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Discuss about the Impact of Break Time and Frequency on the Productivity of the Nurses in the ICU.

Background

Nurses and doctors working in intensive care unit (ICU) can handle significant work-related stress, the symptoms of staff emergencies are described as common, and previous studies have highlighted the high Levels of exhaustion symptoms in intensive care staff have been identified. Exhaustion is a psychological term that is often used in response to long-term emotional and interpersonal stress, usually in the context of work. Exhaustion can be the result of too much work and very little improvement. The clinical effect of exhaustion can reduce welfare, such as insomnia, irritability, food problems and depressive problems, and the increase in employee sick leave. It has been shown that the high levels of emotional exhaustion between nurses predict a reduction in the benefits and a greater willingness to leave the work (Duffield et al., 2011). The characteristic features of the organization and the workload, social support and autonomy can be linked to job satisfaction and psychological reactions such as staff exhaustion (Stimpfel, Lake, Barton, Gorman, & Aiken, 2013). The present article aspires to relate the productivity of nurses in critical care units with duty breaks and working environment in the critical care units (Faye et al., 2011; Stimpfel, & Aiken, 2013). A descriptive approach with cause and effect analysis with regression approach has been exercised as tools of quantitative analysis (Gurses, & Carayon, 2009).

Previous ICU studies have identified several factors related to the development of Exhaustion: personal characteristics, working conditions, especially in the form of long-term overload, ICU and conflict, low support and nonsense useful work. Conflicts have been found to be common and associated with increased stress at work. Personality has also been shown to influence problem-solving strategies and stress observations at work, and neurotic have been considered to be predictors of exhaustion correlated with emotional exhaustion. Nurses with extroverted personalities reported more personal effort and were more satisfied (Kleinpell, Ely, & Grabenkort, 2008). 

Research in this area has reached a point where systematic reviews of literature and other studies on links between different combinations of nursing staff, workload, working environment, and patient results are carried out (Hoonakker et al., 2011; Jennings, 2008). Previously, it had concluded that evidence of the positive effect of a larger proportion of nurses satisfied in the patient's performance in the intensive care and surgery was strong and consistent (Dehghan Nayeri, Salehi, & Ali Asadi Noghabi, 2011). Higher quality caregivers are associated with less hospital mortality, emergency theft, cardiac arrest, hospital inflammation, and less other unwanted occurrences. The results were stronger in the post studies than in the hospital, country or country studies. They concluded that future research should include additional factors such as the organization of Nursing and personnel units, patient characteristics and doctors' patterns in large multicenter studies. The researcher concluded that the risk of reduced frequency of off times, and reduced length of breaks in ICU shifts includes a lack of salvation and the dedication of the nurses, which eventually help to decrease the efficiency of the nursing staff with ever increasing number of patients (Kawano, 2008).

Rationale

It is believed that the differences in working mode and the perception of professional stress are able to reflect differences in personality between the doctors themselves. Knowledge of the relationship between the personality and exhaustion of intensive care unit workers is, however, inadequate and has not previously been studied among nurses and doctors.  Several researchers have used the revised index of nursing work as a measure for the working environment. It and measures the sovereignty of the nurse, control over the practice of relationship between nurses and patients, leadership in nursing and the adequacy of performance level. No survey was found designed to collect nursing workload in 12-hour shift, work environment, and break timings in the patient results in a design because the data have not been available in the three aspects of the model.

The research question was framed with the help of three hypotheses based on the aim of the research.

H01: Productivity level of nurses was not affected by the containment level about break time during 12 hours shift.

H02: There was no statistical evidence of the impact of the number of breaks on productivity level of nurses in ICU

H03: Increase in duration of break time has no significance in the increase in productivity.

The present article researches the following three objectives generated from the break time survey of the nurses of the critical care unit. The objectives are,

  1. If the productivity level of nurses corresponds to the containment level about their satisfaction of break time during their 12 hours shift.
  2. Impact of number of breaks on productivity level of nurses in ICU
  3. Whether the increase in duration of break time increases productivity for the nurses.

The outcome factor or dependent variable was considered as the difference in the productivity of the performance of nurses (DV) in their duties in the critical care unit. The character of the variable was nominal and categorical in nature.

The three control or independent variables were considered as the perception about the sufficiency of the number of breaks in duty shift (IV1), the number of actual breaks granted within the duty hours (IV2), and length of break time during their 12-hour shift (IV3). The first independent variable was nominal and categorical in nature, the number of breaks in duty shift was a scale and discrete variable, and length of break time during their 12-hour shift was considered as an ordinal and categorical variable. The inferential analyses were performed in accordance with the characteristics of the outcome as well as control variables.

The statistical analyses were performed in the SPSS environment. A cross-sectional survey was conducted to collect responses from the nurses about their opinion on break times or recess during their duty shifts. The survey was conducted in a reputed hospital of the town, where the ICU had the facility to treat 20 critical patients. The nurses were highly and professionally trained, with at least 4 years of experience. The survey was conducted with a prior notification to the hospital management. Responses from 82 nurses were collected, and response forms of nurses with experience less than 5 years were excluded. A valid data sample was created with 78 nurses. The categorical responses were coded with binary codes. “Yes” option was coded with 1 and “No” was coded with 0. Regarding the ordinal response of total length of break time, codes from 1 to 4 were assigned. No missing responses were noticed in the responses of 78 nurses.

Aim

Sufficiency of number of breaks in duty shift (IV1)

From Figure 1 the views about the sufficiency of the length of break time were easily interpreted. Most of the nurses (N = 53, P = 67.95%) in the ICU were noted to be satisfied with the length of the breaks in their 12 hours of shifting duty. Rest of the nurses (N = 25, P = 32.05%) were found to be disappointed with the time-span of the breaks within duty timings. It has to be considered that hospitality to the ICU patients is an utmost important issue, and 32.05% dissatisfied nurses could be a problem for patients as well as management of the hospital.

Figure 1: Percentage Summary of Opinion about Enough Break Time

The responses to the number of off or breaks were analyzed for the descriptive summary. It was found that most of the nurses (N = 46, P = 59%) were used to get 2 breaks in their shift of 12 hours. Rest of them had different views, but very few (N = 3, P = 3.8%) nurses opined that they got more than 3 breaks in their duty hours. More than few nurses (N = 17, P = 21.8%) were identified to get 3 breaks in a shift. Rest of them noted to (N = 12, P = 15.4%) receive two breaks in a particular shift during their duty in ICU.

Figure 2: Percentage Summary of Opinion about Number of Breaks in 12 Hour Shift 

From Figure 3 the inspections on the length of a single break in a single shift of 12 hours of duty were wrapped up. A high number of nurses (N = 38, P = 48.7%) told that they were enjoying breaks of length between 30 to 60 minutes. Among the remaining respondents, 22 (P = 28.2%) said that their break times were in between 15 to 30 minutes. Very few of the nurses (N = 11, P = 14.1%) were identified to enjoy breaks of more than 1 hour in their shifts. From the summary of the break length during a shift of 12 hours, it was possible to infer that sample subjects (nurses) were getting the full benefit of breaks from the hospital management. But, the question was, whether the sufficient number of nurses was getting the benefits.

Figure 3: Percentage Summary of Opinion about Duration of Break Time

On the subject of the impact on productivity in the patient care and critical issues in ICU, almost every nurse (N = 72, P = 92.3%) expressed that frequency and length of breaks in a shift have tremendous consequences.  Successful performance in medical emergencies and constant attention to critical patients demands steady attention for all the time. Hence, breaks and long breaks become inevitable for the nurses. Therefore, this outright inclination to correlate productivity and enough breaks were obvious. A mere 6 nurses (P = 7.7%) were found to have a different opinion than rest of the nurses.

Description of Variables

Figure 4: Percentage Summary of Opinion about Break Time Impact

The dependent variable was nominal or Binomial in nature, with 0.5 estimated probabilities for both opinions. The confidence interval estimation regarding the hypothetical difference of the two proportions being zero was tested by the Wald Chi-square test. The confidence interval of the difference of proportions was found to be [0.031, 0.15], which did not contain the hypothetical difference. It was concluded that the proportion of nurses agreeing to the opinion that enough breaks do have a difference in productivity, had a statistically significant difference from another opinion.

Hypothesis H01 (by Chi-Square Test)

The views on the difference in productivity (DV) and enough amounts of breaks in duty hours (IV1) were cross-tabulated. It was noted that the two-way comparison was statistically significant at 5% level of significance. The proportion of nurses in favor of the view that enough breaks have an impact on the productivity level in ICU was found to have a statistically significant difference with the negative view.  

The contingency coefficient was 0.387 (p < 0.05) at 5% level and signified a statistically significant correlation between the control (IV1) and outcome (DV) variables.

Hypothesis H02 (by Chi-Square Test)

The views on the difference in productivity (DV) and the number of breaks granted within the duty hours (IV2) were cross-tabulated. It was noted that the two-way comparison was statistically significant at 5% level of significance. The proportion of nurses in favor of 2 breaks (P = 59%) was found to have a statistically significant difference between the other three ordinal level of the number of breaks.

The contingency coefficient was 0.597 (p < 0.05) at 5% level and signified a statistically significant correlation between the control (IV2) and outcome (DV) variables.

Hypothesis H03 (by Chi-Square Test)

The views on the difference in productivity (DV) and the total amount of breaks time in duty hours (IV1) were cross-tabulated. The two-way comparison was statistically significant at 5% level of significance, where the proportion of nurses in with break time within 15 to 30 minutes was found to have a statistically significant difference with other levels of break time length. The difference across all the break times yielded a significant impact on productivity level in ICU. The association was found to have statistical significance at 5% level of significance.

The contingency coefficient was 0.58 (p < 0.05) at 5% level and signified a statistically significant correlation between the control (IV3) and outcome (DV) variables.

A binary logistic regression model was constructed to assess the impact of the three control variables on the binary outcome of the dependent variable. From the classification table, it was found that 92.3% times the current strategy of nurses (agreeing with the fact that enough breaks impact productivity in ICU) would be correct. Predicted odds of the validity of the current model was found to be Exp (Beta) = 12, as 72 out of 78 nurses agreed with the positive impact of the break time on productivity.

Block 1 output of the model added all the categorical variables except the responses from those subjects who expressed that enough number of breaks was not provided to them. The omnibus test of model coefficients provided a chi-square test value, which rejected the null hypothesis of the present regression model at 5% level of significance. Addition of all the above mentioned independent variables significantly increased the ability of the model to 96.2% to predict the outcome variable. The coefficient of determination or Cox & Snell R-square of 0.334 indicated that the control factors were able to explain merely 33.4% of the outcome factor.  The estimated regression equation was found to be, Enough / sufficient breaks was found to have no impact whatsoever on the outcome variable, or on the views about the difference in productivity due to breaks in 12 hours of shifting duty. The odds in favor of the model for the IDV2 and IDV3 were provided by the Exp (Beta) in the new model. Unfortunately, all the predictors were statistically non-significant in predicting the views about the difference in productivity in ICU.

Data Management

Table 1: Binary Logistic Model of the Research

Correlations and tests of association were done with the help of the contingency coefficient. The outcome and the independent factors in the study were all categorical in nature, where the outcome variable was nominal in nature. Hence, Chi-square test was applied to identify the level of association between the predictor and the outcome variables. The response to the difference in productivity in ICU was found to have a two-way significant relation with enough breaks during the shift. But, the regression model implied that there was no effect on the outcome variable. The categorical levels of the number of breaks were noted to be statistically different across the binary levels of the dependent variable, but, had no significant prediction for assessing the impact on productivity. The break time lengths were significantly different in association with the DV, and in the regression model it indicated that for one level up for the break length, the productive ratio will increase by odds of 20.69, but, no statistical significance was observed in the regression model.

The Intensive Care Unit is a very stressful environment, not only for patients and careers but also for medical personnel. Difficult life insurance solutions are met and suffering exhaustion is common in intensive care personnel. Awareness of work satisfaction and satisfaction is important because it can affect the quality of patient care, poor communication with loved ones and high workers fluctuations (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Schmalenberg, & Kramer, 2008). This cross-sectional study looked at exhaustion, work satisfaction and expected stress in the work of nurses and intensive care physicians (Myhren, Ekeberg, & Stokland, 2013). Although people who have experienced all three measurements of exhaustion have the greatest degree of exhaustion, emotional depletion is invoked as the main feature. It was also found that for estimating Exhaustion in medical professionals, individual elements of measuring emotional depletion and depersonalization (Lewis, & Malecha, 2011).   

This study documents the professional characteristics associated with low productivity and the intention to remain in the care of nurses who are engaged in the immediate care of the patient in hospital life. Nurses in this study usually worked on a 12-hour day or a night plow. This investigation shows that the nurses in a hospital reports of frequent breaks in a work more than 12 hours a day. The synthesis of literature has shown that long working time contributes to the stress and operational deficiency, as well as increasing of the error. Interestingly, despite the reported inability of the nurses to cope up in the shift duties due to excess pressure and less off time, participants were found to report higher satisfaction regarding the breaks provided in the hospital. as well as moderate reductions in labor, most of them were still satisfied with their work. In this study, staff satisfaction was not related to productivity or the intention to remain in care when variables were taken into account in other categorical work situations

Conclusion

Ward environments are much more volatile than those shown in the federal or hospital-level analysis. In most countries, it will not be difficult to obtain residual data analysis, including staff levels, at the individual hospital level. Attention in future studies to identify data on the relationship between the nurse's personality and the workload in the form of special cases of mixtures, patient and circulatory acuity, leadership and management qualities, in the section work, and the results of patients will be profitable, not only of scientific interest, but also of public health policy and institutional well-being (June, & Cho, 2011).  The nurses were much satisfied with their work with the schedule of breaks in the shift of duties. Suffering from exhaustion means that the estimates were relatively low, but higher levels of exhaustion were for the vulnerability of personal qualities, low job satisfaction and high-stress levels of work. Satisfaction with the work of the three intensive care units varies considerably (Kramer, Maguire, & Brewer, 2011). The reason for this is unknown but requires a study of the differences in both diagnoses of the patient and intensive management in the field of exhaustion among the intensive staff.

References

Dehghan Nayeri, N., Salehi, T., & Ali Asadi Noghabi, A. (2011). Quality of work life and productivity among Iranian nurses. Contemporary nurse, 39(1), 106-118.

Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied nursing research, 24(4), 244-255.

Faye, H., Rivera-Rodriguez, A. J., Karsh, B. T., Hundt, A. S., Baker, C., & Carayon, P. (2010). Involving intensive care unit nurses in a proactive risk assessment of the medication management process. The Joint Commission Journal on Quality and Patient Safety, 36(8), 376-AP1.

Gurses, A. P., & Carayon, P. (2009). Exploring performance obstacles of intensive care nurses. Applied ergonomics, 40(3), 509-518.

Gurses, A. P., Carayon, P., & Wall, M. (2009). Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life. Health services research, 44(2p1), 422-443.

Hoonakker, P., Carayon, P., Gurses, A. P., Brown, R., Khunlertkit, A., McGuire, K., & Walker, J. M. (2011). Measuring workload of ICU nurses with a questionnaire survey: the NASA Task Load Index (TLX). IIE transactions on healthcare systems engineering, 1(2), 131-143.

Jennings, B. M. (2008). Work stress and exhaustion among nurses: Role of the work environment and working conditions.

June, K. J., & Cho, S. H. (2011). Low back pain and work?related factors among nurses in intensive care units. Journal of clinical nursing, 20(3?4), 479-487.

Kawano, Y. (2008). Association of job-related stress factors with psychological and somatic symptoms among Japanese hospital nurses: effect of departmental environment in acute care hospitals. Journal of occupational health, 50(1), 79-85.

Kleinpell, R. M., Ely, E. W., & Grabenkort, R. (2008). Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Critical care medicine, 36(10), 2888-2897.

Kramer, M., Maguire, P. A. T., & Brewer, B. B. (2011). Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. Journal of Nursing Management, 19(1), 5-17.

Lewis, P. S., & Malecha, A. (2011). The impact of workplace incivility on the work environment, manager skill, and productivity. Journal of Nursing Administration, 41(1), 41-47.

McHugh, M. D., Kutney-Lee, A., Cimiotti, J. P., Sloane, D. M., & Aiken, L. H. (2011). Nurses’ widespread job dissatisfaction, exhaustion, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2), 202-210.

Myhren, H., Ekeberg, Ø., & Stokland, O. (2013). Job satisfaction and exhaustion among intensive care unit nurses and physicians. Critical care research and practice, 2013.

Schmalenberg, C., & Kramer, M. (2008). Clinical units with the healthiest work environments. Critical Care Nurse, 28(3), 65-77.

Stimpfel, A. W., & Aiken, L. H. (2013). Hospital staff nurses’ shift length associated with safety and quality of care. Journal of Nursing Care Quality, 28(2), 122.

Stimpfel, A. W., Lake, E. T., Barton, S., Gorman, K. C., & Aiken, L. H. (2013). How differing shift lengths relate to quality outcomes in pediatrics. The Journal of nursing administration, 43(2), 95.

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