research problem statement in critical care nursing

The First Step: Ask; Fundamentals of Evidence-Based Nursing Practice

In this module, we will learn about identifying the problem, start the “Ask” process with developing an answerable clinical question, and learn about purpose statements and hypotheses.

Content includes:

• Identifying the problem
• Determining the Population, Intervention, Comparison, and Outcome (PICO)
• Asking a Research/Clinical Question (Based on PICO)

Statements of Purpose

Objectives:

• Describe the process of developing a research/practice problem.
• Describe the components of a PICO.
• Identify different types of PICOs.
• Distinguish function and form of statements of purpose.
• Describe the function and characteristics of hypotheses.

Development of a Research/Practice Problem

Practice questions frequently arise from day-to-day problems that are encountered by providers (Dearholt & Dang, 2012). Often, these problems are very obvious. However, sometimes we need to back up and take a close look at the status quo to see underlying issues. The basis for any research project is indeed the underlying problem or issue. A good problem statement or paragraph is a declaration of what it is that is problematic or what it is that we do not know much about (a gap in knowledge) (Polit & Beck, 2018).

The process of defining the practice/clinical problem begins by seeking answers to clinical concerns. This is the first step in the EBP process: To ask . We start by asking some broad questions to help guide the process of developing our practice problem.

• Is there evidence that the current treatment works?
• Does the current practice help the patient?
• Why are we doing the current practice?
• Should we be doing the current practice this way?
• Is there a way to do this current practice more efficiently?
• Is there a more cost-effective method to do this practice?

Problem Statements:

For our EBP Project, we will need to ask these broad questions and then develop our problem that exists. This establishes the “background” of the issue we want to know more about.

For example, if we are choosing a clinical question based on wanting to know if adjunct music therapy helps decrease postoperative pain levels than just pharmaceuticals alone, we might consider the underlying problems of:

• Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery (Gan, 2017).
• Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs (Gan, 2017).
• Multimodal analgesic techniques are widely used but new evidence is disappointing (Rawal, 2016).

In the above examples, we are establishing that poorly managed postoperative pain is a problem. Thus, looking at evidence about adjunctive music therapy may help to address how we might manage pain more effectively. These are our problem statements. This would be our introduction section on the EBP poster. For the sake of our EBP poster, you do not need to list these on the poster references. A heads up: The sources used to help develop our research/clinical program should not be the same resources that we use to answer our upcoming clinical question. In essence, we will be conducting two literature reviews: One, to establish the underlying problem; and, two: To find published research that helps to answer our developed clinical question.

Here is the introduction to the article titled, “The relationships among pain, depression, and physical activity in patients with heart failure” (Haedtke et al, 2017). You can read that the underlying problem is multifocal: 67% of patient with heart failure (HF) experience pain, depression is a comorbidity that affects 22% to 42% of HF patients, and that little attention has been paid to this relationship in patients with HF. The researchers have established the need for further research and why further research is needed.

Here is another example of how the clinical problem is addressed in an EBP poster that wants to appraise existing evidence related to dressing choice for decubitus ulcers.

When trying to communicate clinical problems, there are two main sources (Titler et al, 1994, 2001):

• Problem-focused triggers : These are identified by staff during routine monitoring of quality, risk, adverse events, financial, or benchmarking data.
• Knowledge-focused triggers : There are identified through reading published evidence or learning new information at conferences or other professional meetings.

Sources of Evidence-Based Clinical Problems:

Most problem statements have the following components:

• Problem identification: What is wrong with the current situation or action?
• Background: What is the nature of the problem or the context of the situation? (this helps to establish the why)
• Scope of the problem: How many people are affected? Is this a small problem? Big problem? Potential to grow quickly to a large problem? Has been increasing/decreasing recently?
• Consequences of the problem: If we do nothing or leave as the status quo, what is the cost of not  fixing the issue?
• Knowledge gaps: What information about the problem is lacking? We need to know what we do not know.
• Proposed solution: How will the information or evidence contribute to the solution of the problem?

If you are stumped on a topic, ask faculty, RNs at local facilities, colleagues, and key stakeholders at local facilities for some ideas! There is usually “something” that the nursing field is concerned about or has questions about.

Components of a PICO Question

After we have asked ourselves some background questions, we need to develop a foreground (focused) question. A thoughtful development of a well-structured foreground clinical/practice question is important because the question drives the strategies that you will use to search for the published evidence. The question needs to be very specific, non-ambiguous , and measurable in order to find the relevant evidence needed and also increased the likelihood that you will find what you are looking for.

In developing your clinical/practice question, there is a helpful format to utilize to establish the key component. This format includes the Patient/Population, Intervention/Influence/Exposure, Comparison, and Outcome (PICO) (Richardson, Wilson, Nishikawa, & Hayward, 1995).

Let’s dive into each component to better understand.

P atient, population, or problem: We want to describe the patient, the population, or the problem. Get specific. We will want to know exactly who we are wanting to know about. Consider age, gender, setting of the patient (e.g. postoperative), and/or symptoms.

I ntervention: The intervention is the action or, in other words, the treatment, process of care, education given, or assessment approaches. We will come back to this in more depth, but for now remember that the intervention is also called the “Independent Variable”.

C omparison: Here we are comparing with other interventions. A comparison can be standard of care that already exists, current practice, an opposite intervention/action, or a different intervention/action.

O utcome: What is that that we are looking at for a result or consequence of the intervention? The outcome needs to have a metric for actually measuring results. The outcome can include quality of life, patient satisfaction, cost impacts, or treatment results. The outcome is also called the “Dependent Variable”.

The PICO question is a critical aspect of the EBP project to guide the problem identification and create components that can be used to shape the literature search.  

Let’s watch a nice YouTube video, “PICO: A Model for Evidence-Based Research”:

“PICO: A Model for Evidence Based Research” by Binghamton University Libraries. Licensed CCY BY .

Great! Okay, let’s move on and discuss the various types of PICOs.

Types of PICOs

Before we start developing our clinical question, let’s go over the various types of PICOs and the clinical question that can result from the components. There are various types of PICOs but we are concerned with the therapy/treatment/intervention format of PICO for our EBP posters. 

Let’s take a look at the various types of PICOs:

The first step in developing a research or clinical practice question is developing your PICO. Well, we’ve done that above. You will select each component of your PICO and then turn that into your question. Making the EBP question as specific as possible really helps to identify specific terms and narrow the search, which will result in reducing the time it times searching for relevant evidence.

Once you have your pertinent clinical question, you will use the components to begin your search in published literature for articles that help to answer your question. In class, we will practice with various situations to develop PICOs and clinical questions.

Many articles have the researcher’s statement of purpose (sometimes referred to as “aim”, “goal”, or “objective”) for their research project. This helps to identify what the overarching direction of inquiry may be. You do not need a statement of purpose/aim/goal/objective for your EBP poster. However, knowing what a statement of purpose is will help you when appraising articles to help answer your clinical question.

The following statement of purpose was written as an aim. The population (P) was identified as patients with HF, the interventions (I) included physical activity/exercise, and the outcomes (O) included pain, depression, total activity time, and sitting time as correlated with the interventions.

In the articles above, the authors made it easy and included their statements of purpose within the abstract at the beginning of the article. Most articles do not feature this ease, and you will need to read the introduction or methodology section of the article to find the statement of purpose, much like within article 3.1.

In qualitative studies, the statement of purpose usually indicates the nature of the inquiry, the key concept, the key phenomenon, and the population.

Function and Characteristics of Hypotheses.

A hypothesis (plural: hypothes es ) is a statement of predicted outcome. Meaning, it is an educated and formulated guess as to how the intervention (independent variable – more on that soon!) impacts the outcome (dependent variable). It is not always a cause and effect. Sometimes there can be just a simple association or correlation. We will come back to that in a few modules.

In your PICO statement, you can think of the “I” as the independent variable and the “O” as the dependent variable . Variables will begin making more sense as we go. But for now, remember this:

Independent Variable (IV): This is a measure that can be manipulated by the researcher. Perhaps it is a medication, an educational program, or a survey. The independent variable enacts change (or not) onto the independent variable. 

Dependent Variable  (DV): This is the result of the independent variable. This is the variable that we utilize statistical analyses to measure. For instance, if we are intervening with a blood pressure medication (our IV), then our DV would be the measurement of the actual blood pressure.

Most of the time, a hypothesis results from a well-worded research question. Here is an example:

Research Question : “Does sexual abuse in childhood affect the development of irritable bowel syndrome in women?”

Research Hypothesis : Women (P) who were sexually abused in childhood (I) have a higher incidence of irritable bowel syndrome (O) than women who were not abused (C).

You may note in that hypothesis that there is a predicted direction of outcome. One thing leads to something.

But, why do we need a hypothesis? First, they help to promote critical thinking. Second, it gives the researcher a way to measure a relationship. Suppose we conducted a study guided only by a research question. Take the above question, for example. Without a hypothesis, the researcher is seemingly prepared to accept any  result (Polit & Beck, 2021). The problem with that is that it is almost always possible to explain something superficially after the fact, even if the findings are inconclusive. A hypothesis reduces the possibility that spurious results will be misconstrued (Polit & Beck, 2021).

Not all research articles will list a hypothesis. This makes it more difficult to critically appraise the results. That is not to say that the results would be invalidated, but it should ignite a spirit of further inquiry as to if the results are valid.

Hypotheses (also called alternative hypothesis) can be stated as:

• Directional or nondirectional
• Simple or complex
• Research or Null

Simple hypothesis : Statement of causal (cause and effect) relationship – one independent variable (intervention) and one dependent variable (outcome).

Example : If you stay up late, then you feel tired the next day.

Complex hypothesis : Statement of causal (cause and effect) or associative (not causal) between two or more independent variables (interventions) and/or two or more dependent variables (outcomes).

Example :  Higher the poverty, higher the illiteracy in society, higher will be the rate of crime (three variables – two independent variables and one dependent variable).

Directional hypothesis : Specifies not only the existence but also the expected direction of the relationship between the dependent (outcome) and the independent (intervention) variables. You will also see this called “One-tailed hypothesis”.

Example : Depression scores will decrease  following a 6-week intervention.

Nondirectional hypothesis : Does not specify the direction of relationship between the variables. You will also see this called “Two-tailed hypothesis”.

Example : College students will perform differently from elementary school students on a memory task (without predicting which group of students will perform better). 

Null hypothesis : The null hypothesis assumes that any kind of difference between the chosen characteristics that you see in a set of data is due to chance. Now, the null hypothesis is why the plain old hypothesis is also called alternative hypothesis. We don’t just assume that the hypothesis is true. So, it is considered an alternative to something just happening by chance (null).

Example : Let’s say our research question is, “Do teens use cell phones to access the internet more than adults?” – our null hypothesis could state: Age has no effect on how cell phones are used for internet access.

And then, further develop the problem and background through finding existing literature to help answer the following questions:

• Knowledge gaps: What information about the problem is lacking? We need to know what we do not  know.

With the previous example of pain in the pediatric population, here is an example of an Introduction section from a past student poster:

• What was the research problem? Was the problem statement easy to locate and was it clearly stated? Did the problem statement build a coherent and persuasive argument for the new study?
• Does the problem have significance for nursing?
• Was there a good fit between the research problem and the paradigm (and tradition) within which the research was conducted?
• Did the report formally present a statement of purpose, research question, and/or hypotheses? Was this information communicated clearly and concisely, and was it placed in a logical and useful location?
• Were purpose statements or research questions worded appropriately (e.g., were key concepts/variables identified and the population specified?
• If there were no formal hypotheses, was their absence justified? Were statistical tests used in analyzing the data despite the absence of stated hypotheses?
• Were hypotheses (if any) properly worded—did they state a predicted relationship between two or more variables? Were they presented as research or as null hypotheses?

References & Attribution

“ Green check mark ” by rawpixel licensed CC0 .

“ Light bulb doodle ” by rawpixel licensed CC0 .

“ Magnifying glass ” by rawpixel licensed CC0

“ Orange flame ” by rawpixel licensed CC0 .

Chen, P., Nunez-Smith, M., Bernheim, S… (2010). Professional experiences of international medical graduates practicing primary care in the United States. Journal of General Internal Medicine, 25 (9), 947-53.

Dearholt, S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd Ed.). Indianapolis, IN: Sigma Theta Tau International. 

Gan, T. (2017). Poorly controlled postoperative pain: Prevalence, consequences, and prevention. Journal of Pain Research, 10, 2287-2298.

Genc, A., Can, G., Aydiner, A. (2012). The efficiency of the acupressure in prevention of the chemotherapy-induced nausea and vomiting. Support Care Cancer, 21 , 253-261.

Haedtke, C., Smith, M., VanBuren, J., Kein, D., Turvey, C. (2017). The relationships among pain, depression, and physical activity in patients with heart failure. Journal of Cardiovascular Nursing, 32 (5), E21-E25.

Pankong, O., Pothiban, L., Sucamvang, K., Khampolsiri, T. (2018). A randomized controlled trial of enhancing positive aspects of caregiving in Thai dementia caregivers for dementia. Pacific Rim Internal Journal of Nursing Res, 22 (2), 131-143.

Polit, D. & Beck, C. (2021).  Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research  (10th ed.). Wolters Kluwer Health.

Rawal, N. (2016). Current issues in postoperative pain management. European Journal of Anaesthesiology, 33 , 160-171.

Richardson, W.W., Wilson, M.C., Nishikawa, J., & Hayward, R.S. (1995). The well-built clinical question: A key to evidence-based decisions. American College of Physicians, 123 (3), A12-A13.

Titler, M. G., Kleiber, C., Steelman, V.J. Rakel, B. A. Budreau, G., Everett,…Goode, C.J. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13 (4), 497-509.

Evidence-Based Practice & Research Methodologies Copyright © by Tracy Fawns is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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• Research article
• Open access
• Published: 06 September 2019

Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study

• Juan Escrivá Gracia   ORCID: orcid.org/0000-0002-7106-3581 1 ,
• Ricardo Brage Serrano 1 &
• Julio Fernández Garrido 1  

BMC Health Services Research volume  19 , Article number:  640 ( 2019 ) Cite this article

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Metrics details

Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors.

This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3.

The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate).

Conclusions

Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.

Peer Review reports

Pharmacotherapy is a very important resource within the health system context. However, it is not without patient risk and its improper use can cause a wide variety of damage, both iatrogenic in nature and those derived from mistakes made as part of the complex processes comprising the drug-use system. The term ‘drug-related problems’ is now preferred because it encompasses a much broader range of adverse drug reactions and medication errors and interactions [ 1 , 2 , 3 , 4 ].

The magnitude of this problem was highlighted in 1999 by the Institute of Medicine, which estimated the annual mortality due to medication errors at 7000 deaths, with clinical error being the most prevalent problem [ 5 ]. Comparison of different publications is difficult because of differences in the variables used, measurement and detection methods, and study populations, as well as the lack of an internationally standardised taxonomy that clearly defines what constitutes an error, potential error, error cause, or contributing factor [ 6 ]. Despite this, various studies estimate that incidents related to medication account for 6–12% of hospital admissions and 2 in every 1000 hospital deaths, and therefore constitute a serious public health problem [ 7 , 8 , 9 ].

Intensive care units (ICUs) are especially vulnerable to errors and their consequences, which are potentially more serious for ICU patients. Critically ill patients admitted to the ICU accumulate an average of 1.7 medical errors every day, and many patients suffer a potentially life-threatening error during their stay. Medication errors are the most common type of error and account for 78% of serious medical errors in the ICU [ 10 , 11 ]. This is because of the critical nature of the patients in these units, the broad, dynamic, and complex pharmacotherapy used to treat them, and the organisation of the service (excessive care burdens, communication problems, frequent changes of staff, etc.), all of which is aggravated by the urgent nature of the work undertaken in these units [ 10 , 11 , 12 ].

However, little or nothing is said about the lack of training or experience of the professionals working in ICUs [ 13 ]. Most studies focus on the drug administration stage, and claim that most errors occur during this pharmacotherapeutic administration stage [ 14 ]. Nonetheless, how errors in the initial stages of prescription and transcription can generate later repercussions is also worth studying [ 7 , 15 ].

Published work has identified certain pharmacological groups as having extensive multicausality error risks; among these, antibacterial drugs are particularly important because of their widespread use and frequency of errors in their use [ 16 , 17 ]. Another high-risk group are pharmaceuticals that cannot be administered via a nasogastric tube (NGT) [ 18 , 19 ] as well as high-risk medications in general [ 6 , 20 , 21 , 22 ]. However, key determinants must first be identified in order to define effective error prevention strategies [ 10 , 23 , 24 , 25 ].

Several authors claim that human factors (e.g., errors in dose calculation, absence of double checking, low adherence to protocols, and especially, poor drug knowledge among professionals) most strongly influence the medical error rate [ 6 , 13 , 21 , 26 , 27 ]. Effective prevention strategies currently focus on detecting failures and redesigning the system to prevent such problems based on the relationships between the causes (or individual factors) and the environment. In this sense, it is clear that human errors are a consequence of the system, rather than a specific cause of error [ 7 , 28 ].

Aims if this study

This study identifies the main medication errors that occur in the ICU at a general hospital in the city of Valencia (Spain). We analyse the causes of these errors, based on the perception of expert professionals and determine if the level of knowledge that nurses have of the use and administration of medications is related to the errors most commonly committed in this context.

To exhaustively explore the above question, we carried out a mixed method study with an embedded or nested concurrent design. The study structured into three phases that involves collecting quantitative and qualitative data at the same time, but the quantitative data of the first phase dominated and guided the investigation, nesting other qualitative (second phase) and quantitative (third phase) techniques to allow us to a more complete and profound view of the phenomenon [ 29 , 30 ].

The study was carried out at a general resuscitation and intensive critical care unit in a tertiary-level hospital serving a population of 364,255 inhabitants. Of the total 535 beds at the centre, the ICU had 13 beds, of which 4 were in isolation rooms.

In the first phase of the study (phase 1), a random sample of 87 admitted episodes was selected from the total admissions over the year. We set the confidence level at 95%, the design effect was 1 (simple random sampling), and the accuracy was 10%. The random selection of cases was carried out through the statistical program SPSS 22. For the second phase (phase 2), a discussion group was formed which comprised four professionals with extensive healthcare experience as well as a researcher and a teacher in the field of nursing. In the last phase (phase 3), the sample comprised nurses from the unit who voluntarily gave their consent to participate in the research.

Procedure and data collection instruments

In phase 1, we carried out an analysis of medical records (prescription and transcription records) in order to understand the baseline situation at the unit being studied. This included a sociodemographic description of the sample, an analysis of the main active ingredients in the drugs most commonly administered and their respective administration routes, high-risk medications, potential errors, potential drug interactions, and the main areas of risk. Medication errors were analysed according to the methodology proposed by the Adverse Drugs Events Prevention Study [ 31 ]. In the same way, the error (type) classification, cause, and/or contributing factor(s) were defined using the taxonomy published by the National Coordinating Council for Medication Error Reporting and Prevention [ 32 ]. To determine the existence and level of severity of potential drug interactions, we used the Multi-Drug Interaction Checker® database from Medscape (2018) [ 33 ].

A qualitative phenomenological methodology was proposed for phase 2 which allowed the detailed study of determinants that influence the causes of medication errors through the perceptions or experiences of the professionals at the frontline in the ICU under study.

In phase 3 we designed a form to describe and evaluate the level of drug knowledge nurses, and the drugs most commonly used and/or misused in critical care. No validated questionnaires designed for purposes like our own had previously been published in the literature and so we developed a tool based on our results from the previous two study phases and the input and opinions of leading professionals in the field. Finally, a questionnaire was elaborated with closed questions of multiple answers, of which the participants had to choose one.

This questionnaire was organised around five well-differentiated areas with the aim of collecting data about the sociodemographic characteristics of the sample (1), access to information (2), notification of errors (3), consideration of errors (4), and levels of drug knowledge (5).

For the design of the questions of part 1 (sociodemographic characteristics) and 2 (access to information) we base ourselves on no validated questionnaires published in the bibliography [ 13 , 34 ]. Experts helped us in the elaboration of the questions of part 3 (notification of error) aimed at knowing how nurses notify an error, if they know the existence of the notification procedure of errors of the center and if they use it. In part 4 (consideration of errors) we wanted to know if the nurses knew how to differentiate between error of medication and cause of error, for this we consulted the taxonomy published by the National Coordinating Council for Medication Error Reporting and Prevention [ 32 ]. In section 5 (level of drug knowledge) from the results of phase 1, experts in pharmacology elaborated questions in relation to the drugs most used and with which the nurses committed a greater number of errors. To guide the writing of the questions in this part, no validated questionnaires published in the literature were consulted [ 13 , 34 ]. Finally, a total of 13 questions were included, the topics were as follows (number of questions for each shown in brackets):

Pharmacology: identification type antibiotic (18), pharmacological target (27), posology (20), interactions (25), identification high risk drugs (26).

Drug management: administration routes (21, 22, 23, 24), high risk medication administration (28, 30).

Drug dose calculation: dilution, concentration and infusion rate of high-risk medications (19, 29).

Successive revisions and a previous pilot test (with 15 participants) were necessary to analyze the convenience of the different questions, answers, writing, design and presentation, adapting and merging some items to adjust the response time to about 15–20 min, as well as the elimination of some questions to increase the internal consistency with a Cronbach’s alpha of 0.801. The final questionnaire is presented in the Additional file  1 .

Data analysis

The research focuses on a broad phenomenon (medication errors, their determinants or causes and the level of drug knowledge), this forces us to use a multiple methods design in which quantitative data predominate (analysis of medication errors) nesting other qualitative (determinants of medication errors) and quantitative data (the level of drug Knowledge) that complement first phase. This own differentiation in the objectives that each phase of the study aims to achieve requires us to analyze and interpret the data of each phase separately.

The quantitative data relating to phases 1 and 3 were analysed using SPSS (v22) software. Because the variables did not follow a normal distribution we used nonparametric statistical tests and searched for correlations between variables using Spearman’s linear correlation coefficient analysis. To establish possible differences between quantitative and qualitative variables, the Kruskal–Wallis test was used for variables from three or more independent groups, and the Mann–Whitney U test was used for variables from two groups.

The qualitative analysis of the data from the second phase of the study was characterized by what Valles calls “omnipresence of the analysis” [ 35 ], referring to the fact that said analytical activity occurs at all moments of the investigation; It was already present in the formulation of the problem and the design of the study, in the field work with the discussion group to try to discover important determinants or direct the conversation towards aspects that were interesting for the researcher. However, what is usually associated as equivalent to data analysis was the transcription of the conversation, the coding and recoding of text segments, as well as their ordering and regrouping. In this phase, the greatest analytical deployment and synthetic replication of the interpretive activity took place, in order to finally identify four major categories from which different subcategories emerge whose relationships are represented graphically in a conceptual map.

Initially, the analysis of the content of the transcript was carried out by three experts in the investigation of medication errors in an independent way, afterwards several commons were made until reaching a consensus in which the same codes were reached regarding certain portions of text, making various adjustments and saturating codes to reduce redundancy and variability, as well as ensuring the validity, coherence and sensitivity of the data presented [ 36 ].

Ethical and legal considerations

The study was undertaken according to the conditions of respect for individual fundamental rights and the ethical postulates affecting biomedical research on human beings, according to the Declaration of Helsinki and the Good Clinical Practices of the European Union. In addition, the research protocol was approved by the Clinical Research Ethics Committee at General Hospital of Valencia (Spain) (authorisation number JUA-FAR-2015-01) prior to commencing the study. Likewise, the authors declare the non existence of any type of conflict of interests.

Phase 1: review and analysis of medical records

Of the total 87 episodes admitted to the ICU, 51.7% were men; the average patient age was 57.7 ± 16.13 years and the average length of stay was 5.97 ± 7.41 days. Most of the patients (63.22%) were admitted to the unit postoperatively after complex major surgery (critical surgical patients), whereas 36.78% of the cases were admitted for a non-surgical critical problem. We analysed 2634 drug-dose units used, corresponding to 152 different main active drug ingredients, of which 23.5% were considered high-risk. Each patient received an average prescription of 14.51 medications.

For the 2634 medications administered, we detected a total of 316 potential errors, corresponding to a global medication error index (GMEI) of 1.93%. The intravenous route was the most commonly used (76.92%), followed by pressurised inhalation (8.96%), and the subcutaneous (4.82%), nasogastric (4.25%), and oral (3.42%) routes. Other routes (epidural, rectal, transdermal, sublingual, and intramuscular) were used at rates accounting for less than 1% of the total.

When reviewing the prescriptions and transcriptions for these 87 admissions, we identified an error rate of 1.32%. The most common error (accounting for 71% of the total) was the lack of a complete written prescription, while 29% of the remaining errors occurred during transcription of the prescriptions (omission of dose, incorrect dose, or erroneous dose-administration frequency or infusion rate). A more detailed analysis of the drug groups or administration techniques indicated as potential areas of risk in the literature, revealed substantially higher error rates in this study (Fig. 1 ).

Error rate for the risk areas analysed

Among the errors detected, deviations in the schedule of antibiotics administration—important because their efficacy is time dependent— were found in 65.9% of cases. In addition, there were significant errors in the dilution, concentration, and infusion rate used for high-risk drugs, especially those containing noradrenaline (32.9%) or potassium chloride (ClK) (47.9%) as active substances. Administration via a NGT caused errors resulting from the manipulation of oral pharmaceutical formats, with acetylsalicylic acid being involved in 32% of cases. The rate of drug interactions (Fig.  2 ) was also very high (f i  = 1811), although the clear majority of these were mild or moderate.

Classification of the potential drug interactions identified

There were significant correlations between most of the variables analysed, and this confirmed that there is a wide range of causes behind these errors. As expected, the more drugs administered and the longer the hospital stay in the unit, the higher the probability of detecting more errors and drug interactions ( p  = 0.001 for both relationships). There was also a strong relationship between the causes of error identified in the prescription and the subsequent errors committed in the transcription of these prescriptions ( p  = 0.003); the use of abbreviations and the absence of a dose, administration route, and/or schedule specified in the prescription was the main reason for errors related to dose omission, incorrect doses or administration frequency, and/or erroneous infusion rates in the transcript.

Importantly, we also found significant differences (Mann-Whitney U test p  < 0.05) between patients in intensive medical care versus those admitted to the critical care unit post-surgery in relation to key variables in the commission of medication errors (Table  1 ). Similarly, the presence of secondary diagnoses or comorbidities also affected the number of errors detected for these patients (Table  2 ).

Phase 2: discussion group

The information obtained from the focus group conversation allowed us to identify four major areas that lead to medication errors: (1) the critical-care context itself; (2) organisation of the ICU service; (3) personal factors; and (4) the medication administration process. These categories emerged from several subcategories which can be drawn on a broad conceptual map of interrelations. According to the professionals in the focus group these medication errors result from varying and complex multiple causes which are present in ICUs (Fig.  3 ). Among this wide network of subcategories, the most commonly cited were relationships in the work environment; level of professional knowledge; preparation of dilutions; and the belief or perception that mistakes are not made (also including a mistaken understanding of what constitutes an error).

Conceptual map of the results from the focus group discussion

Phase 3: level of drug knowledge

The level of drug knowledge was analysed in 38 nurses (81.6% female). Of these, 75% had participated in continuing education, 15% of them specifically in pharmacology. In turn, 60% of the professionals in our sample did not know if the centre’s training program offered courses related to pharmacotherapy or error prevention. We discovered that 32.5% of the sample reported possible errors following the procedure established at the hospital, 27.5% informed the attending physician and/or pharmacy service, and the remaining 35% limited their communication to their colleagues and/or supervisor. It also became clear that professionals have an erroneous understanding of what constitutes a medication error for different variables; 85% of the participants identified the omission of a dose as an error, while only 45% identified a delay of more than 1 h in the administration of an antibiotic dose as an error.

With respect to drug knowledge, 42.5% of the nurses in our sample failed more than half the questions on the test. The average score was 47% and the highest score was 69.2%, which reveals a low level of drug knowledge among these professionals. The main drug knowledge gaps detected by this test are shown in Table  3 .

Human factors are responsible for numerous medication errors [ 27 ]. However, it has now been shown that effective prevention must focus on the system, and so the main risk factors present at different stages of the pharmacotherapeutic process must be identified and evaluated so that the system for medication use can be redesigned to be stronger and more error-proof [ 37 ].

In our study, we identified a global medication error index (GMEI) of 1.93%, slightly higher than that obtained in other large multicenter Spanish studies (1.74%). However, the lack of a common and homogeneous criterion and taxonomy that clearly defines medication errors, causes and contributing factors explains the existence of such disparate published results, with a rate that varies from 0.2 to 25.7% [ 3 , 38 , 39 , 40 ]. In turn, this lack of criteria makes it difficult for professionals to have a clear view of the error, its magnitude and importance in clinical practice.

We identify that in the prescription stage a greater number of errors occur than in the transcription, being in this last stage much more varied the type of errors. Our results are similar to others in the literature, however, we find again disparity due to the lack of homogeneous criteria and diversity in the designs of the studies [ 41 ]. In any case, there is a significant correlation between the lack of a correct and complete written prescription and the subsequent presence of errors during transcription. Failures that occur through transcriptions (caused by the lack of a written recipe, abbreviations, etc.) are one of the most frequent causes of errors and one of the most dangerous errors because they are often not detected or not are considered subjectively as errors [ 23 , 37 ].

A logical and well-studied factor that reaffirms the results obtained in our study is the correlation between the use of a greater number of drugs and a longer stay as factors that increase exposure and therefore the risk of medication errors and interactions [ 42 , 43 , 44 ].

The differences in the errors committed between critical patients admitted for medical versus post-surgical care are very interesting. In this sense, the specific nature of post-surgical patient critical care (the therapeutic purpose, physiopathological processes involved, their programmed admission, and continuity of care) and the relative absence of comorbidities, are intrinsic characteristics associated with shorter hospital stays and simpler pharmacotherapeutic programs with a lower risk of exposure, and therefore, of medication errors and drug interactions [ 42 , 43 , 44 ].

From a pharmacological point of view, together with previously published results, our findings confirm the existence of important risk areas in critical care related to the administration of medications via NGTs, although the intravenous route is the most widely used in this context [ 18 , 19 ]; the dose interval of antibiotics [ 16 , 17 ]; and the dilution, concentration, and infusion speed of high-risk medications [ 6 , 21 , 22 , 45 , 46 ].

It is also important to account the possible consequences derived from the numerous potential moderate-risk drug interactions that we identified in the ICU in this study [ 47 ].

In our study, the professionals identify important determinants that influence the problem (discussion group). These results coincide with those published in the literature by other authors [ 15 ]. These variables are lack of communication, poor relationships with the work environment, excessive pressure at work, interruptions in work and a misunderstanding of what constitutes an error, combined with the urgent and critical nature of the provision of professional medical attention in this context. The key variables and root causes of this problem must be continuously analysed so that specific prevention strategies can be defined and to verify their efficacy in clinical practice through successive observational studies.

The medication errors are have a wide variety of interrelated root causes, with nurses’ level of drug knowledge and/or access to information being strongly determining element [ 6 , 13 , 21 , 25 , 26 , 48 ].

Although we cannot prove that increase in drug knowledge is not necessarily associated with changes in clinical practice, many published studies reach similar conclusions to us, and point out a poor of drug knowledge among nurses, especially in the context of ICUs with the drugs most used and in which accumulate a higher error rate [ 24 , 37 ].

Limitations

Our study is partially limited by the intrinsic limitations that contain the error analysis methods we have used, which are described in the literature. Another potentially important limiting factor was that our analysis sample was small and comprised exclusively nurses, to whom we passed an not validated ad hoc questionnaire. Consequently, we have not been able to make solid inferences to the general population. However, in the absence of validated questionnaires, this instrument served to provide an approximate description of the level of drug knowledge, and to reduce the possible bias, we passed our questionnaire to all the nurses of the studied ICU.

A considerable number of medication errors occur in ICUs, especially with critical medical patients. The administration of medications via NGTs, the dose interval of antibiotics and the dilution, concentration, and infusion speed of high-risk medications constitute important areas of risk of medication errors in ICU. Nurses identify four major areas that lead to medication errors: the critical-care context itself; organisation of the ICU service; personal factors; and the medication administration process. In addition, the nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.

Availability of data and materials

The datasets supporting the conclusions of this article are available in the OSF repository: https://osf.io/te7sa/ .

Abbreviations

Anatomical, Therapeutic, Chemical

Potassium Chloride

Global Medication Error Index

Intensive Care Unit

Nasogastric Tube

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Escrivá Gracia, J., Brage Serrano, R. & Fernández Garrido, J. Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC Health Serv Res 19 , 640 (2019). https://doi.org/10.1186/s12913-019-4481-7

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Improving the intensive care experience from the perspectives of different stakeholders

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• Nancy Kentish-Barnes 3 ,
• Theresa Jacques 4 , 5 ,
• Marc Wysocki 6 ,
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The intensive care unit (ICU) is a complex environment where patients, family members and healthcare professionals have their own personal experiences. Improving ICU experiences necessitates the involvement of all stakeholders. This holistic approach will invariably improve the care of ICU survivors, increase family satisfaction and staff wellbeing, and contribute to dignified end-of-life care. Inclusive and transparent participation of the industry can be a significant addition to develop tools and strategies for delivering this holistic care. We present a report, which follows a round table on ICU experience at the annual congress of the European Society of Intensive Care Medicine. The aim is to discuss the current evidence on patient, family and healthcare professional experience in ICU is provided, together with the panel’s suggestions on potential improvements. Combined with industry, the perspectives of all stakeholders suggest that ongoing improvement of ICU experience is warranted.

Introduction

Critical illness impacts patient and relatives. Evidence suggests that prolonged intensive care unit (ICU) stay is associated with physical, mental, cognitive and psychological sequelae for ICU survivors, which can persist long after ICU discharge (Post-ICU Syndrome). Decision-making during ICU stay is often shared with patient’s relatives, which can increase the inherent anxiety and depression from having a loved-one in the ICU [ 1 ]. Furthermore, the ICU environment is an emotional place for healthcare professionals, who experience challenging situations that provoke conflicting emotions such as isolation, sadness, anger, shame, love, and happiness [ 2 ].

Structured interventions and approaches aimed at improving patient, family and healthcare experiences have recently been the focus of research in the ICU [ 3 , 4 , 5 ]. We present an overview of the discussion raised by a panel of experts, who participated in a GE Healthcare-sponsored symposium held during the LIVES2021 congress of the European Society of Intensive Care Medicine (ESICM). This was a multi-national and multi-disciplinary symposium with presentations from colleagues with extensive experience in ICU. We decided to add representation from the sponsoring company, recognising the importance of technology in creating an optimum ICU environment. The aim of this report is to discuss and present expert suggestions that may improve the ICU experience of patients, their relatives, and healthcare professionals, including the perspectives of industry.

The patient perspective

Individual aspects of patient experience, such as quality of sleep, pain and sedation, are measured during ICU admission to guide and assess our interventions. The ICU survivors recall their experience to varying degrees and their recollection may be factual or illusory [ 6 ]. Measuring and understanding recalled patient discomfort has the potential to provide a global measure of patient ICU experience.

Measuring recalled discomfort

Van de Leur et al. demonstrated a link between patient’s factual recall of ICU events and the recollection of discomfort experienced during an ICU stay [ 7 ]. Focusing on recalled discomfort is important because it is associated with post-ICU syndromes, such as sleep disturbance, anxiety, mood disorders and Post-Traumatic Stress Disorder (PTSD).

The validated IPREA ( Inconforts des Patients de REAnimation ) questionnaire measures perceived or recalled discomfort from an ICU episode and can be used irrespective of the diagnosis, the disease or the organ support the patient receives. The ICU survivors are asked at ICU discharge about possible causes of discomfort, using an 18-item questionnaire, and rate the severity of each cause. The questionnaire has been translated into English [ 8 ]. The IPREA studies show that sleep deprivation, discomfort due to lines and tubes, pain, and thirst are the highest scored items on the discomfort scale [ 9 ], with ICU experiences of discomfort being similar across countries and cultures.

Improving patient experience

Consideration of the 18 domains of discomfort in Fig. 1 (adapted from Kalfon et al. [ 10 ]) should be incorporated in ICU daily practice. By understanding patient experiences and components of their discomfort clinicians can modify the ICU environment, the care provided and the communication with patients. Environmental factors in ICU design that should be considered include noise reduction, provision of natural light, presence of a clock, telephone and TV, as well as maintaining privacy. Aspects of ICU care such as visiting hours, communication of information, mouth and airway care, pain and sedation are paramount in delivering high quality and safe care to ICU patients.

ICU factors related to discomfort

The incidence of PTSD in ICU survivors is approximately 20%. There have been mixed successes in studies using interventions to mitigate PTSD development in the post-ICU phase. The POPPI study, a nurse-led preventative psychological intervention among ICU survivors, did not demonstrate significant reduction in PTSD symptoms at 6 months [ 11 ]. In contrast, the IPREA AQVAR group published a tailored multi-component programme, which used comfort champions and local strategies and showed a significant reduction in overall discomfort and a decrease in PTSD at 12 months post-ICU discharge [ 12 ]. Another recent study reported reduction in PTSD symptoms using a virtual reality programme for ICU discharged patients [ 13 ].

Exploring discomfort post-ICU discharge can provide insights into patient ICU experiences and the impact of quality of care. The incidence or severity of post-ICU syndromes may be reduced by addressing various aspects of discomfort, but more research is warranted. Suggestions to reduce discomfort among ICU patients are presented in Table 1 . The COVID-19 pandemic has highlighted even more the importance of assessing ICU patient experiences and the long-term impact of critical illness and ICU interventions.

The family perspective

Family-centred care is defined as an approach to healthcare that is respectful of and responsive to individual families’ needs and values, and in which partnership and collaboration are key concepts [ 4 , 14 ]. Research has contributed to develop family-centred care by helping clinicians to better understand and improve family members’ experience.

Humanizing the ICU

Debates over closed versus open visiting policies have been numerous, with significant variations in practice between and within countries [ 15 , 16 ]. Unfortunately, the COVID-19 pandemic generated a considerable setback, as ICUs felt compelled to restrict visiting. Importantly, open visiting policies are associated with decreased anxiety and better understanding of information [ 17 ]. In the technical ICU environment, qualitative research has provided dimensions of humanization important to family members, such as personalization (vs. objectification), agency (vs. passivity), togetherness (vs. isolation) and sense-making (vs. loss of meaning) [ 18 ]. Moreover, families in the ICU are sensitive to clinicians’ empathy and to reciprocal relationships [ 19 ].

Families’ psychological burden

Family members are extremely vulnerable during the patient’s ICU stay. They only understand approximately half of the medical information given to them by the ICU team [ 20 ], generating difficulties to adapt and manage hope. Families also remain vulnerable after the patient’s discharge or death. Three months post-ICU discharge, up to 70% suffer from symptoms of anxiety, 35% from symptoms of depression [ 21 ], and up to one third suffer from PTSD-related symptoms [ 22 ].

Communication

Communication is at the heart of the family’s experience. It consists of verbal communication (words) and non-verbal communication (body language), the latter determining the quality of the speakers’ message and its ability to be received [ 23 ]. In highly emotional situations, such as being in ICU, family members are extremely sensitive to non-verbal communication. The quality of overall communication impacts on relatives’ well-being: unsatisfactory communication is associated with higher risk of developing PTSD related symptoms [ 22 ] and in bereaved relatives, it is associated with increased risk of developing complicated grief at 6 and 12 months after the patient’s death [ 2 ].

Improving family experience

Most randomized controlled trials aiming to improve families’ wellbeing have focused on improving communication between ICU clinicians and relatives. The Family End-of-Life Conference, a meeting between the patient’s clinicians and the family, encourages clinicians to V alue family statements, A cknowledge family emotions, L isten to the family, U nderstand the patient as person and E licit questions from families [ 3 ]. In a French trial, this pro-active communication strategy was associated with a decreased risk of developing anxiety, depression and PTSD related symptoms three months after the patient’s death [ 24 ]. Including a nurse facilitator in the family conferences was associated with a decreased risk of developing depression symptoms in family members 6 months after the patient’s ICU discharge or death [ 25 ]. Furthermore, a three-step support strategy for relatives of patients dying after a decision to withdraw treatment, including a family conference before the patient’s death, a room visit during dying and death, and a meeting after the patient’s death, was associated with a decreased risk of developing prolonged grief, as well as anxiety, depression and PTSD related symptoms 6 months after the patient’s death [ 26 ]. More research is needed to evaluate the developed strategies as some interventions have proven to be deleterious [ 27 , 28 ]. Suggestions to improve the family experiences are presented in Table 2 .

The healthcare professionals’ perspective

The COVID-19 pandemic generated a new dimension on the experiences of ICU professionals. Survey studies have indicated the increase physical and psychological burden of ICU staff while caring for COVID patients [ 29 , 30 , 31 ]. Qualitative studies generated a deeper understanding of the impact [ 32 , 33 ], which can be summarised as the ‘emotional impact affecting the personal self’, the ‘professional fellowship among colleagues’ and the ‘recognition and support from the outside’.

Emotional comfort

The experiences of ICU healthcare professionals have mainly been studied by qualitative research methods [ 5 , 34 ]. In these studies, a range of emotions have been identified, with one of the six reported themes being that of emotional impact [ 35 ]. Within this theme, ICU nurses addressed empathy as an important skill to develop, whereas for ICU doctors, the overarching themes were the risk and benefits of empathy, the spectrum of connection and distance from patients/families, and the facilitators and barriers to empathy development [ 36 ]. A scoping review indicated that empathy among intensivists is not a dichotomous phenomenon and that a deeper understanding is needed to create a supportive environment where ICU professionals feel safe to demonstrate their empathy to patients and relatives [ 36 ].

Complexity of decision-making

The complexity of ICU patients and their pathway to recovery or death influences the performance of ICU staff and impact on their mental health. This complexity does not only relate to caring for certain patient groups but also to participation in decision-making. The involvement in decisions relating to treatment withdrawal or organ donation has been challenging for many ICU professionals [ 37 , 38 , 39 ]. The low research priority given to delirium care has caused frustration to ICU nurses, due to the resulting lack of confidence in assessing delirium. 15 Most studies conclude that continuous specialist education is required to provide high quality-of-care to the increasingly complex ICU patient.

Improving healthcare professional experience

Improving the ICU experience of healthcare professionals is necessary in order to maintain safe ICU environment, high quality ICU staffing and a sustainable workforce. It is essential for the formation of a positive ICU climate, which will help healthcare professionals cope with the most complex needs of ICU patients and relatives, and provide high quality of care [ 40 , 41 ]. Staff empathy skills can be taught, as demonstrated by a 5-day course on empathy education, including simulation training, which significantly increased the empathy levels of student nurses [ 42 ]. Further suggestions to support the health and well-being of ICU health professionals are presented in Table 3 .

The industry perspective

Professional organizations are describing the ICU as ‘very daunting place… equipped with many devices to monitor the patients… sophisticated machines and screens... alarms… with the devices connected to a central station…’ [ 43 ].

Medical devices and impact on comfort

Medical devices, such as ventilators, renal replacement equipment, infusion pumps and extracorporeal membrane oxygenators have the potential to influence patients’, families’ and healthcare professionals’ ICU experience. In Fig. 1 it is obvious that discomfort is often generated by medical equipment, such as alarms inducing excess of noise or lines, tubes and cables constraining the patient. Noise is a common source of patient discomfort and may have negative impact on the visiting family and healthcare professionals [ 10 ]. By mapping the various sources of noise in ICU, Darbyshire et al. found that a significant proportion originated from equipment alarms in extremely limited areas, very close to patients’ ears [ 44 ].

Improving by digital transformation

The contribution of industry can have a positive impact on the entire ICU ecosystem (Fig. 2 ). By digital adjustment and automatization, the unavoidable clerical burden needed for resource allocation and documentation, can be alleviated, allowing staff to dedicate their time to spending clinical time with patients and the families. In an 18-bed academic medical-surgical ICU, Bosman et al. reported a 30% reduction in documentation time by using a clinical information system at the bedside; time, which was completely re-allocated to patient care [ 45 ]. The digital transformation of ICU helps reduce not only the documentation burden but also improves patient comfort and family engagement and communication. Dashboards displaying discomfort scores may act as reminders and influence the provided care, enhancing ICU experience. A dedicated ICU clinical information system may also general reminders to alert ICU staff that a communication with the family is needed and thus preventing potential conflict.

Conceptual framework for an holistic approach of discomfort in the ICU.

If patient’s discomfort is relatively well documented (Baumstarck 2014), family discomfort and healthcare provider discomfort need to be further investigated. The concept is assuming that some of the source of discomfort are unavoidably shared by all the participants (patient, family, healthcare providers). Improving ICU experience by reducing discomfort may be best achieved by considering the entire ICU ecosystem, including peoples (patient, family, healthcare providers), various workflow and process and the surrounding medical equipment and devices.

A redesign of the ICU environment to move alarm sounds away from the bedside may significantly reduce noise-related discomfort. Improving the operational value and the usability of alarm signals, without being unnecessarily distracting or disturbing, is also the goal of recently updated safety standards (ISO 60601-1-8) which need to be followed by manufacturing companies. Sophisticated stand alone or embedded alarm management solutions have been developed not only to reduced noise-related discomfort but also to avoid family anxiety and caregivers’ annoyance and alarm fatigue [ 46 ]. Collaboration in equipment design and digital solutions between clinicians, patients and industry is part of the solution for stakeholder experience in ICU.

Critically ill patients experience various discomforts during their ICU stay, that may be related to the environment (noise, light, temperature, etc.), some aspects of care organisation (continuous light, limited visiting hours, lack of privacy, etc.), and also specific ICU therapeutics (mechanical invasive and non-invasive ventilation renal replacement therapy, or painful procedures). This conference paper has focused on interventions that may enhance ICU experience not only for patients but also for families and critical care staff. The daily assessment and recognition of potential patient discomfort in ICU will ensure greater insight into their experience and improve the quality of the offered care. Improving communication both at an individual but also at a collective level has been highlighted as the most important intervention for improving family experience, by making family-centred care a quality standard. Revisiting ICU staffing models and training of nurses and doctors on empathy and communication skills are important in order to create a positive ICU climate with a sustainable workforce. The transparent involvement and collaboration of industry in developing tools and technologies that are aimed at humanising the ICU environment is increasingly recognised as an important part of the equation.

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GE-Healthcare organised the industry-sponsored session at the LIVES2021 congress of the European Society of Intensive Care Medicine. The speakers and chairs of this session received funding from GE Healthcare. GE Healthcare was involved in the programme but not involved in the content of the presentations. GE Healthcare was involved in the previous draft of this manuscript and delivered the content of the section ‘the industry perspective’.

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VM and EA were the chairs of the industry-sponsored session at the LIVES2021 congress and wrote the introduction and discussion sections of the manuscript. TJ, NKB and JML were speakers at the industry-sponsored session at the LIVES2021 congress and wrote the first three main perspectives sections of the manuscript. MW organised the industry-sponsored session at the LIVES2021 congress and wrote the section on industry perspectives. All authors wrote parts of the manuscript text. TJ prepared Fig. 1 and Table 1 ; NKB prepared Table 2 ; JML prepared Table 3 ; MW prepared Fig. 2 . All authors read and approved the final manuscript.

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JML has over 30 years of critical care experience as a nurse and is currently a professor in clinical nursing. His main clinical and academic interest and achievements in ICU are family-centred care, ICU staff leadership and shared decision-making. He is the Chair-elect of the Ethics Section of the European Society of Intensive Care Medicine.

NKB is a sociologist and currently co-director of the Famiréa research group at the Saint Louis hospital, AP-HP, France. Her research includes quantitative and qualitative studies on end-of-life in the ICU, communication and support strategies, post-ICU burden, and organ donation.

TJ was Director of ICU, St George Hospital, Australia for over 30 years. She has a longstanding interest in the long term outcome of ICU care and education and simulation. Her study on measuring patient comfort was awarded best scientific paper by the College of Intensive Care Medicine in 2018.

MW is a board certified intensivist and was practicing for almost 20 years as senior ICU co-director of a university affiliated hospital in Paris, France. As global medical director for GE Healthcare his clinical and academic expertise on various ICU domains is instrumental to the development of medical device and solutions in the acute care domain.

EA is an Intensive care medicine specialist at the Saint-Louis university hospital of Paris and Paris Cité University.

VM is a consultant in Critical Care in King’s College Hospital, London. Her main academic and clinical interests are palliative care and end of life in ICU, management of patients with haemato-oncological malignancy and critical care outreach services.

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The financial competing interest are: JML, NKB; TJ, EA and VM received a fee for presenting or chairing at the GE Healthcare sponsored session at the LIVES2021 congress. MW is a representative of GE Healthcare, and this commercial company sponsored the industry-sponsored session at the LIVES2021 congress. GE Healthcare adhered to the Good Publication Practice guidelines for pharmaceutical companies. In addition, EA has received fees for lectures from Gilead, Pfizer, Sanofi, and Alexion. His research group has been supported by Baxter, Fisher & Payckle, Jazz Pharma, and MSD. VM has received lecturing fees from Gilead. The non-financial competing interests are: All authors declare that the content of the manuscript reflect their own view and not of any organisation.

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Latour, J.M., Kentish-Barnes, N., Jacques, T. et al. Improving the intensive care experience from the perspectives of different stakeholders. Crit Care 26 , 218 (2022). https://doi.org/10.1186/s13054-022-04094-x

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Research Article

Sepsis assessment and management in critically Ill adults: A systematic review

Contributed equally to this work with: Mohammad Rababa, Dania Bani Hamad, Audai A. Hayajneh

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Adult Health Nursing Department, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

• Mohammad Rababa, 
• Dania Bani Hamad, 
• Audai A. Hayajneh

• Published: July 1, 2022
• https://doi.org/10.1371/journal.pone.0270711
• Reader Comments

Early assessment and management of patients with sepsis can significantly reduce its high mortality rates and improve patient outcomes and quality of life.

The purposes of this review are to: (1) explore nurses’ knowledge, attitude, practice, and perceived barriers and facilitators related to early recognition and management of sepsis, (2) explore different interventions directed at nurses to improve sepsis management.

A systematic review method according to the PRISMA guidelines was used. An electronic search was conducted in March 2021 on several databases using combinations of keywords. Two researchers independently selected and screened the articles according to the eligibility criteria.

Nurses reported an adequate of knowledge in certain areas of sepsis assessment and management in critically ill adult patients. Also, nurses’ attitudes toward sepsis assessment and management were positive in general, but they reported some misconceptions regarding antibiotic use for patients with sepsis, and that sepsis was inevitable for critically ill adult patients. Furthermore, nurses reported they either were not well-prepared or confident enough to effectively recognize and promptly manage sepsis. Also, there are different kinds of nurses’ perceived barriers and facilitators related to sepsis assessment and management: nurse, patient, physician, and system-related. There are different interventions directed at nurses to help in improving nurses’ knowledge, attitudes, and practice of sepsis assessment and management. These interventions include education sessions, simulation, decision support or screening tools for sepsis, and evidence-based treatment protocols/guidelines.

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis in critical care patients.

Nurses have poor to good knowledge, practices, and attitudes toward sepsis as well as report many barriers related to sepsis management in adult critically ill patients. Despite all education interventions, no study has collectively targeted critical care nurses’ knowledge, attitudes, and practice of sepsis management.

Citation: Rababa M, Bani Hamad D, Hayajneh AA (2022) Sepsis assessment and management in critically Ill adults: A systematic review. PLoS ONE 17(7): e0270711. https://doi.org/10.1371/journal.pone.0270711

Editor: Paavani Atluri, Bay Area Hospital, North Bend Medical Center, UNITED STATES

Received: December 1, 2021; Accepted: June 14, 2022; Published: July 1, 2022

Copyright: © 2022 Rababa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the article and its files.

Funding: This study was funded by The deanship of research at Jordan University of Science and Technology (grant number 20200668).

Competing interests: The authors have declared that no competing interests exist.

Introduction

Sepsis is a global health problem that increases morbidity and mortality rates worldwide and which is one of the most common complications documented in intensive care units (ICUs) [ 1 ]. About 48.9 million cases of sepsis and 11 million sepsis-related deaths were documented in 2017 worldwide [ 2 ]. Sepsis is an emergency condition leading to several life-threatening complications, such as septic shock and multiple organ dysfunction and failure [ 3 ]. Sepsis has negative physiological, psychological, and economic consequences. Untreated sepsis can lead to septic shock; multiple organ failure, such as acute renal failure [ 4 ]; respiratory distress syndrome [ 5 ]; cardiac arrhythmia (e.g. Atrial Fibrillation) [ 6 ]; and disseminated intravascular coagulation (DIC) [ 7 ]. Also, sepsis is associated with anxiety, depression, and post-traumatic stress disorder [ 8 ]. As for the financial burden of sepsis on the healthcare system, the cost of healthcare services and supplies for ICU critical care patients with sepsis is high [ 1 ]. In 2017, the estimated annual cost of sepsis in the United States (US) was over $24 billion [ 2 ].

Previous studies have shown that among nurses, misunderstanding and misinterpretation of the early clinical manifestations of sepsis, poor knowledge, attitudes, and practices related to sepsis, and inadequate training might lead to delayed assessment and management of sepsis [ 9 – 11 ]. Moreover, the limited numbers of specific and sensitive assessment tools and standard protocols for the early identification and assessment of sepsis in critical care patients leads to delayed management, therefore increasing sepsis-related mortality rates [ 10 ].

Critical care nurses, as frontline providers of patient care, play a vital role in the decision-making process for the early identification and prompt management of sepsis [ 11 ]. Therefore, improving nurses’ knowledge, attitudes, and practices related to the early identification and management of sepsis is associated with improved patient outcomes [ 12 , 13 ]. To date, there remains a wide gap between the findings of previous research and sepsis-related clinical practice in critical care units (CCUs). Furthermore, there is no evidence in the nursing literature regarding nurses’ knowledge, attitudes, and practices related to the early identification and management of sepsis in adult critical care patients and the association of these factors with patient health outcomes. Therefore, summarizing and synthesizing the existing research on sepsis assessment and management among adult critical care patients is needed to guide future directions of sepsis-related clinical practice and research. Accordingly, this review aims to identify nurses’ knowledge, and attitudes, practices related to the early identification and management of sepsis in adult critical care patients.

Materials and methods

The present review used a systematic review design guided by structured questions constructed after reviewing the nursing literature relevant to sepsis assessment and management in adult critical care patients. The authors (MR, DB, AH) carefully reviewed and evaluated the selected articles and synthesized and analyzed their findings to reach a consensus. This review was guided by the following questions: (a) what are nurses’ knowledge, attitudes, and practices related to sepsis assessment and management in adult critical care patients?, (b) what are the perceived facilitators of and barriers to the early identification and effective management of sepsis in adult critical care units?, and (c) what are the interventions directed at improving nurses’ sepsis assessment and management?

Eligibility criteria

The review questions were developed according to the PICOS (Participants, Interventions, Comparisons, Outcome, and Study Design) framework, as displayed in Table 1 .

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Inclusion criteria.

The articles were retrieved and assessed independently by two researchers (MR, DB) according to the following inclusion criteria: (1) being written in English, (2) having an abstract and reference list, (3) having been published during the past 10 years, (4) focusing on critical care nurses as a target population, (5) examining knowledge, attitudes, and practices related to the assessment and management of sepsis, and (6) having been conducted in adult critical care units.

Exclusion criteria.

Studies were excluded if they were (1) written in languages other than English, and (2) conducted in pediatric critical care units or non-ICU. Dissertations, reports, reviews, editorials, and brief communications were also excluded.

Search strategy.

An electronic search of the databases CINAHL, MEDLINE/PubMed, EBSCO, Embase, Cochrane, Scopus, Web of Science, and Google Scholar was conducted using combinations of the following keywords: critical care, intensive care, critically ill, critical illness, knowledge, awareness, perception, understanding, attitudes, opinion, beliefs, thoughts, views, practice, skills, strategies, approaches, barriers, obstacles, challenges, difficulties, issues, problems, limitations, facilitators, motivators, enablers, sepsis, septic, septic shock, and septicemia. The search terms used in this review were described in S1 File . The search was initially conducted in March 2021, and a search re-run was conducted in April 2022. The search was conducted in the selected databases from inception to 4/2022. The initial search, using the keywords independently, resulted in 1579 articles, and after using the keyword combinations, this number was reduced to 241 articles. Then, after applying the inclusion and exclusion criteria, the number of articles was reduced to 92. A manual search of the reference lists of the 92 articles was carried out to identify any relevant publications not identified through the search. The researcher (MR) used the function “cited by” on Google Scholar to explore these publications in more depth. The researchers (MR, DB) then screened the identified citations of these publications, applying the eligibility criteria. In case of discrepancies, the researchers (MR, DB) discussed their conflicting points of view until a consensus was reached. Then, after careful reading of the article abstracts, 61 irrelevant articles were excluded, and a total of 31 articles were included in this review. Fig 1 below shows the Preferred Reporting Items for Meta-Analysis (PRISMA) checklist and flow chart used as a method of screening and selecting the eligible studies.

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Data extraction

The following data were extracted from each of the selected studies: (1) the general features of the article, including the authors and publication year; (2) the characteristics of the study setting (e.g., single vs. multisite); (3) the sociodemographic and clinical characteristics of the target population, including mean age, and medical diagnosis (e.g., sepsis, septic shock, and SIRS); (4) the name of the sepsis protocol used, if any; (5) the characteristics of the study methodology (e.g., sample size and measurements); (7) the main significant findings of the study; and (8) the study strengths and limitations. All extracted data were summarized in an evidence-based table ( Table 2 ). Data extraction was performed by two researchers (MR, DB). An expert third researcher (AH) was consulted to reach a consensus between the two researchers throughout the process of data extraction.

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Ethical considerations

There was no need to obtain ethical approval to conduct this systematic review since no human subjects were involved.

Quality assessment and data synthesis

A quality assessment of the selected studies was performed independently by two researchers based on the guidelines of Melnyk and Fineout-Overholt [ 14 ]. Disagreements between the two researchers (MR, DB) were identified and resolved through a detailed discussion held during a face-to-face meeting. For complicated cases, the researchers (MR, DB) requested a second opinion from a third researcher (AH). According to the guidelines of Melnyk and Fineout-Overholt [ 14 ], twelve of the studies were at level 3 in terms of quality, four studies at level 5, and nine studies at level 6.

A qualitative synthesis was performed to synthesize the findings of the reviewed studies. The following steps were applied throughout the process of data synthesis:

• The data in the selected studies were assessed, evaluated, contrasted, compared, and summarized in a table ( Table 2 ). This data included the design, purpose, sample, main findings, strengths/limitations, and level of evidence for each of the studies.
• The similarities and differences between the main findings of the selected studies were highlighted.
• The strengths and limitations of the reviewed studies were discussed.

Description of the selected studies

Most of the reviewed studies were conducted in Western countries [ 9 , 11 , 12 ], with only one study conducted in Eastern countries [ 1 ], and two in Middle-Eastern countries [ 15 , 16 ]. The detailed geographical distribution of the studies and other characteristics are described in Table 2 .

Nurses’ knowledge, attitudes, and practices

Nine of the selected studies assessed nurses’ knowledge and attitudes related to sepsis assessment and management in critically ill adult patients [ 1 , 9 , 12 , 15 , 17 – 21 ] ( Table 3 ) . Nucera et al. [ 18 ] found that ICU nurses had poor attitudes towards blood culture collection techniques and timing and poor levels of knowledge related to the early identification, diagnosis, and management of sepsis. For example, the majority of nurses reported that there is no need to sterilize the tops of culture bottles, and there is no specific time for specimen collection [ 18 ]. However, the participating nurses reported good levels of knowledge related to blood culture procedures and the risk factors for sepsis. Similarly, R. J. Roberts et al. [ 19 ] found the participating nurses to have good knowledge of septic shock and good attitudes toward the initiation of antibiotics for critically ill adult patients with sepsis. Only two studies assessed nurses’ practices related to sepsis assessment and management [ 15 , 19 ]. For example, in the study of R. J. Roberts et al. [ 19 ], 40% of the nurse participants reported that they were aware of the importance of initiating antibiotics and IV fluid within one hour of septic shock recognition [ 20 ]. Also, Yousefi et al. [ 15 ] found the participating nurses to have good practices related to sepsis assessment and management.

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Barriers to and facilitators of sepsis assessment and management

The reviewed studies identified three types of barriers to the early identification and management of sepsis, namely patient-, nurse-, and system-related barriers ( Table 4 ). Meanwhile, only nurse- and system-related facilitators were reported in the reviewed studies. The most-reported barriers and facilitators were system-related. The reported barriers included (a) the lack of written sepsis treatment protocols or guidelines adopted as hospital policy [ 22 , 23 ]; (b) the complexity and atypical presentation of the early symptoms of sepsis [ 19 ]; (c) nurses’ poor level of education and clinical experience [ 1 , 12 ]; (d) the lack of sepsis educational programs or training workshops for nurses [ 22 , 23 ]; (e) the high comorbid burden among patients with sepsis, which complicates the critical thinking process of sepsis management [ 19 ]; (f) nurses’ deficits in knowledge related to sepsis treatment protocols and guidelines [ 22 – 24 ]; (g) the lack of mentorship programs in which junior nurses’ actions/activities are strictly supervised by experienced nurses [ 17 , 23 ]; (h) heavy workloads or high patient-nurse ratios [ 22 ]; (i) the shortage of well-trained and experienced physicians, particularly in EDs [ 19 , 22 , 23 ]; (j) the lack of awareness related to antibiotic use for patients with sepsis [ 19 , 22 ]; (k) the lack of IV access and unavailability of ICU beds [ 25 ]; (l) the non-use of drug combinations for the treatment of sepsis [ 22 , 26 , 27 ], and (m) poor teamwork and communication skills among healthcare professionals [ 22 , 26 ]. Only three facilitators of sepsis assessment and management were identified in the reviewed studies. These facilitators were (1) nurses’ improved confidence in caring for patients with sepsis, (2) increased consistency in sepsis treatment, and (3) positive enforcement of successful stories of sepsis management [ 22 , 27 ].

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Measurement tools of sepsis-related knowledge, attitudes, and practices

One of the reviewed studies used a Knowledge, Attitudes, and Practice (KAP) questionnaire developed according to the Surviving Sepsis Campaign (SSC) guidelines [ 15 ] to measure nurses’ knowledge, attitudes, and practices related to sepsis assessment and management. Meanwhile, eight studies [ 1 , 9 , 12 , 17 – 21 ] used self-developed questionnaires based on the literature and SSC guidelines and validated by expert panels. Details of these measurement tools and their psychometric properties are summarized in Table 5 .

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Interventions directed at improving nurses’ sepsis assessment and management

Educational programs..

Only four of the selected studies examined the impact of educational programs on nurses’ knowledge, attitudes, and practices related to sepsis management and found significant improvements in nurses’ posttest scores ( Table 6 ) [ 11 , 15 , 28 , 29 ]. For example, Drahnak’s study [ 28 ] implemented an educational program developed by the authors and integrated with patients’ health electronic records (HER) and found significant improvements in nurses’ post-test nursing knowledge scores. Another educational program developed by the authors was implemented to improve ICU nurses’ knowledge, attitudes, and practices related to sepsis and found a significant improvement in posttest scores among the intervention group [ 15 ]. Another study was designed to examine the effectiveness of the Taming Sepsis Educational Program® (TSEP™) in improving nurses’ knowledge of sepsis [ 11 ]. A 15-minute structured educational session was developed to decrease the mean time needed to order a sepsis order set for critically ill patients through improving ER nurses’ knowledge about SSC guidelines and found that the mean time was reduced by 33 minutes among the intervention group [ 29 ].

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Simulation.

Only two studies examined the effect of using simulation in improving the early recognition and prompt treatment of sepsis by critical care nurses ( Table 6 ) [ 30 , 31 ]. Vanderzwan et al. [ 30 ] assessed the effect of a medium-fidelity simulation incorporated into a multimodel nursing pedagogy on nurses’ knowledge of sepsis and showed significant improvements in six of the nine questionnaire items. While Giuliano et al. examined the difference in mean times required for sepsis recognition and treatment initiation between nurses exposed to two different monitor displays in response to simulated case scenarios of sepsis and showed a significant reduction in the mean times required for sepsis recognition and treatment initiation by those nurses who were exposed to enhanced bedside monitor (EBM) display [ 31 ].

Decision support tools.

Four of the selected studies examined the effectiveness of decision support tools, adapted based on the SSC guidelines and the “sepsis alert protocol”, on the early identification and management of sepsis and confirmed the effectiveness of these tools ( Table 7 ) [ 32 – 35 ]. The decision support tools used in three of the studies guided the nurses throughout their decision-making processes to reach effective assessment, high quality and timely management of sepsis, and, in turn, optimal patient outcomes [ 32 , 33 , 35 ]. However, no significant differences in the time of blood culture collection and antibiotic administration were reported between the intervention and control groups in the study of Delawder et al. [ 34 ].

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Sepsis protocols.

Eight of the selected studies examined the effectiveness of sepsis protocols [ 24 , 36 – 38 ] and sepsis screening tools [ 16 , 39 – 41 ] for the early assessment and management of sepsis ( Table 7 ). All of these articles revealed that the implementation of sepsis screening tools or protocols based on the SSC guidelines leads to the early identification and timely management of sepsis, as well as the improvement in nurses’ compliance to the SSC guidelines for the detection and management of sepsis. For example, in one study, patients who received Early Goal-Directed Therapy (EGDT) had a lower mortality rate as compared to patients who received usual care [ 16 ]. The sepsis screening tools and guidelines were also tested to examine their impact on some patient outcomes, and variabilities were identified. For example, the use of the Modified Early Warning Score (MEW-S) tool revealed no significant improvement in patient mortality rate [ 41 ]. In contrast, mortality rates were decreased by using the Nurse Driven Sepsis Protocol (NDS) [ 40 ], Quality Improvement (QI) initiative [ 38 ], and a computerized protocol [ 37 ]. In addition, nurses in the computerized protocol group had better compliance with the SSC guidelines than did nurses in the paper-based group [ 37 ]. One of the selected studies compared between a paper-based sepsis protocol and a computer-based protocol and found that antibiotic administration, blood cultures, and lactate level checks were conducted more often and sooner by nurses in the computerized protocol group [ 37 ]. Two of the selected studies used the EGDT as a screening tool for sepsis and found no significant differences in times of diagnosis, blood culture collection, or lactate measurements between the control and intervention groups [ 16 , 24 ]. However, significant differences were found in the time of antibiotic administration in the study of Oliver et al. [ 24 ]. Although El-khuri et al. [ 16 ] revealed no significant differences in the time of antibiotic administration, the mortality rate among patients in the intervention group declined significantly.

Most of the reviewed studies focused on assessing critical care nurses’ knowledge, attitudes, and practices related to sepsis assessment and management, revealing poor levels of knowledge, moderate attitude levels, and good practices. Also, this review revealed that the three most common barriers to effective sepsis assessment and management were nursing staff shortages, delayed initiation of antibiotics, and poor teamwork skills. Meanwhile, the three most common facilitators of sepsis assessment and management were the presence of standard sepsis management protocols, professional training and staff development, and positive enforcement of successful stories of sepsis treatment. Moreover, this review reported on a wide variety of interventions directed at improving sepsis management among nurses, including educational sessions, simulations, screening or decision support tools, and intervention protocols. The impacts of these interventions on patient outcomes were also explored.

The findings of our review are consistent with the findings of previous studies which have explored critical care nurses’ knowledge related to sepsis assessment and management [ 42 ]. Also, recent studies conducted in different clinical settings support the findings of our review regarding nurses’ knowledge of sepsis. For example, a recent study conducted in a medical-surgical unit revealed that nurses had good knowledge of early sepsis identification in non-ICU adult patients [ 43 ]. The variations in nurses’ levels of knowledge related to sepsis assessment were attributed to variations in educational level and work environment (i.e., ICU vs. non-ICU).

The evidence indicates that the successful treatment of critically ill patients with suspected or actual sepsis requires early identification or assessment [ 44 , 45 ]. Early assessment is a critical step for the initiation of antibiotics for patients with sepsis, leading to improved patient outcomes and a decline in mortality rates [ 44 ]. The current review also revealed the significant role of educational programs in improving nurses’ knowledge, attitudes, and practices related to the early recognition and management of sepsis. These findings are in line with the findings of another study, which tested the impact of e-learning educational modules on pediatric nurses’ retention of knowledge about sepsis [ 45 ]. The study revealed that the educational modules improved the nurses’ knowledge acquisition and retention and clinical performance related to sepsis management [ 45 ]. The findings of our review related to sepsis screening and decision support tools are in congruence with the findings of a previous clinical trial which assessed the impact of a prompt telephone call from a microbiologist upon a positive blood culture test on sepsis management [ 46 ]. The study revealed that this screening tool contributed to the prompt diagnosis of sepsis and antibiotic administration, improved patient outcomes, and reduced healthcare costs [ 46 ]. The findings of our review related to the effectiveness of educational programs in improving the assessment and management of sepsis were consistent with the findings of a recent quasi-experimental study. The study found that incorporating sepsis-related case scenarios in ongoing educational and professional training programs improved nurses’ self-efficacy and led to a prompt and accurate assessment of sepsis [ 47 ]. One of the interventions explored in this review was a simulation that facilitated decision-making related to sepsis management. The simulation was found to be effective in mimicking the real stories of patients with sepsis and proved to be a safe learning environment for inexperienced nurses before encountering real patients, increasing nurses’ competency, self-confidence, and critical thinking skills [ 48 ]. Also, a recent study showed that the combination of different interventions aimed at targeting sepsis assessment and management, including educational programs and simulation, may lead to optimal nurse and patient outcomes [ 49 ].

Limitations

The present review has several limitations. There is limited variability in the findings of the reviewed studies in terms of the main variable, sepsis. Moreover, the review excluded studies written in languages other than English and conducted among populations other than critical care nurses. However, there may be studies written in other languages which may have significant findings not considered in this review. Further, only eight databases were used to search for articles related to the topic of interest, which may have limited the number of retrieved studies. Finally, due to the heterogeneity between the selected studies, a meta-analysis was not performed.

Relevance to clinical practice

Our findings could help hospital managers in developing continuous education and staff development training programs on assessing and managing sepsis for critical care patients. Establishing continuous education, workshops, professional developmental lectures focusing on sepsis assessment and management for critical care nurses, as well as training courses on how to use evidence-based sepsis protocol and decision support and screening tools for sepsis, especially for critical care patients are highly recommended. Also, our findings could be used to development of an evidence-based standard sepsis management protocol tailored to the unmet healthcare need of patients with sepsis.

To date, nurses remain to have poor to good knowledge of and attitudes towards sepsis and report many barriers related to the early recognition and management of sepsis in adult critically ill patients. The most-reported barriers were system-related, pertaining to the implementation of evidence-based sepsis treatment protocols or guidelines. Our review indicated that despite all educational interventions, no study has collectively targeted nurses’ knowledge, attitudes, and practices related to the assessment and treatment of sepsis using a multicomponent interactive teaching method. Such a method would aim to guide nurses’ decision-making and critical thinking step by step until a prompt and effective treatment of sepsis is delivered. Also, despite all available protocols and guidelines, no study has used a multicomponent intervention to improve health outcomes in adult critically ill patients. Future research should focus on sepsis-related nurse and patient outcomes using a multilevel approach, which may include the provision of ongoing education and professional training for nurses and the implementation of a multidisciplinary sepsis treatment protocol.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0270711.s001

S1 File. Search strategies.

https://doi.org/10.1371/journal.pone.0270711.s002

Acknowledgments

The authors want to thank the Liberian of Jordan University of Science and Technology for his help in conducting this review.

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