experience, five of the twelve had between 15-30 years as an ICU nurse, and

seven of the twelve had less than 10 years functioning in the resource nurse role. (Table 1)

Setting

Participants were recruited from a pool of seventeen permanent ICU Resource Nurses from

all seven-critical care units. All of the potential participants received an email communication

from the nurse scientist that facilitated the focus groups. The nurse scientist had no reporting

relationship with the Resource Nurses which provided a non-biased environment allowing for the

participants to be comfortable and candid with their responses. The email that was sent to all

seventeen of the resource nurses outlined the goals of the study and asked for the willingness to

participate. Along with the goals and objectives, the benefits and risk of the resource nurse’s

participation was described as well as that participation in the focus group was completely

voluntary and that all information would be kept confidential. (Appendix F) Prior to the direct

communication to the potential participants the Nursing Directors of the ICU were asked for


their support in the Resource Nurses participation in the focus groups. All six of the Nursing

Directors agreed to their Resources Nurses’ participation and provided coverage for the time the

Resources Nurses would be away from their units. The Institutional Review Board (IRB) at

BIDMC reviewed and approved this study and recommended that the ICU Resource Nurses had

the opportunity to participate in the focus groups in a neutral setting away from their work

environment. On approval the IRB suggested that three focus groups be conducted. However,

after reviewing the transcripts of the first two focus groups it was evident that there had been a

saturation of data with 77% of the ICU Resource Nurses participating. With the endorsement of

the IRB the sampling was completed with two focus groups.

It was crucial to get the support from the Nursing Directors to allow the resource nurses to

participate in the focus groups. Providing coverage for the Resource Nurse allowed them to be

away from their units and be fulling engaged and thoughtful in the process. Two focus groups

were scheduled in June 2017 for ninety minutes, over lunch; each focus group consisted of six

ICU Resource Nurses.

Data Collection

The focus groups were scheduled away from the ICU units for ninety minutes over lunch.

The nurse scientist, who has no reporting relationship with the participants, and who also is

familiar with this type of qualitative data collection, facilitated the sessions. A thirty-minute

orientation of the I3application was provided to the ICU Resource Nurse by one of the primary

investigators of the I3 study at the start of each session. It is important to note that this was the

first introduction that any of the participants had to the I3 application which helped to ensure that

the Resource Nurses would not have had a predisposed bias to the technology. The orientation


portion of the focus group session provided a demonstration of the visual functionality of the

application and an explanation of the statistical analyses behind the data that was used to develop

the algorithms in the tool. On completion of the overview of the application the semi-structured

focus group interviews were conducted facilitated by a nurse scientist who has no reporting

relationship with the participants. A prepared set of open ended questions were developed that

were consistent with the research questions as described earlier. (Appendix D) Unidentified

demographic information was obtained from the participants for accurate data collecting.

(Appendix E

In semi structured interviews the interviewer’s job is to encourage participant to talk freely

about all the topics from the prepared questions and to tell stories in their own words. This

technique ensures that researchers will obtain all the information required and gives people the

freedom to provide as many illustrations and explanations as they wish (Polit, 2017). This

approach was appropriate for group interaction and allowed the ICU Resource Nurses to respond

in a familiar social setting. The focus group facilitator recorded actual text and narrative from

the participants.

Data Processing and Analysis

Transcript analysis was performed using constant comparison analysis, also known as the

method of constant comparison. The constant comparative analysis method is an iterative and

inductive process of reducing the data through constant recoding (Glaser B, 1967). The first

stage was reading the transcripts a number of times and coding the data into small units of

relevant descriptors. The second stage of the analysis consisted of grouping the codes into

categories, a process that was done with a team so that continual comparing of new emerging


concepts could be explored. It was through this process of comparing concepts to incidents that

allowed for newly developed ideas to develop from the data. (Appendix G) Finally, in the third

stage themes developed that express the content of each of the categories. (Appendix H) Each

level of analysis required a reworking of the data to recognize emerging and embedded themes.

Ethical Considerations

Generally, there was no risk to the participants participating in this study. There was no

intent to evaluate the Resource Nurse role or the difference in how participants functioned in the

role. The focus groups were facilitated by a non-biased nurse scientist who was familiar with

facilitating focus group and who had no reporting relationship with the participants. All of the

information shared in the focus groups was used to identify themes that informed the

development of an implementation plan for the I3 application. Participants were told that they

may refuse to answer any of the questions or even decide to leave the study. The focus group

discussions were audio recorded and destroyed after the transcriptions were completed. The

transcription of the recording did not have any participants’ names. Information describing the

study and the intent of the focus group was given to the participants. (Appendix F) Additionally,

autonomy, anonymity, confidentiality and voluntariness were assured to all participants.

This study was approved by the Institutional Review Board (IRB) at BIDMC as an

amendment to the already existing IRB approved submission for the Optimizing ICU Safety by

Managing Risky States to Prevent Harm.

Plan for Dissemination

These research finding have been shared with the principle investigators, Dr. Jennifer

Stevens, and Dr. Patricia Folcarelli, of the I3 risk assessment IT application to inform the


implementation phase of their project. Additionally, the results were presented to the Nursing

Directors of each of the ICU and to the focus group participants. The study suggested that ICU

Resource Nurses value their own nursing intuition over electronic technology data to assess

patient risk. As a result of these findings the I3 principle investigators have changed the

implementation plan for the application, as the findings here have convinced us that the ICU

Resource Nurses are not ready to accept this technology. Findings will also be shared with the

nursing leadership of the ICUs at BIDMC. Although qualitative studies are not generalizable

there are other themes that will be described in the findings that should be shared with nursing

leaders at BIDMC and have potential to inform future studies.


CHAPTER FOUR

Findings

Introduction

The development of the ICU Intensity Index (I3) at Beth Israel Deaconess Medical Center

(BIDMC) was a result of a grant from the Betty and Gordon Moore Foundation. In collaboration

with system engineers from Massachusetts Institute of Technology, a group of senior colleagues

from The Center for Healthcare Delivery Science, and Critical Care at BIDMC studied two years

of patient safety data, along with environmental and staffing factors in the ICU that contribute to

actual patient harms. The factors that emerged as contributors or drivers to the risk of a patient

harm in the ICU can be seen in table 3. The patient harm data was extracted from both the

voluntarily patient safety reporting system as well as patient harms that were not reported but

could be as preventable harms from the electronic medical record. Patient harms that are

defined in the application are listed in table 2. The analysis of the relationship between both

environmental factors in the ICU, and actual patient harms, is able to provide an electronic out

put that signals the level of risk that exist in the unit for a patient harm to occur. (Appendix A)

The adoption of this innovative technology is dependent on the perceived value that the data

will enhance clinical practice, or the effect that it has on the operational functioning of the unit.

Describing patient harm in the ICU at the unit level rather than at the patient specific level is a

fundamental shift in how ICU nurses have thought about patient safety. Readiness for change is

perhaps the most difficult goal to achieve but is essential for successful quality and safety

transformation. At BIDMC there are seventeen ICU Resource Nurses who are informal and

influential leaders in their prospective units. The ICU Resource Nurses’ attitudes and behaviors


towards such innovative technology will influence the frontline clinicians’ adoption of the I3 as a

risk assessment tool in the ICU.

Focus groups were an efficient method for obtaining the data from the ICU Resource Nurses

to understand their beliefs and attitudes towards the I3 risk assessment tool. The Nursing

Directors of all seven of the ICUs were supportive of the Resource Nurses participating which

resulted in twelve of the seventeen Resource Nurses attending one of the two focus groups. In

June of 2017 all seventeen ICU resources nurses received an email that included the goals of the

project and two semi- structured focus groups that would be facilitated by a nurse scientist who

was familiar with conducting this type of qualitative data collection. Each focus group consisted

of six ICU Resource Nurses and at the beginning of the session one of the principle investigators

(PI) for the I3 reviewed the application. Providing the Resource Nurses with an orientation of

the functionality of the application gave the participants enough knowledge to understand the

potential impact the application would have on their work flow.

The focus groups consisted of a set of questions to engage the participants in honest feedback

regarding their belief and attitudes towards the I3 as an electronic tool to assess patient risk at the

unit level. The participants were asked about their overall years of experience as nurses, how

long they had practiced in the ICU, and how long they functioned in the resource role. (Table 1)

From multiple reviews and comparing of the transcriptions, it was evident there was consistent

and saturated feedback.

The following five themes emerged from the data: (1) lack of trust and accuracy of the tool

and in the ability of the tool to capture the full range of factors influencing the risk/intensity level

of the ICU; (2) nurses clinical experience and intuition is more reliable than electronically


pulled data; (3) concerns that the tool would result in loss of control/ autonomy in staffing

decisions by the resource nurse; (4) concerns related to the changing landscape of critical care

environment and initiative overload; (5) risk in an ICU is accepted as a normal work

environment. The following sections will expand on each of these themes.


Theme 1: Lack of trust and accuracy of the I3 tool and in the ability of the tool to capture

the full range of factors influencing the risk/intensity level of the ICU.

The most dominant theme that emerged from the data was that the Resource Nurses had a

lack of trust that the I3 as electronic risk assessment tool would adequately capture and portrait

the real-time activity in the ICU. Resource Nurses did not believe that an electronic risk

assessment tool would be able to reliably capture the real-time activity of an ICU. As the

workflow for the ICU does not always allow for documentation in real time, this delay in

documentation had the potential to influence the accuracy or the tool - which impacts the

reliability of the current state of the environment.

The concerns centered on the ICU nurses work flow and the nuances of a complex and

dynamic environment. The participants characterized their concerns as an inability of an

electronic tool to capture every aspect of critical activity an ICU. As an example, the following

are relevant verbatim that characterize the perceptions of the tool:

“I just think there’s too much potential for error when you run all these things together.”

“All computer generated, no input from a human being saying what else might be going

on”.

The nurses’ workflow in the ICU is unpredictable. In an ICU, there are many aspects of care

for patients that require the nurse to regularly reprioritize activities, such as code blue response

which is systematic approach to the resuscitation and lifesaving activities for a patient. In this

instance when a code blue is called it generates a very standard and predictable response to the

event and every member of the response team knows their role. Although the response to a code

blue event in the ICU is highly predictable, the occurrence of the event is not. It is these high


priority responses that leave other tasks, such as the electronic documentation of a patient being

transferred to radiology, or the updating of the staffing system, as less of a priority. The unit

activities of a patient being transported off the unit, or the change in staffing skill mix, are just

two of the environmental factors that are part of the electronic configuration of the I3 tool.

Participants expressed skepticism that the tool could reflect and capture the true current state of

the units because of the unpredictable nature of how events unfold in an ICU. The nurses’

workflow in the ICU is impacted by these unpredictable events, and subsequently the ability to

keep electronic documentation current was a concern expressed by the participants. Some of

the verbatim that illustrated this belief:

“You know if you are having a crazy day you’re not going to think to check that box off

that I went to CAT Scan or Angio or MRI.”

“Am I going to spend the extra time with the patient doing patient care or charting?”

“Difficult for our documentation to show the accurate level of activity on the unit.”

The Resource Nurses did not trust that an electronic tool was able to accurately capture all of the

complexities of the ICU environment. Their doubts are based on the nature of electronically

pulled data not being timely and therefore not reflective of the current state of the unit.

Theme 2: Nurses clinical experience and intuition is more reliable than electronically

pulled data.

Experienced ICU Resource Nurses expressed the belief that they were able to rely on their

past experiences and intuition to assess potential risk in the ICU more accurately than an

electronic tool. ICU Resource Nurses consistently expressed trust and reliance on their own

intuitive knowledge for assessing patient risk and unit needs, over the use of an electronic tool.


It was evident from the Resource Nurses’ responses that their own intuitive reasoning was often

used when they made decisions. Participants expressed confidence in using intuition and

described it as:

“A gut feeling, like you just know something bad is going to happen.”

“No system of pulling information is going to give you that judgment, the human

judgement piece.”

“All of these situations are very well known, we just know it, so I don’t know how the

information being in a program format is going to change anything.”

Hogarth (2001) defines intuition as responses reached with little apparent effort and typically

without conscious awareness and which involve little or no conscious deliberation. (Hogarth,

2001) Clinicians and researches rely heavily on evidence based practice but there is a growing

body of work supporting intuition as a seemingly acceptably way of thinking and knowing in

clinical decision making. (Pearson, 2013) The ICU Resource Nurses believed that their intuition

was reliable and more readily accessible in a complex and dynamic environment than an

electronic tool.

Theme 3: Concerns that the tool would result in loss of control/autonomy in staffing

decisions by the resource nurse.

The Resource Nurses expressed the belief that unless an electronic risk assessment tool would

support the justification for additional nursing staff there would be no value in the I3 as a tool

that could be used to reduce risk for patient harm. The finite staffing resources and the

complexity of adjusting staffing to meet patient acuity, was a consistent concern expressed by

the Resource Nurses. The Resource Nurses have autonomous decision-making responsibility


regarding staffing of their units but that is limited to manipulating the known current staffing

resources. A widely available electronic tool that would enable nursing supervisors or nursing

directors from other units to influence their staffing decisions was a concern. One statement that

exemplified this was;:

“Supervisors only look at the numbers they don’t come and spend time in the unit to

know what’s going on.”

Additionally, the overwhelming attitude was that unless an electronic tool that validated acuity

and risk in the unit would ultimately result in the ability to provide the unit with additional

nursing staff they did not see a lot of value in the tool.

“So, it’s nice to have a risk assessment tool so it is Red, what are we doing about that?”

“It would help if you have the nurses to give us, other than that what good is it.”

Along with mistrust in how management is making staffing decisions, participants believed

that there was a different standard for expected nurse workload between units and the that the

nursing supervisor did not have the necessary skills to assess the needs unit by unit. Among the

feedback was a consistent concern that there was an inability to increase staffing:

“So, when you are in trouble you can put out a call and say we are drowning but it’s

not typically responded to, there’s no extra pair of hands around.”

These data suggested an overall hopelessness that although an electronic tool may indicate a unit

that is in a “risky state” , there was an expressed fear of a loss of control related to staffing

decisions, and that the data from the I3 would not alleviate any staffing concerns. Another

relevant verbatim:


“So, no matter what this tool says it’s not going to change anything, if there aren’t the

resources to address what the tool is indicating.”

The Resource Nurses assess and adjust staffing needs on a regular basis based on their clinical

judgment of the patient acuity and needs of the unit. There is concern that the I3 would take

away the Resource Nurses autonomy in decision making.

Autonomy and control over nursing practice is described as the freedom and authority of

nurses to engage in decision making related to the context of nursing practice including

organizational and clinical decision. (Weston M, 2008) The ICU Resource Nurses value the

influence they have over nursing practice and the operational running of the unit.

Theme 4: Concerns related to the changing landscape of critical care environment and

initiative overload.

This studied suggested that ICU Resource Nurses are experiencing a changing ICU

environment in relation to their past experience as ICU nurses. Quality improvement initiatives

are perceived as increasing the workload for the bedside nurse. The participants expressed a

considerable concern over the impact that number of new initiates have had on the workflow for

the nurse at the bedside. Repeatedly the participants shared examples of added patient care

requirements which add to the nurses’ workload. Specific examples included the increased

nursing work required for early patient mobility in the ICU; decreased patient sedation; and

efforts to decrease catheter associated infections.


The following verbatim illustrate this theme:

“It seems like every week or month there’s constantly new things, new initiatives

starting, new things to document, new equipment, there’s more and more.”

“All these things add to the day, but nothing’s been eliminated.”

“More with less”

“It seems like more and more and more there are always new initiatives.”

The belief is that new technology and quality initiatives are contributing to an increased nursing

workload and a feeling of initiative overload. Often those with long term investment in certain

routines and skills often hesitate to give up the security of those habits. (Barton-Leonard D,

2017)

Theme 5: Risk in an ICU is accepted as a normal work environment.

ICU Resource Nurses have normalized the burden of risk in an ICU as an expected condition.

They described the risk in their work environment as something that they expect every day.

There is acceptance of the complexity in the environment. An example of how this was described

is:

“This is what it’s going to be, I don’t honestly think of it as risk, I just think it’s just

craziness.”

“I don’t think of it as risk, just normal.”

The ICU Resource Nurses in this study had a combined 347 years of nursing experience

(Table 1) with 287 years of ICU nursing experience. The many years of nursing experience

among these ICU Resource Nurses may have contributed to them normalizing what they see


every day. In other words, as a result of their many years of experience in a critical care unit they

have accepted high-risk environments as the norm. With this acceptance of the complexity in

their environment as normal, the ICU Resource Nurses didn’t see the value in a tool that would

alert them and identify elements in the unit that are contributing to states of risk. Despite the

Resource Nurses acknowledging the complexity of the work environment, they expressed a

tolerance to the risk. The many years of nursing experience among the participants may account

for the normalization of a high-risk environment. Equally important the many years of

experience has fostered the development of high degree of intuitive knowledge and expert

clinical skills, which may protect them from seeing the everyday activity as anything but normal.


Summary

Although the five themes identified in the study may not be generalizable nonetheless they

identify the beliefs and values of the ICU Resource Nurses at BIDMC and need to be considered

in planning for a successful implementation of the I3 risk assessment tool at BIDMC.

Introducing technology into an organization presents a set of challenges and engaging the

resource nurses as key stakeholders’ shows that their input is valued. Equally important,

proactively managing the risk of an unsuccessful roll out by understanding how the users will

adapt to and accept the application prior to implementation can avoid many hours and resources

spent only to have a implementation fail. The themes that the Resource Nurses identified will

influence the actions taken by the I3 implementation phase of this application.

The ICU Resource Nurses expressed considerable skepticism in the value of an electronic risk

assessment tool. The data indicated that they rely on their nursing intuition and clinical skill in

determining when the unit is at risk and have mistrust that an electronic tool can capture the

complexity of acuity and activity in an ICU. Additionally, there was expressed concern over

loss of control and autotomy regarding staffing decisions. The ICU Resource Nurses are

empowered to make staffing decisions based on their knowledge and experience and there was a

concern that the I3 would not be able to adequately address staffing concerns for the unit.


CHAPTER FIVE

Discussion and Implications

The goals of this study were to understand the beliefs and values of the ICU Resource Nurses

towards an electronic risk assessment tool that was developed to assist staff in recognizing ICU

intensity conditions that could potentially increase the risk of patient harm. The ICU Resource

Nurses are influential leaders in the ICU and engaging them in the potential implementation

planning processes was important for successful implementation and adoption of the tool by

front line clinical staff. The I3 is an innovative technology that has the ability to alert staff that

there are elements within the ICU environment that have the potential to contribute to a patient

harm event. This predictive application tool has the potential to be used in a number of ways by

decision makers in the ICU. For example, the tool has the ability to consider factors such as the

experience mix of the nursing staff and the current nursing workload intensity which may

influence decisions regarding where to admit patients across all seven units or inform the timing

of a bedside procedure. The I3 was designed to provide clinicians and decision makers with

information to allow for proactive mitigating actions at the unit level. This is a novel approach

to the current risk assessment tools that provide retrospective data from patient specific safety

reports and from traditional nursing acuity tools. The ICU Resource Nurses were thought to be

most influential in the adoption of this transformational way of thinking about reducing patient

harm.

The conclusion of our qualitative analysis of focus groups with the ICU Resource Nurses is

that they did not see the value and usefulness of I3 application and could not envision how they

would integrate this tool into their daily work flow. Specifically, the ICU Resource Nurse


described skepticism and a lack of trust in the accuracy of an electronic tool that would capture

the full range of factors that could contribute to patient risk in an ICU. The Resource Nurses

described the dynamic nature of the ICU and the inability for an electronic documentation to be

consistent and current. The focus group participants agreed that the very nature of the ICU

demands that staff make quick decisions and react to both obvious and subtle changes in patient

conditions. The ICU Resource Nurses described scenarios that could never be captured by an

electronic documentation tool in real time. As an example, if a patient needs to emergently be

taken to radiology for a CT scan, (which can require a nurse to be away from the unit for many

hours), that nurse may not have the time to document in the electronic medical record the time

the patient and nurse were off the unit.

Additionally, the ICU Resource Nurses could not envision the concept that an electronic tool

could be more reliable than their nursing intuition in determining when the ICU was at risk for

potential patient harm. Intuition is an integral part of nursing practice that comes into action

when nurses access their unconscious knowledge without inhibition or second guessing. (Robert

R, 2014) Alternatively, intuition in clinical practice is a polarizing concept, as it is intangible

and often perceived as irrational and it is rejected by many as irrelevant to the decision-making

process for nurses. (Robert R, 2014) Despite the controversial nature of intuition as a tool,

research validates its use in sound decision making among nurses. Critical care nurses have

reported intuitive processes guiding them in anticipating problem and knowing what to assess.

(Robert R, 2014) Given the many years of ICU clinical experience among the study participants

it is reasonable to conclude that they would have a very well-developed knowledge base and skill

level allowing them to have a great deal of trust in the use of their own intuition. Dr. Patricia

Benner is a nursing theorist who first developed a model for the stages of clinical competence in


her classic book “From Novice to Expert: Excellence and Power in Clinical Nursing Practice”.

Her model is one of the most useful frameworks for assessing nurses’ needs at different stages of

professional growth. (From Novice to Expert, 2018) Benner uses the Dreyfus Model of Skill

Acquisition as a foundation for her work which has five levels of nursing proficiency from

novice to expert. In describing the expert level of proficiency Benner described the nurse who

no longer relies on an analytical principle (rule, guideline, and maxim) to connect an

understanding of the situation to an appropriate action. The expert nurse, with an enormous

background of experience, has an intuitive grasp of the situation and zeros in on the accurate

region of the problem without wasteful consideration of a large range of unfruitful possibilities.

(Benner, 1987) As a nurse evolves from novice to expert, and as the amount of nursing

experience increases, use of intuition expands. (Pretz, 2011) In this study group 83% of the ICU

Resource Nurses had greater than 15 years of nursing experience with a wealth of knowledge

and skill in caring for complex ICU patients. They expressed that they did not trust an

electronic tool over their own intuition in making clinical and operational decisions. It remains

to be seen if the usefulness of this tool for a wider population of ICU nurses, who have less

years’ experience than the resource nurses, may have a different response.

Autonomy and control of the ICU Resource Nurses work environment should be considered

when introducing new technology. In nursing and management literature, employee

participation in decision making is touted as an important strategy for enhancing employee

satisfaction and improving the quality of performance and improved patient outcomes. (Weston

M, 2008)

The changing ICU environment was found to have a profound effect of the ICU Resources

Nurse readiness to accept new technology, or to see value in quality improvement initiatives.


The care of the ICU patient has changed dramatically of the last several years. As an example,

patients in the ICU receive less sedation and are more alert necessitating the bedside nurse to be

vigilant to safety needs. In addition, such interventions as early mobility required increased

staffing resources to support the ambulation of ventilated patients, requiring the bedside nurses to

coordinate the additional resources needed. Increasing quality improvement initiatives have

increased the workload for the nurse at the bedside and from this study there is an expressed

concern of initiative overload. The results of this study underscore the importance of

considering nurses’ different work settings and work flow prior to implementing change in

practice. Based on these findings it will be important for nursing administrators to manage

changes in the work environment of nurses in the ICU at BIDMC by considering mitigating

strategies that lessen the burden of overall of initiative overload. Moreover, the consequences of

the Resource Nurses perception of an ever-changing work environment in the ICU offers an

opportunity for further study.

These findings have informed the next phase of the I3 implementation at BIDMC. The PIs

for the I3 have been open to hearing the ICU Resource Nurses feedback and have expressed

value in them as key stake holders in the ICU. The summary of these findings was that the ICU

Resource Nurse do not trust the validity or accuracy of the I3 and therefore are not ready to

accept the tool to be used at the unit level. Change is vital to progress, yet the nursing literature

identifies numerous complexities associated with transforming plans into action; and attempts to

change often fail because change agents take an unstructured approach to implementation.

Despite the reluctance of the ICU Resource Nurses to adopt this risk assessment technology the

literature recommends including the use of information technology to improve quality in health

care and curb medical errors. The evidence is convincing regarding the use of technology to


improve patient safety. Conclusions from this study are that assuring user readiness should be

considered for successful implementation and adoption of new initiatives and technology.

Complex work environments are often dynamic, unstable and, therefore, unpredictable. New

technologies can disrupt ingrained practice patterns, impose new learning demands, or force

system operators to devise novel responses or accommodations to new work challenges. (Banja

J, 2010) ICU nurses value their ability to work in a high intensity clinical settings and

maintaining control over their work environment is a priority. The introduction of technology

that has the potential to limit their autonomy and reduce the ability to use their own clinical

decision making creates uncertainty and skepticism.

The findings of this study have changed the direction of the implementation phase for this

new technology. The ICU Resource Nurses are likely not the right audience for this technology

at this time. Due to these finding the implementation team is investigating the use of the I3 at an

administrative level where higher strategic decisions are made. As an example, there is

consideration to utilize the application in the patient transfer center to help inform decisions

related to the acceptance of ICU patients from outside hospitals.

As a result of the lack of trust in the data of the I3 by the ICU Resource Nurses, mitigation

strategies will be required if the tool is to be used at the unit level. Although it is apparent from

this study that the ICU Resource Nurses at BIDMC are not ready for implementation of the I3,

further exposure and education for the Resource Nurses should be considered. Gaining the trust

of the Resource Nurses regarding this innovative technology will require a planned approach that

includes evidence to support the data, and greater consideration of how the nursing work flow

will be impacted.


The literature is clear that innovative technology is important to enhance patient safety and

improve efficiencies in healthcare. Todd Dunn, Director of Innovation at Intermountain

Healthcare, stated that the role of innovation should not be to create answers immediately; rather,

the focus should be to define the context of the issues before answering it. (Din B, 2016) This

study provided needed knowledge to the implementation team. Additionally, as Dunn suggested,

the data from this study defined the context of the issues prior to a roll out of the I3 risk

assessment tool in the ICU. Furthermore, this study prevented the investment of resources and

time on an implementation plan in the ICU, which, without the trust and belief from the

Resource Nurses had a high probability of failure.


Study Limitations

These study findings do not claim to give insight into the whole ICU nursing workforce.

The focus groups included the ICU Resource Nurses who have many years of ICU experience

and therefore likely possessed a high degree of intuitive nursing judgement and clinical skill.

ICU nurse with fewer years of experience and not as well developed intuitive knowledge may

have had a different response to the value of an electronic risk assessment tool. Two focus

groups sessions were conducted with 77% of the ICU Resource Nurses participating.

Qualitative descriptive research findings are not meant to be generalizable.


Table 1.

Focus Groups Demographics

Years of Nursing Experience Number of Participants

31-45 years as RN 7

15-30 years as RN 3

<15 years as RN 2

Total 12

Years as an ICU Nurse Number of Participants31-45 years 4

15-30 years 5

<15 years 3

Total 12

Period of time as ICU Resource Nurse at BIDMC Number of Participants10+ years 5

<10 years 7

Total 12


Table 2

Harm Definition

Arrest Cardiac Arrest or Code Blue

Code Purple Shifts on which hospital police was dispatched to the unit

Fall A patient falls, or nearly falls in the ICU

Hemoglobin A shift with an abrupt drop in hematocrit greater than 4 within 24 hours, given it happens after 2 hours of admission to the ward

Identification Errors or near misses in which the wrong patient was given an intervention

Lab Errors or near misses related to lost, misunderstood, or preprocessed lab procedures

Medication Errors or near misses related to wrong dose, or wrong medication

Safety Errors or near misses related to safety disturbances in the unit

(Traina A, 2015)


Table 3

Environmental Category Driver

Acuity Patient SOFA scorePatients first 24 hours in the unitLength of stay in the ICU

Unfamiliarity Float Nurse assigned to the unitNovice NurseBoarding patient in ICU (medicine pt in CCU)

Utilization Nurses Workload (TISS 28 acuity tool)Nurse to patient ratioAdmissions activity during a shiftDischarge activity during a shift

Others EU critical (unidentified patient)Night Shift/ Day ShiftWeekendUnit

(Hu Y, 2017)


Appendix

Appendix A

This is a screen shot of the ICU Intensity Index (I 3) Dashboard illustrating that at this point in

time the SICU is experiencing High intensity contributing factors are staffing and clinical acuity.


Appendix B

http://eliteagent.com

The innovativeness dimension, as measured by the time at which an individual adopts and

innovation or innovations, is continuous. The innovativeness variable is portioned into five

adopter categories by lying off standard deviations from the average time of adoption. This

method of adopter categorization is the most widely used in diffusion research today. Terms

such as innovators and early adopters are widely used and understood by the public. (Rogers E,

2003)

http://eliteagent.com/

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiky9XrtObSAhWH6oMKHRB4AR0QjRwIBw&url=http://eliteagent.com.au/the-innovation-bell-curve/&bvm=bv.150120842,d.amc&psig=AFQjCNHVak3y9tkTlJbdGmtv7xj2CrwNNA&ust=1490144750908728


Appendix C

(Rogers, Diffusion of Innovations, 2003)

The innovation process consists of a sequence of five stages, two in the initiation sub process and

three in the implementation sub process. The first two of the five stages in the innovation process,

agenda –setting and matching, together constitute initiation, defined as all the information gathering,

conceptualizing, and planning for the adoption of an innovation, led up to the decision to adopt. (Rogers,

Diffusion of Innovations, 2003)


Appendix D

Focus Group Discussion Guidelines

Topic Area Question

1. ICU Resource Nurse Role What do you see as the Resource Nurse role in the assessment of unit risk for patient harm?

In the Resource Role how are you alerted to a patient harm event?

2. “Risk” in the ICU How do you think about risk? Nurses often describe a unit as out of control, are these two things the same or different?

How do you currently know when the unit is “out of control”? What are the things that contribute to this?

3. Current Decision Aids/ Sources of Information

What tools does the ICU Resource Nurse currently rely on to make decisions? What tools do you rely on to manage situations that are out of control?

4. I3 as a Potential Decision Aid How would the I3 Dashboard impact the care of patients in the ICU?

How would the I3 Dashboard impact the patient assignment and staffing decisions for the ICU? How could the I3 Dashboard be used at the bed meeting?

What if any do you see as the major benefits of the I3 Dashboard?


5. Barriers to Implementation What challenges would you anticipate in the implementation of this innovative technology in the assessment of unit risk?

What, if any, do you see as the major concerns about using the I3 Dashboard in the ICU?

6. “Reality Check” How often would you rely on the I3

Dashboard in making decisions for the unit?

What other roles in the ICU do you think might find the I3 Dashboard of value? How do you think they could use it, different from how you might use it?


Appendix E

Focus Group Demographic Information

No person identifiers should be included

How Long Have You Been an ICU Nurse ____________________________________________?

How Long Have You Been an ICU Resource Nurse at BIDMC ___________________________?

Have You Received an Overview of The ICU Intensity Index Application (I3)? Y____N____

Have You Had the Opportunity to Monitor the Functionality of the I3? Y_____N______

If Yes How Much Time Have You Spent on the I3 Application

10-20 minutes ______

20-30 minutes_______

1hr – 2hrs ___________

More than 2 hrs. ________


Appendix F

ICU Resource Nurses Beliefs and Values Towards a Risk Assessment Application, ICU Intensity Index (I3): A Focus Group Study

Study Information Summary

Q: What is the purpose of this research study? A: The main purpose of this study is to understand the beliefs and values of ICU Resource Nurses towards an innovative ICU risk assessment application, I3. The beliefs and values of the ICU resource nurses will inform the development of the implementation phase of the I3 application.

Q: Who is conducting this research study? A: The researchers include: Jane Foley, RN, BSN, MHA, Susan Desanto-Madeya RN, PhD

Q: Who will be taking part in this research study? A: Approximately 12-16 ICU Resource Nurses at Beth Israel Deaconess Medical Center will participate in the study. We plan on conducting 2 focus groups with 6-8 Resource Nurses in each group.

Q: What will happen if I am interested in taking part in this research study? A: If you agree to take part in the study you will participate in a group discussion that will last between 45-60 minutes. Prior to the discussion you will receive a basic overview of the I3

application and how it interacts with both ICU environmental and patient data. We will ask you to provide some basic information about yourself and your experience as a Resource Nurse and overall nursing experience. We will ask the group a series of questions about your role as a Resource Nurse, how you assess for risk in your unit, and tools you use to make decisions. Additionally, we will ask what you see as the risk and benefits of implementing the I3 dashboard as a risk assessment application.

Q: What are the risks to taking part in this study? A: Generally, there is no risk to taking part in this study, there is no intent to evaluate the Resource Nurse role or the difference in how participants function in the role, no answer is wrong. The discussion groups will be facilitated by a non-bias RN whom you have no reporting relationship with. All of the information shared is to inform themes of benefits and challenges that may exist in the implementation of innovative technology. You may refuse to answer any of the questions or even decide to leave the study. We will audio record the sessions but then we will transcribe the recordings without recording your name. We will then destroy the audio recordings.


Q: What are the benefits to taking part in this study? A: There is no direct individual benefit to you from being in this study. However, in the Resource Nurse role you have direct influence on the culture and staff in the ICUs. The knowledge gained from your feedback, along with beliefs and values in the I3, will inform a successful implementation plan throughout all the ICUs.

Q: Will it cost me anything to take part in this research study? A: No, it will not cost you anything to be part of this study, except for your time, refreshments will be severed.

Q: What if I decide not to take part in this research study? A: Participation in this study is voluntary. You have the right to decide not to take part in the study. You will not be penalized if you decide that you do not want to participate in the study. We will not share your decision to participate or to not participate with anyone.

Q: Whom should I talk to or call if I have questions about this study? A: If you have any questions about this research, you should contact Jane Foley at 617-632-7176 or email [email protected]. I will follow up via email to see if you would like to participate. If you do not want to be contacted, please let me know and I will not contact you about the study. If you have questions about the study, or about your rights as a research subject and you wish to speak with someone independent of the research team, you may contact the Beth Israel Deaconess Human Subject Protection Office at 617-667-0469

Resource Nurse Focus Group: 4-18-17

mailto:[email protected]


Appendix G

ICU Resource Nurses Beliefs and Values towards Risk Assessment Application

Focus Group Categories Notable Quotes

Lack of trust in I3 Tool accuracy and validity of current state

" But there's really nothing to do by developing a tool that already tells me what I already know unless we're going to do something about that, I don't see it a s a huge improvement" "I just think there's too much potential for error when you run all these things together" "I think that's going to be problematic if it isn't able to capture what's really happening"

Assumption that gut, experience & intuition of ICU Nurse is better than an electronic tool

"So even though you don't use the word risk we're always taking the temperature of the unit, how's everyone doing" "All of these situation are very well known, so I don't know what the information being in a program format is going to change anything" "You use your experience and your instinct to know that a patient is in a certain state and they may not always be, we have some nurses who are afraid to say they need help" " A gut feeling, like you just know something bad is going to happen" "No system of pulling information is going to give you that judgement, the human judgement piece which I think should be a part of this"

Inconsistency in escalation process for needed resources (staff)

"So, when you are in trouble you can put out a call and say we are drowning but it's not typically responded to, there's no extra airs of hands around"

Lack of trust in standard approach to acuity assessment, unit specific & supervisors

"Supervisors only look at the numbers" "I think what every unit calls one-to- one might be different" "ED admit GI bleed, happens many times and it's all hands on deck and there's no way of staffing that up" " We look ahead at what is the acuity then it doesn't always work out""the ACS they don't come and spend time in our unit to know what's going on"

Perception that electronic documentation is not timely and therefore not reflective of current state of the ICU.

"Concern about the accuracy of the acuity tool all computer generated, no input from a human being saying what else might be going on" "Difficult for the documentation to show the accurate levels on the unit" "There's not a lot of time to be documenting everything" "So that patient might take up a lot of a nurse's time, but they're not on CRT and they're not traveling MRI and they're not on pressers" "Yah, but you can't leave the room, there's no place that you can document Code Purple in MetaVision""Am I going to spend the extra time with the patient doing patient care or charting?""You know if you are having a crazy day you're not going to think to check that box off that I went to CAT Scan or Angio or MRI""Does it kind of reflect rally what the day is like in the unit versus what is just being pulled"

Concern that the unmeasurable elements of the environment will not be captured (travel time with patient, family social support)

"There's still things that aren't going to be captured"

Hopelessness that the tool will not provide the needed value of additional resources, staffing

" So, it's nice to have a risk assessment tool so it is Red, what are we doing about that?" "There is no flex, there's no flexibility""Maybe it will help with the supervisors, I just honestly don't see them coming around that often anyway" "So no matter what this tool says it's not going to change anything, if there aren't the resources to address what the tool is indicating""It would help if you have the nurses to give us, other than that""I think it will hurt us and work against us, then it will create Riskier States."


Risk is identified at the specific unit level, not overall community of ICU

"Help with traveling, I think having someone that can be pulled that they can identify more risky states then it could be useful"" And then people don't feel like they want to help each other out they don't feel like there's any reciprocity"" Finard 4 in itself every day makes it a Risky State, if something happens you don't get people there as quickly as you necessarily would like them there"

Normalization of risk as acceptable "Everything is usually a perfect storm" "This is what it's going to be, I don't honestly think of it as risk, I just think it's just craziness." " I don't think of it as risk, just norm"

Current changes in the overall ICU environment

" I don't know if this has anything to do with the question, but I think when you have two patients it is busier than it has ever been" "You can't even take 5 minutes" " you have to be extremely organized" "We're not all super human, then you're like you've got to do this, do all these trips by 5 o'clock and that is risky" "It seems like every week or month there’s constantly new things, new initiatives starting, new things to document, new equipment, there's more and more." "Even from when I started nine years ago it is so different" " There's so much more to do now" "The big CAUTI-FOLEY initiatives, when a patient doesn't have a Foley, that takes more time" "Early mobility is a huge one, plus we're getting patients into a chair" "These are things that take more time, but their staffing numbers have not increased" "It seems like more and more and more there's all these new initiatives" "Everything's changing and it is more and more for nurses to do, I now when you have a two patient assignment, I mean you go , go ,go, you have to take a report on two patients, read up on your 2 patients and then get going" "We have huddles in the morning, we never used to have a huddle, a morning huddle with physical therapy" " All these things add on to our day, but nothing's been eliminated" " More with less" "It's not like they're increasing staffing numbers because now you're supposed to be getting your patient out of bed three times a day even though they're on the vent"" They're less sedated so they're on the call light"" It's a lot riskier, you can miss something, you know that"" And they were completely sedated so you didn't have to worry""Those were the good old days right?"" More good for the patient but a higher risky state"" Yeah you didn't have to worry about them pulling out their tube, everybody had a Foley, the second the tube went in, they got a Foley, that's just how it was it's much different now with all the new research and the different things going on" "Don't know if it is good or bad but sometimes newer staff come from the floor are used to having a four-five-six patient assignments, but they do better with the two patient because they're used to that"

Interchangeable perception of safety and risk

"I would say risk is potential harm" "Just new terminology that you want us to start thinking about" "Many things happening at one time for the amount of people you have to manage that situation"

Identified their own level of anxiety and stress / not patient level of safety or risk

"Rounds take so long so then all the traveling takes place in the afternoon 5-6 o'clock that is when people try and get things wrapped up to hand over" "All the line placements take place in the afternoon""We spend so much time just figuring out staffing and covering sick calls, acuity wise for what staff you have on""No matter if we're in the red I have my own problems""I can't be looking at the dashboard when I'm trying to put out all the fires in my unit, I'm not going to have time to""It would be nice if it was designed and it worked to help us, it's not going to be nice if it hurts us and sort of goes against what we say and what we know to be true"

Need for I3 tool validation by ICU resource nurse in real time

"There should validated by a resource nurse somewhere saying last 10 hours or 12 hours predicted to be in this state, it should have some sort of validation from


somebody in the unit""Hopefully it’s going to reflect what's going on in the unit and how we see it"

Resource Nurse identified components of risk

"Two people off the unit for a good chunk of the day really affects ability to admit patients - it really does put you in a bad place" "Because you're looking at staffing, you're not out on the unit looking at risky states, because you're actually looking at staffing level" "And it also depends on the age of the staff, like new staff it can be very chaotic whereas if you have older staff in that same situation????" "And in that out of controlness people are at risk" "Resident on the night get pummeled with five, seven admissions in a night that is unsafe" "We have to keep an eye on the residents too" "The fact that you have a border in another unit, that puts them at risk. It puts everybody at risk because you don't know if they're good or bad" "I think the unit can be very, very quiet and risky for patients there" " It's usually when it's quiet because people slow down, they're not in that state as when its's busy"" People are runny around like crazy, nobody sitting down, everyone's busy""The alarms""Traveling" "I think with all the initiatives that they want us to do, with all the added work and no more extra staff, I think that equals risk right there"

Methods Resource Nurse uses to gather data

"See it, hear it, talk about it" "Someone will let me know" "Just a constant upload of information about what's going on in the unit" "We know what the assignments are, who's in what room, what's going on in room, we don't have any written tools, but we do have an equation where we say well, we have --- in my unit""We don't follow tools, I think it's just getting a feel for the unit""What helps me is actually going to each room""You instinctively know, this person is going to be busy""There is no tool, it was passed down by being trained as a resource nurse or years of experience that if somebody meets certain criteria then that's who go 1 to 1"

Optimism in an ideal state "So, does this help level the playing field for staffing" "In an ideal world supervisors would look at this information""I think if it works well it might help us get more staffing""I think if we have a tool that actually works and shows, yes, we are at a very Risky State right now, it might give us extra time""What would be perfect is if the ACS said we can see from this that you are very busy, we're going to give you another nurse for the night shift""And I feel like I'm never going to prevent risky states, but if it's used well, you 're in the red, you need help, there's going to be some kind of help provided for you at that time"


Appendix H

Themes and Definitions

Theme Description Notable Quotes in that theme

Lack of trust in the accuracy of the tool and in the ability of the tool to capture the full range of factors influencing the risk/intensity level of the ICU.

An electronic risk assessment tool cannot reliably capture the real time activities of an ICU.

" But there's really nothing to do by developing a tool that already tells me what I already know unless we're going to do something about that, I don't see it a s a huge improvement" "I just think there's too much potential for error when you run all these things together"

"I think that's going to be problematic if it isn't able to capture what's really happening"

"Concern about the accuracy of the acuity tool all computer generated, no input from a human being saying what else might be going on"

"Difficult for the documentation to show the accurate levels on the unit"

"There's not a lot of time to be documenting everything"

"You know if you are having a crazy day you're not going to think to check that box off that I went to CAT Scan or Angio or MRI"

Clinical experience, and nursing intuition is more reliable than electronically pulled data

Experienced ICU Resource Nurses feel that they are able to rely on their past experiences to make assessment of potential risk in the ICU more accurately than an electronic tool.

"All of these situation are very well known, so I don't know what the information being in a program format is going to change anything"

"You use your experience and your instinct to know that a patient is in a certain state and they may not always be, we have some nurses who are afraid to say they need help"

" A gut feeling, like you just know something bad is going to happen"

"No system of pulling information is going to give you that judgement, the human judgement piece which I think should be a part of this"

Loss of control/autonomy of staffing decisions made by the resource nurse.

The solution to increased risk in an ICU is to increase the number of ICU nurses. Unless an acuity tool can support the justification for additional nursing staff the resource nurses do not see a lot of value in using the tool. Staffing resources are needed to mitigate risk in the ICU environment.

" So, it's nice to have a risk assessment tool so it is Red, what are we doing about that?" "There is no flex, there's no flexibility" "So, no matter what this tool says it's not going to change anything, if there aren't the resources to address what the tool is indicating"

"It would help if you have the nurses to give us, other than that"

"I think it will hurt us and work against us, and then it


will create Riskier States." Changing landscape of critical care environment and initiative overload.

The ICU nurses are experiencing a changed ICU environment. Increasing quality improvement initiatives have increased the workload for the nurse at the bedside. The improvement initiatives are seen as just more work for the bedside nurse i.e. (early mobility, decreased sedation for pt, decreasing catheter associated infections)

"It seems like every week or month there’s constantly new things, new initiatives starting, new things to document, new equipment, there's more and more."

"The big CAUTI-FOLEY initiatives, when a patient doesn't have a Foley, that takes more time"

"Early mobility is a huge one, plus we're getting patients into a chair"

"It seems like more and more and more there's all these new initiatives"

"Everything's changing, and it is more and more for nurses to do, now”

"We have huddles in the morning, we never used to have a huddle, a morning huddle with physical therapy"

" All these things add on to our day, but nothing's been eliminated"

"It's not like they're increasing staffing numbers because now you're supposed to be getting your patient out of bed three times a day even though they're on the vent"

" They're less sedated so they're on the call light"

" And they were completely sedated so you didn't have to worry"

"Those were the good old days, right?"

" More good for the patient but a higher risky state"

" Yeah you didn't have to worry about them pulling out their tube, everybody had a Foley, the second the tube went in, they got a Foley, that's just how it was it's much different now with all the new research and the different things going on"

Risk in an ICU is accepted as a normal work environment.

ICU nurses have normalized the burden of risk in an ICU as an expected condition.

"Everything is usually a perfect storm"

"This is what it's going to be, I don't honestly think of it as risk, I just think it's just craziness." " I don't think of it as risk, just norm"


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