|Year : 2022 | Volume
| Issue : 3 | Page : 30-33
Impact of nursing interventions on patient satisfaction in a Covid intensive care unit during peak of pandemic in resource-limited setting
Ashish Kumar Simalti1, Vedika A Vijayan2, Suman Pramanik3, C Jancy Mathew2, Neha Gupta1, K Malvika1
1 Department of Pediatrics, Military Hospital, Dehradun, Uttarakhand, India
2 Department of Nursing, Military Hospital, Dehradun, Uttarakhand, India
3 Department of Hematology, Army Hospital R and R, New Delhi, India
|Date of Submission||02-Sep-2021|
|Date of Decision||12-Oct-2021|
|Date of Acceptance||27-Oct-2021|
|Date of Web Publication||01-Jul-2022|
Dr. Ashish Kumar Simalti
Departments of Pediatrics, Military Hospital, Dehradun, Uttarakhand
Source of Support: None, Conflict of Interest: None
Background: Caregivers not being allowed into the COVID wards prevented them from being involved in caring for their relatives in respect of day-to-day activities such as eating, drinking, and walking to the washroom. The aim of this study was to observe the challenges faced by patients admitted to intensive care unit (ICU) with COVID-19 pneumonia. We also observed the impact of two simple nursing interventions related to feeding and defecation and noted their impact in terms of patient's satisfaction. Materials and Methods: A semi-structured feedback questionnaire was prepared to cover common challenges faced by patients after interview with 10 patients admitted at a COVID ICU. Two simple nursing interventions were performed related to feeding and defecation. Results: Breathlessness was the most common issue as all the patients admitted were hypoxic. Inability to perform routine day-to-day functions such as feeding, drinking, sitting, and walking were other common issues. Emotional issues like anxiety, fear homesickness, and loneliness were also very high. Most (69.44%) patients were satisfied with a blended diet which was easy to take for patients with breathlessness. Most (77.28%) of patients were satisfied with intervention of helping them sit on a commode chair while on oxygen. Conclusion: During this pandemic, where all our efforts seemed insufficient in face of this unprecedented crisis yet these small seemingly insignificant steps helped both the patients as well as nurses in making the atmosphere more positive.
Keywords: COVID-19, nursing care, patient satisfaction
|How to cite this article:|
Simalti AK, Vijayan VA, Pramanik S, Mathew C J, Gupta N, Malvika K. Impact of nursing interventions on patient satisfaction in a Covid intensive care unit during peak of pandemic in resource-limited setting. J Mar Med Soc 2022;24, Suppl S1:30-3
|How to cite this URL:|
Simalti AK, Vijayan VA, Pramanik S, Mathew C J, Gupta N, Malvika K. Impact of nursing interventions on patient satisfaction in a Covid intensive care unit during peak of pandemic in resource-limited setting. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 9];24, Suppl S1:30-3. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/30/347865
| Background|| |
The WHO designated the year 2020 as international year of Nurses and Midwives to coincide with the 200th birth anniversary of Florence Nightingale. Unfortunately, the same year witnessed the outbreak of global pandemic Covid 19 taking the lives of millions. As guidelines for COVID-19 management continue to evolve, importance of good nursing care has remained crucial. Overwhelming number of breathless patients during the pandemic brought forward unique challenges to nurses caring for these patients. Caregivers not being allowed into the COVID wards prevented them from being involved in caring for their relatives in respect of day-to-day activities like eating, drinking, and walking to the washroom. During prepandemic times, these issues used to be taken care of easily but as healthcare system got overwhelmed attention got diverted from these concerns which adversely impacted patient care. This study was planned to fulfill this lacuna. The aim of this study was to observe the challenges faced by patients admitted to intensive care unit (ICU) with COVID-19 pneumonia. We also observed the impact of two simple nursing interventions related to feeding and defecation and noted their impact in terms of patient's satisfaction.
| Materials and Methods|| |
It was a single -center prospective observational study conducted at a busy COVID hospital in north India during the peak of COVID pandemic. The period of observation was from April 15, 2021, to May 30, 2021, which was the peak of pandemic in the state of Uttarakhand. Only patients requiring oxygen therapy were admitted to the ICU during the period of observation as there was an unprecedented surge in hypoxic patients during this period.
A semi-structured feedback questionnaire was prepared to cover common challenges faced by patients after interview with 10 patients admitted at our hospital in Dehradun. It was prepared in two languages – English and Hindi and was pre-validated by expert opinion. This semi-structured questionnaire comprised of 10 questions (9 were kept closed-ended and one was open-ended). [Table 1] represents the questions and response of patients interviewed along with observations made by nurses on duty. All patients admitted in one COVID ICUs during the study period were included in this study after informed consent. Patients requiring mechanical ventilation or with altered sensorium were excluded from the study. Each respondent was given assurance of the confidentiality of his or her responses. The approval of the ethical committee of the institute was taken for the study. Descriptive statistics was utilized. Closed-ended question had a binary response and presented in the form of percentage. Data from open-ended question were categorized into themes. We did a multiple correspondence analysis to visually detect clustering between various responses. We fit multivariate Bernoulli distribution likelihood in Bayesian framework with PyMC3 package in Python 3.8 and get the marginal probabilities of the responses and also get the association between various responses.
|Table 1: Common challenges faced by patients admitted in COVID intensive care unit|
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One of the interventions being studied was to address nutritional requirement. Usually, the patients on high flow oxygen support require special assistance and care in maintaining their nutritional requirement. Patients need to remove mask to eat but they get breathless as soon as they remove the mask. Because of this, they are not able to eat adequately. Patients requiring oxygen support through nonrebreathing mask were provided blended diets designed by a trained dietician to ensure adequate calories and protein. Patients were provided with straws to drink it from a glass. Patients were provided these liquid diets 6 times a day [Figure 1].
|Figure 1: (a) Blended diet as served to breathless patients. (b and c) Patients being assisted with feeding while on oxygen support|
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The second intervention which was studied for its impact on patient's sense of wellbeing was related to their bowel movement. Patients who were not able to walk because of breathlessness were forced to defecate in bed only. Most of these patients were uncomfortable and were not passing stool for many days at a stretch. They were also too embarrassed to report it as a problem. Commode chairs were placed by the bed with a built-in toilet pan for patients who could get out of bed but had limited ability to walk to the toilet. Patients were helped in sitting on a commode chair while receiving oxygen where they could defecate in a relatively comfortable position [Figure 2]. The impact of these nursing interventions was assessed in terms of patient satisfaction level after 4 days of regular application. The subjectivity of satisfaction was turned into an objective parameter by coding responses into ordinal categories. Responses were recorded in three categories; satisfied, not satisfied, and neutral. Relative proportions of 3 responses were analyzed in Bayesian frame work. Proportions with 94% credible interval and percentage with actual numbers are shown in [Table 2].
|Figure 2: (a) Commode chair kept at the bedside. (b) Patient being assisted to sit on the chair while on oxygen support|
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| Results|| |
Totally 127 patients were admitted during the study period. Responses to questionnaire and independent observation by nurses during rounds are tabulated in [Table 1]. Breathlessness was the most common issue as all the patients admitted were hypoxic. Inability to perform routine day-to-day functions like feeding, drinking, sitting, walking were other common issues. Emotional issues like anxiety, fear homesickness, and loneliness were also very high. Multiple correspondence analyses were used to assess the clustering between various variables in a visual manner. Symptoms of breathlessness, inability to sit, talk, and walk were clustered with each other, which indicate that the presence of one of the variable will make the presence of other variables more likely. Furthermore, difficulty in feeding and maintaining of oxygen delivery were clustered with each other. Another arm of the study was to see the impact of simple nursing interventions related to feeding and defecation. Patient satisfaction in response to these interventions was taken as endpoint for this study. Relative proportions of 3 responses (satisfied, not satisfied, and neutral) were analyzed in Bayesian framework. Proportions with 94% credible interval are given in [Table 2]. Most (69.44%) patients were satisfied with blended diet which was offered to patients who were not able to eat because of breathlessness. While few (6.51%) patients were not satisfied with this measure as they did not like the taste and consistency of the blended diet or found it monotonous. Similarly tracking patient's bowel movements and helping them sit on bedside commode chair with continued oxygen support helped patients regularize their bowel functions and 77.28% of patients were satisfied with this intervention. Asking direct questions regarding these challenges and these nursing interventions led to improved overall satisfaction level among patients as shown in [Table 2].
| Discussion|| |
Our ICU was actually a pediatric (PICU) converted into adult Covid ICU during pandemic. Authors, pediatric intensivist and pediatric trained nurses, were used to having mothers admitted with children who play a crucial role in looking after sick children. The absence of a mother-like caring attendant for these breathless adult patients admitted with pneumonia was a sharp contrast to pediatric practice and this drew our attention towards the crucial role nurses have to play in this regard. Once admitted to the ICU, patients with respiratory distress not requiring invasive ventilation are generally treated with oxygen delivered through various delivering devices such as nasal prongs, face mask, non-re-breathing mask, high-flow nasal cannula, or noninvasive ventilation in ascending order of oxygen requirement. Because of breathlessness, oral intake decreases significantly. This decrease in energy/protein intake is associated with increased catabolism and muscle loss leading to a prolonged hospital stay and poor outcome. In an audit Pironi et al. found that 75% of the COVID-19 patients were at a risk of malnutrition. A consensus report from the global clinical nutrition community reported the incidence of severe malnutrition to be as high as 54% using global leadership initiative on malnutrition (GLIM) classification. Rouget et al. also demonstrated the existence of a high prevalence of malnutrition (37.5%) in a general cohort of inpatients with COVID-19 according to the GLIM criteria. In our study, we found that 46 patients were so breathless that they were not able to eat and without early intervention, they would have become malnourished very fast as energy requirements increased significantly among critical patients suffering from pneumonia.
Critically ill patients suffer from many problems related to gastrointestinal tract like anorexia, feed intolerance, dyspepsia, nausea, vomiting, constipation, and diarrhea. In our observation, constipation was the predominant issue among patients with COVID-19 Pneumonia. Mostafa et al. documented very high incidence of constipation (83%) in patients admitted to ICUs. They reported that among ICU patients, meantime for the first defecation from day of admission was 4.8 days. This can extend to 6 days among mechanically ventilated patients. Constipation also affect breathing because of increased abdominal pressure. Constipation has been found to be associated with delay in weaning from ventilator, other studies have correlated constipation with higher incidence of infections, multi-organ dysfunction, prolonged stay ICU, and overall increased mortality. In our study, we also found very high prevalence of constipation and we also observed that it can be easily overlooked if not asked directly to patients.
Patient satisfaction depends on many factors out of which nursing care is one of the most important factors. Interestingly patient satisfaction also reciprocally impacts quality of nursing care by increasing job satisfaction among nurses. A multinational study spanning six European countries correlated patient satisfaction with caring behavior of nurses in our study also we found that very act of asking questions improved patient's satisfaction level. Both the interventions had significant positive impact on patient's satisfaction as mentioned in [Table 2]. Traditional outcome like mortality benefits was not in the purview of this study hence not recorded or commented upon. However, patient satisfaction which in itself was an important outcome. Although the study did not aim to measure the impact of this intervention on nursing staff anecdotally all the staff involved reported improved sense of job satisfaction and willingness to be part of these interventions. There are many limitations in this study because of the circumstances in which it was conducted. The questionnaire was not validated. Questions were not vetted and given scores based on importance. Nutritional rehabilitation was not evaluated in terms of objective parameters of nutrition status and patient satisfaction being a subjective feeling may not be an accurate indicator of impact of nursing intervention. As these questionnaire and interventions could not be applied to patients who were too sick, there was a survival bias in the study. This survey can serve as a pilot study to develop a patient satisfaction enquiry tool for patients getting admitted to ICU.
| Conclusion|| |
Because of contagious nature of this disease, there was a barrier between health cares and patients and it resulted in loss of human touch which is vital for holistic care. These interventions were our attempt to add this human touch to the care. During this pandemic where all our efforts seemed insufficient in face of this unprecedented crisis yet these small seemingly insignificant steps helped both the patients as well as nurses in making atmosphere more positive. We feel this article contains an important message as said by American basketball coach John Wooden that “It's the little details that are vital. Little things make big things happen.”
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gethin G, Probst S, Weller C, Kottner J, Beeckman D. Nurses are research leaders in skin and wound care. Int Wound J 2020;17:2005-9.
Griffin KM, Karas MG, Ivascu NS, Lief L. Hospital preparedness for COVID-19: A practical guide from a critical care perspective. Am J Respir Crit Care Med 2020;201:1337-44.
Tabashi S, Mirkheshti A, Dahi M, Abtahi D, Vosoughian M, Sayyadi S, et al.
Supplemental oxygen therapy and non-invasive ventilation in corona virus disease (COVID-19). J Cell Mol Anesth 2020;5:27-31.
Pironi L, Sasdelli AS, Ravaioli F, Baracco B, Battaiola C, Bocedi G, et al.
Malnutrition and nutritional therapy in patients with SARS-CoV-2 disease. Clin Nutr 2021;40:1330-7.
Cederholm T, Jensen GL, Correia MI, Gonzalez MC, Fukushima R, Higashiguchi T, et al.
GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community. J Cachexia Sarcopenia Muscle 2019;10:207-17.
Rouget A, Vardon-Bounes F, Lorber P, Vavasseur A, Marion O, Marcheix B, et al.
Prevalence of malnutrition in coronavirus disease 19: The NUTRICOV study. Br J Nutr 2021;126:1296-303.
Petros S, Engelmann L. Enteral nutrition delivery and energy expenditure in medical intensive care patients. Clin Nutr 2006;25:51-9.
Mostafa SM, Bhandari S, Ritchie G, Gratton N, Wenstone R. Constipation and its implications in the critically ill patient. Br J Anaesth 2003;91:815-9.
Guerra TL, Mendonça SS, Marshall NG. Incidence of constipation in an intensive care unit. Rev Bras Ter Intensiva 2013;25:87-92.
Hodges PW, Gandevia SC. Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J Appl Physiol (1985) 2000;89:967-76.
Gacouin A, Camus C, Gros A, Isslame S, Marque S, Lavoué S, et al.
Constipation in long-term ventilated patients: Associated factors and impact on intensive care unit outcomes. Crit Care Med 2010;38:1933-8.
Nassar AP Jr., da Silva FM, de Cleva R. Constipation in intensive care unit: Incidence and risk factors. J Crit Care 2009;24:12.e9-12.
Asai T. Constipation: Does it increase morbidity and mortality in critically ill patients? Crit Care Med 2007;35:2861-2.
Rathert C, May DR. Health care work environments, employee satisfaction, and patient safety: Care provider perspectives. Health Care Manage Rev 2007;32:2-11.
Koy V, Yunibhand J, Angsuroch Y, Fisher ML. Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: Literature review. Int J Res Med Sci 2015;3:1825-31.
Palese A, Tomietto M, Suhonen R, Efstathiou G, Tsangari H, Merkouris A, et al.
Surgical patient satisfaction as an outcome of nurses' caring behaviors: A descriptive and correlational study in six European countries. J Nurs Scholarsh 2011;43:341-50.
[Figure 1], [Figure 2]
[Table 1], [Table 2]