Evaluation of the relationship between individual workload perception and compliance with isolation measures of emergency and critical care nurses

1 Introduction

Critical care nurses have a major role in delivering long-term health care services, whereas emergency nurses play a key part in the first encounter with the patient. Emergency and critical care unit patients of all ages who require vital and comprehensive care are provided for by nurses. Trained nurses that provide holistic care and provide appropriate health care should be involved in the care of these patients [1, 2].

Isolation measures are the separation of an infected person from patients and healthcare workers in order to prevent the risk of transmission. Hence, it is aimed to reduce the risk of infection of both other patients and healthcare workers. Adequate isolation measures prevent increased mortality, morbidity, length of hospital stay and health care costs [2, 3]. Nurses face the risk of disease in terms of the frequency and intensity of close contact with the patient.

Isolation measures taken by emergency service and critical care nurses are vital for both themselves and other units of the hospital. Nurses’ involvement in infection control and disease prevention also helps reduce the risk of community exposure to disease [4].

Isolation measures may be in the background because emergency nurses focus on emergency response without knowing the infection exposure of the patient they care for [5]. Critical care units are the units where the most invasive interventions are applied to the patients and the patients are most susceptible to infections. Intensive invasive interventions and frequent follow-up applications require nurses to come into contact with patients more frequently, which increase the risk of infection [2].

The high number of patients, insufficient isolation rooms, heavy nurse workload and insufficient management support in the hospital are among the factors that increase the risk of infection. As a result, it makes it inevitable for a nurse, who should only care for the patient in the isolation room, to contact with other patients [6]. In case of an increase in the workload of nurses, the time allocated to the patient decreases, the risk of error increases as a result of carelessness and fatigue, and patient safety is adversely affected [7–9]. The increasing workload and the inadequacy of the number of health workers during the coronavirus 2019 (COVID-19) pandemic have made the measures related to isolation compliance difficult. Healthcare workers had difficulties in following the infection prevention and control instructions due to their workload and had difficulties in using personal protective equipment in the hospital and giving care to isolated patients [9–11]. In a study, it was determined that nurses had to care for many isolated patients and this situation overwhelmingly increased the workload and risk of becoming infected with COVID-19 [10]. Therefore, the increased workload has brought some other problems about health professionals and patients safety [10, 11]. A nurse caring for more than one isolated patient in shifts leads to both working long hours and being busy. On the other hand, the nurse under a heavy workload may forget the procedures that he/she will pay attention to at the point of isolation measures due to carelessness, fatigue and stress [12]. Insufficient implementation of isolation measures causes the proliferation of microorganisms, the spread of infections, and the increase in health costs [13].

When the studies were examined, it was seen that the studies evaluating the relationship between the isolation compliance and the perception of individual workload of nurses working in the emergency service and critical care unit were limited [2–14, 15]. During the COVID-19 pandemic, no study has been found in which the isolation compliance and individual workload perception of nurses working in both units, such as the emergency service and the critical care unit, are considered together. It is considered that revealing the relationship between the workload of nurses and isolation measures may be beneficial regarding workforce planning and prevention of infections in emergency services and intensive care units in hospitals. Evaluation of the individual workload perception and compliance with isolation measures of nurses working in the emergency service and critical care unit.

2 Methods

3 Results

It was determined that the mean age of the nurses (n = 153) was 29.39±5.85 years, 73.2% were female, 84.3% Bachelor’s degree or higher education, 45.8% worked in the emergency department and 54.2% worked in the critical care unit. It was observed that 83.7% of the nurses worked day and night (in shifts), 90.2% of them worked 40 or more hours a week, and their monthly working hours were 198.03±31.19 hours. It was determined that 90.2% of the nurses received training on isolation precautions, 57.5% of them partially accessed the materials related to isolation precautions, and 90.2% applied the most contact isolation (Table 1).

The mean SCIM total score of the nurses participating in the study was 70.70±5.35 (min:34, max:83). The SCIM averages of the socio-demographic and professional knowledge groups of the nurses were statistically compared. Accordingly, a statistically significant difference was found between the SCIM averages of the groups of gender, unit of work, and educational status regarding isolation measures (respectively; p = 0.01, p = 0.01, p = 0.04). It was determined that the female gender, the nurses working in the critical care unit and receiving training on isolation measures had higher SCIM total scale score averages (p < 0.05). In addition, it was found that the total score average of the nurses working 40 or more hours a week in SCIM was lower, but there was no statistically significant difference (p > 0.05) (Table 2).

With the IWPS-R, the socio-demographic and professional data of nurses working in the emergency and critical care units were analyzed. It was determined that the individual workload perception of the nurses working in the emergency service unit was lower, but there was no statistically significant difference (p > 0.05). It was determined that the perception of individual workload was lower in nurses who worked 40 or six hours a week in the emergency service and critical care unit. It was observed that the perception of individual workload of the nurses who received training on isolation precautions and applied respiratory isolation in the unit they worked in was lower than the nurses who did not receive training and did not apply respiratory isolation, but there was no statistically significant difference (p > 0.05) (Table 3).

When IWPS-R and its sub-dimensions were examined, the average of nurses’ individual workload perception was calculated as 3.22±0.54. On the other hand, when the average values of the sub-dimensions of the IWPS are examined, the mean of dimensions of “Colleague Support” (3.46±0.89) and “Unit Support” (3.54±0.61) were found to be higher than the mean of the dimensions “Intention to Stay at Work” (3.15±0.53) “Direct Workload” (3.09±0.70) and “Manager Support” (2.90±1.0).

A weak positive correlation was found between nurses’ perception of individual workload and compliance with isolation measures (r = 0.153; p < 0.05) (Table 4). A weak positive correlation was detected between unit support from individual workload perception sub-dimensions (r = 0.237; p = 0.003), managerial support (r = 0.234; p = 0.004), intention to stay at work (r = 0.174; p = 0.032) and the compliance with isolation measures.

This study was conducted on 153 nurses to examine the relationship between isolation measures and individual workload perception of nurses working in the emergency service and critical care unit during the COVID-19 pandemic. It can be said that the total score average of the nurses’ compliance scale to isolation measures was high. Topics such as hand washing, which is one of the most important components of isolation measures that should be applied while caring for patients, and medical waste management are important points that nurses focus on both during the learning process and when working actively in the field [14–17]. In addition, the fact that the research was carried out during a pandemic suggests that the isolation measures were increased, the awareness of the nurses increased, and the inspections were carried out more frequently.

It was determined that the mean score of the individual workload perception scale of the emergency service and critical care nurses was moderate. Other studies carried out support our results [20, 21]. The lack of hospital management support, adequate equipment and unit support at the desired level may be effective in the moderate level of individual workload perception of nurses working in the emergency service and critical care unit during the pandemic. The increase in the workload of nurses working in these units during the pandemic can be considered as another factor.

In this study, it was determined that nurses working in the emergency service and critical care unit partially accessed the materials at a rate of 57.5% in isolation measures (Table 1). In different studies similar to our study results, it was reported that nurses had problems in accessing materials about applying isolation measures [10, 23]. Considering the use of materials for isolation measures and the time period of the study (COVID-19 pandemic), it is estimated that reaching the materials is more difficult than in a normal period.

It was determined that the compliance of the nurses with a bachelor’s degree or higher education level working in the emergency and critical care units was higher, but there was no statistically significant difference (Table 2). Dogan et al. found in their study that nurses with a bachelor’s degree or higher had higher compliance with isolation measures and there was a statistically significant difference [24]. Lyu et al. found in their study that nurses with higher education levels were more successful in preventing infections in the hospital during the COVID-19 pandemic [25]. As in many fields, the high and qualified level of education in the field of health contributes positively to health services. In this context, it can be concluded that with the increase in the education level of nurses, they use more evidence-based approaches in isolation precautions procedures and prevention of infections.

In this study, it was observed that the compliance of the nurses who were female, working in the critical care unit, and trained in isolation precautions were higher and there was a statistically significant difference (Table 2). Arlı et al. found that female nurses working in the intensive care unit and receiving isolation training were more likely to comply with isolation measures [26]. Similar to the study findings, Şatır et al. also found that female nurses working in the 2019 intensive care unit and receiving isolation training had high compliance with isolation precautions [17]. In the literature, the fact that female nurses are more sensitive about isolation measures has been attributed to being more careful than men in hand hygiene and use of gloves [27].

In this study, it was determined that nurses’ perceptions of individual workload were positively affected by colleague support and unit support. Suliman et al. found that colleague support had a positive effect on reducing the workload of nurses [28]. Welp et al. reported that unit support reduced the individual workload in their study with nurses working in the critical care unit [29]. These results show that colleague and unit support play a role in reducing the individual workload of nurses [21].

It was determined that the individual workload perception of the nurses working in the emergency and critical care units was different according to the number of shifts held (Table 3). It was found that keeping watch for 40 or more hours increased the individual workload. In our study, it was determined that the nurses working in the emergency and critical care units worked an average of 200 hours per month. According to the International Labor Organization (ILO), a nurse has to work 40 hours a week [30]. Taking the working hours determined by the ILO as a reference, it was determined that the nurses stayed at work longer than they should have worked. Various studies conducted with nurses support this result [15–31]. Nurses working in critical care and emergency services are faced with problems such as critical patients, workload and high number of patients. Therefore, it can be considered as an expected result that the increased number of shifts will increase the nurse workload and decrease the overall nurse satisfaction [32–34]. When the relationship between the compliance of the isolation measures and the perception of individual workload of the nurses working in the specified unit was examined, a statistically significant and positive relationship was found (Table 4). As the individual workload of emergency and critical care nurses decreases, their compliance with isolation measures increases. Individual workload perception is evaluated as a whole with its sub-dimensions. Thus, it is thought that the high level of colleague support, adequate equipment, direct workload and unit support of nurses working in the emergency and critical care units contribute to high compliance with isolation measures. Similar to the results of this study, Schoenfelder et al. in their qualitative research on critical care nurses found that nurses’ low perception of individual workload increased the compliance with isolation measures and reduced the risk of nosocomial infections [35]. Similarly, in the study conducted in the critical care unit in Norway, they found that the lower level of individual workload perceived by nurses facilitated compliance with isolation measures [36]. Due to the heavy workload of nurses, there are studies that have determined that the risk of death associated with the lack of isolation measures such as hospital-acquired pneumonia and sepsis increases in critical care patients [37, 38]. The fact that the emergency service and the critical care unit are the two main critical and intensive units and the insufficient number of nurses working here will put a heavy burden on every nurse. Nurses with a heavy workload may miss the points related to isolation measures.

Moreover, when the relationship between nurses’ individual workload perception sub-dimensions and compliance with isolation measures was examined in this study, it was determined that there was a statistically significant and positive relationship between manager support, unit support and intention to stay at work (Table 4). This result means that as nurses’ individual workload perception increases, their compliance with isolation measures decreases. In the studies conducted on emergency service nurses, it was determined that insufficient unit and manager support had a negative effect on the perception of individual workload, reducing the compliance with isolation measures and the desire of nurses to make unit changes [39, 40]. It can be thought that it will be an important step in terms of compliance with isolation measures by reducing the workload with the unit support and manager support at a sufficient level in the emergency service and critical care unit.

5 Limitations

There are some limitations in this study. First of all, the study was conducted in a single center and the results cannot be generalized. The fact that the findings obtained in the study were based on the statements of nurses and that it was not an observational study may have caused the findings not to be objective. Observational studies including nurses from different hospitals and different units can provide more objective evidence to the literature on this subject.

6 Conclusions

According to the findings obtained from the study, it was found that the low individual workload of nurses working in the emergency service and critical care unit during the COVID-19 pandemic increased the compliance with isolation measures. Considering the individual workload perception with its sub-dimensions, it was seen that as unit support and manager support increased, the compliance of the nurses working in the specified unit increased, and as the compliance with the isolation measures increased, the intention to stay at work increased. The two critical units, the emergency service and the critical care unit, and the attitudes of the nurses working in this unit on compliance with isolation measures are very important. It is considered that taking precautions for the workload of nurses and making the necessary plans in this regard will increase the compliance of nurses towards isolation measures. Therefore, it is thought that the quality of patient care will increase and the rate of infection spread will indirectly decrease.