The effect of the intensive care unit nurse manpower on care behaviours and stress level on the nurses

Abstract

BACKGROUND:

Nurses working in the intensive care units (ICU) regarding the work-index-nursing work environment, the effect level ICU environment has on the nurses’ care behaviors and stress levels of the nurses should be determined.

OBJECTIVE:

The study aimed to investigate the effect of the nurse manpower on care behaviours and stress level of the nurses working in the ICU.

METHODS:

This was a cross-sectional and correlational study. The sample of the study consisted of 123 nurses working in the ICUs. The data were collected using the survey form, Distress Thermometer (DT), The Practice Work Environment Scale of the Nursing Work Index (PES-NWI), and Caring Behaviors Scale-24 (CBS-24).

RESULTS:

The mean age of nurses in the ICU was 30.2±5.6 and the mean of working time in the intensive care unit of nurses in the ICU was 3.7 ± 3.1 years. The mean of the DT was 4.8 ± 3.4, and the mean score of PES-NWI was 2.6 ± 1.0 and the mean score of CBS-24 was 4.7 ± 1.1 in nurses in the ICU. The regression model which was studied to investigate the relationship between caring behaviors and stress and nurse manpower of nurses working in intensive care unit was significant.

CONCLUSION:

Care behaviors and stress levels of nurses working in intensive care units are negatively affected by insufficient nurse manpower.

Keywords

Intensive care unit nurse nurse manpower caring behaviors stress

1. Introduction

Intensive care units (ICUs) are the places where complex and a large number of high-level technological care and treatment interventions are applied. Due to these features, intensive care units are the areas with a high potential for experiencing negative situations for the healthcare team along with the patients and their relatives [1, 2]. In addition, modern intensive care work environment often requires nurses to respond rapidly to complex situations with ambiguous patient results. In such work environment, nurses may experience various potential psychological damages such as ethical problems and burnout. These damages are the focal points of the extensive international studies focusing on the disease [3, 4]. It is known that due to their unfavourable working environment, the nurses who work 24/7 in the Intensive care unit (ICU) are the most burnout group among the other profession group members [2]. Factors such as shifts and long working hours, ICU being in a closed and isolated place, high noise level, continuous artificial lighting, excessive patient care procedures where physical strength is used at high levels and frequent deaths are accepted as was negative both working conditions and working environments for nurses [5, 6].

In order to maintain the working conditions and quality of care of nurses working in ICUs at a high level, there are standards set by some international institutions and organizations. The European Society of Intensive Care Medicine suggests that the number of nurse full-time equivalents for running one ICU bed is 6, and that nursing shifts should be 8 h [7]. Australian College of Critical Care Nurses (ACCCN) established standard suggests nurse/patient ratio of at least 1 : 1, and similarly to that, the British Association of Critical Care Nurses (BACCN) proposes an ICU should not go below 1 : 2 nurse/patient [8, 9]. In Turkey, the patient/nurse ratio has been proposed as 2 : 1 by the Ministry of Health in third-line ICUs [10]. The success criterion in nursing care is compliance with this international institutions and organizations and patient satisfaction. Patient satisfaction was achieved by meeting the demands of the patient. Patient demands are determined by medical needs, patient’s experiences from other hospitals, sociocultural and physiological conditions. The satisfaction is ensured by meeting the demands correctly and it improves the quality of the care [11, 12]. The factors that affect the satisfaction levels of the patients are professional knowledge, skill, ability, experience, personality traits (being genial, nice, understanding, compassionate etc.) motivation, perception, cultural levels, family relations, social class and most importantly emotions. That is because nurses meet not only the physical needs of sick or healthy individuals but also their psychological needs [13 –16].

Nursing, which is one of the main elements of health services, is among the professions where the interaction between individuals is the most common [15, 16]. Nurses can perform care functions only through the correct communication methods they establish [13]. This established communication affects the work and human load of the nurses as well as the current stress situation [13, 16, 17].

Nurses working in the hospital, especially in the ICU, struggle with different problems such as heavy workload, workplace hazards, occupational stress stemming from difficult and crucial tasks that cause physical and psychological pressure, and frequent exposure to illness and death are among critical factors that pose a threat to healthcare workers’ welfare [18–20]. Various factors such as heavy workloads, imbalance between the number of nurses and the number of patients, direct therapeutic and care communication with patients and their families, lack of participation and cooperation of members of the care and treatment team, decision making for patients in the late stages of their lives, all can cause stress [19, 21]. On the other hand, the quality of nursing care may decrease and the length of hospital stay may increase [19, 22].

With examining the opinions of the nurses working in the intensive care units regarding the work-index-nursing work environment, the effect level ICU environment has on the burnout level of the nurses should be determined and in line with the results the working conditions of the ICUs should be rearranged for the nurses [15, 23]. Workload is defined as an overall task performed by an individual or team over a period of time [24]. With the increase in the number of patients receiving care in the world, the responsibility of nurses increases more and as a result, the workload of nurses inevitably increases. Ensuring an adequate and safe nurse workforce in intensive care units is becoming a worldwide concern [25]. The World Health Organization’s (WHO) Personnel Needs Workload Indicators (WISN) is one such method that uses nurses’ workload to estimate the nursing manpower needs in hospitals. The optimal nurse-patient ratio should be determined to help the time distribution of nursing care activities, which will both minimize the workload of nurses and increase patient safety and satisfaction [26]. In addition, the complexity of treatment and technological developments have increased in today’s world. In addition, studies addressing the problem of nurse manpower measurement for all clinical departments of the hospital are quite limited. In this context, it becomes very important to protect the current nurse workforce, to ensure its continuity and to optimize manpower planning. In manpower planning, it is important to analyze the workload according to patient classification, care protocols and number of patients for each ICU [26]. The nurses that work in ICU risk factors that affect the workload of the patient that is associated with old age, ICU admission and longer stay in ICU of violence in the high score while in the ICU and associated risk factors; high patient-nurse ratio, nursing workload, sleep deprivation, caregivers, communication failure, stress and can be sorted by inadequate staffing [27 –31].

The literature did not examine the care behaviors, stress levels and nurse manpower of the nurses working in the intensive care unit together, but looked at the effects of the variables individually or in pairs. Among the factors affecting the care behaviors of nurses working in intensive care are the job stress they experience, nurse shortage and nurse workforce. Based on these factors, it has been scientifically supported by examining these variables together that the work stress and manpower of nurses working in intensive care units play an important role on care behaviors. In this study, it was aimed to research the effect of the intensive care unit nurse manpower on care behaviours and stress level on the nurses. When we analyse the literature, no studies were found regarding the effect of the ICU nurse manpower on care behaviours and stress level on the nurses. We think that our study will support the literature on the subject and create awareness about the effect of nurse manpower has on care behaviours and stress level on the nurses.

1.1. Research hypotheses

H1: The manpower of the nurses working in the intensive care unit have an effect on the care behaviors and stress levels of the nurses.

2. Material and method

This was a cross-sectional and correlational study. This research was carried out on the nurses who work in the ICUs of the Health Application and Research Center of a public university in the province of Edirne between April and September 2019. It took about six months to collect the data for the research. The population of the study consisted of n = 132 nurses who are over 18 years of age and working in Health Application and Research Center ICUs of a public university in Edirne province. In the study, no sample calculation was made and the universe was accepted as a sample. The criteria for inclusion of participants in the study were to be over 18 years of age, literate, to work in the ICU and Health Application and Research Center ICUs of a public university in Edirne province. Meanwhile, the sample of the study consisted of n = 123 (93.18%) nurses who didn’t have any health problems and agreed to participate in the study between April and September 2019. The number of nurses working in the ICUs, number of beds, the number of nurses in each shift and the patient/nurse ratio where the data of the study was collected was shown in Table 1 (33). No identifying information was obtained and participants were informed that their participation was voluntary. Nurses who agreed to participate in the study and working ICU were included in the study. Nine nurses did not want to continue to participate in the study, stating that they did not have time and workload. Nurses who did not want to continue the study were excluded from the study.

Table 1.
ICU and nurses working in the ICU characteristics (n = 123).

Variables Number of nurses (%) Number of ICUs beds Patient/nurse ratio

Coronary intensive care 10 16 3/1

Newborn Intensive Care 23 15

•1st degree 4 5/1

•2nd degree 8 4/1

•3th degree 3 2/1

Internal Medicine Intensive Care 36 23 4/1

Surgical Intensive Care 18 11 3/1

Reamination Intensive Care 11 6 2/1

Child Intensive Care 13 6 2/1

Post-op Intensive Care 9 10 3/1

Cardiovascular Intensive Care 12 4 2/1

Total 132 91 –

Variables	Number of nurses (%)	Number of ICUs beds	Patient/nurse ratio
Coronary intensive care	10	16	3/1
Newborn Intensive Care	23	15
•1st degree		4	5/1
•2nd degree		8	4/1
•3th degree		3	2/1
Internal Medicine Intensive Care	36	23	4/1
Surgical Intensive Care	18	11	3/1
Reamination Intensive Care	11	6	2/1
Child Intensive Care	13	6	2/1
Post-op Intensive Care	9	10	3/1
Cardiovascular Intensive Care	12	4	2/1
Total	132	91	–

Note. M: mean; SD: Standart Deviation; n: Number; %: Percent.

2.1. Data collection tools and data collection

The research data was gathered with Distress Thermometer (DT), Nursing Work Index-Nursing Work Environment Rating Scale, Care Behaviours Scale-24 and a Survey Form prepared by the researchers who examined the literature. In line with the purpose of our study, three different scales were used to evaluate the stress, care behaviors and manpower of working nurses in the ICU and to determine the effect on each other.

The research nurses in the ICU were individually asked for their consent and the survey form was applied through one-to-one interviews. The nurses were informed that their personal data would be confidential. The survey form was collected in 15 to 20 minutes for working nurses in the ICUs.

2.1.1. Survey form

Created by the researchers who reviewed the literature, it consists of a total of 16 questions which include 5 questions (age, sex, marital status, education, income status) about the personal characteristics of the nurses and 11 questions (total working time (year), working time in the ICU (year), number of patients in the intensive care unit, want to work in ICU, reason for requesting to work in the ICU, reason for not wanting to work in the ICU, satisfaction of nursing care given to the patient in the ICU, the reason of not being satisfied with nursing care given to the patient in the ICU, having intensive care nursing certificate, ICU worked, assistive staff in ICU) about the features related to work life [1, 5, 32].

2.1.2. Distress Thermometer (DT)

It is a scale developed by Roth et al. in 1998 to measure psychosocial distress in cancer patients [34]. Distress level is a visual analogue scale rated between 0 and 10 with thermometer analogy. The practitioner expresses his distress through the figures on the said thermometer. Score 0 indicates that the individual has not experienced distress and score 10 indicates that his distress is at the highest limit [34]. In our country, the validity and reliability study of DT was conducted by Ozalp et al. in 2006 [35]. In the study of Özalp et al., the cut-off point of the scale was found to be 4 [34]. In this study, the Cronbach alpha value of the scale was found to be .98. When the literature is examined, it is shown that the distress thermometer is used on nurses working and surgery patients [36, 37].

2.1.3. The Practice Work Environment Scale of the Nursing Work Index (PES-NWI)

It’s a scale developed by Lake in 2002 and adapted to Turkish by Turkmen et al. in 2011, consists of 31 items and five sub-scale [38, 39]. In calculating the score of the scale, the scale score between 1-4 is obtained by dividing the total score with the number of questions. As the score increases the attitudes of the nurses towards the work environment also increases positively. During the development of the scale Cronbach alpha value was found to be .94 by Turkmen [39]. In this study, the Cronbach alpha value of the scale was found to be .99 and the Cronbach alpha values of the sub-scales were found to be between .95 and .99.

2.1.4. Care behaviours scale-24

The scale which was first developed by Wolf as 75 items in 1981 was revised in 1994 and the number of items was reduced to 42. 42-item scale, which was suitable for bidirectional diagnosis by patients and nurses, was reduced to 24 items in 2006 by Wu et al. and was reorganized into 4-subscales as assurance, knowledge-skill, respect and commitment [40, 41]. The scale was designed to evaluate the nursing care process as a six-point Likert type. The validity and reliability study of the Turkish form of the Scale was carried out in 2012 by Kursun and Kanan [42]. For the scale and each sub-scale, the scores obtained by summing up the scores of the items are divided by the number of items and sub-scale scores between 1-6 are obtained. In the validity and reliability study, it was stated that the Cronbach alpha value whose total scale and sub-scales were calculated was above .80 [42]. In this study, the Cronbach alpha value of the scale was .98 and the Cronbach alpha values of its sub-scales were found to be between .82–.98.

2.2. Data analysis

The data gathered in the study was analysed by using the SPSS (Statistical Package for Social Sciences) for Windows 23.0 software. The Kolmogorov-Simirnov test, which is one of the normal distribution tests of quantitative data, was used to see if the study data showed normal distribution. Numbers, percentage, average and standard deviation were used as descriptive statistics in the data evaluation. Care behaviours of the nurses who work in the ICU and prediction of stress’ effect on the nurse manpower was evaluated by regression analysis. Whether the scale scores can be included in the regression model was evaluated by multilinear correlation analysis for regression. Among the scale scores, the ones whose variance Inflation Factor (VIF) value were lower than 10 and the ones whose tolerance value was more than.2 were included in the model. Analysis was performed using logistic regression analysis, which was appropriate for the evaluation model. p < .005 value was considered statistically significant in all tests.

2.3. Ethical considerations

Ethical approval numbered TUTF-BAEK 2019/165 was received from the Scientific Research Ethics Committee of Trakya University. Written permission was obtained from Trakya University Health Practice and Research Center to carry out the study. For the used scales, permission to use them was obtained from the researchers who carried out the Turkish validity and reliability. The participants who wanted to participate in the research were informed about the purpose and application of the research and verbal permission was obtained.

3. Results

Table 2 shows descriptive characteristics of nurses working in the ICU. It was found that the average age of the nurses working in ICU was 30.2±5.6 and 87.8% of them was women, 52.8% was married, 80.5% was bachelor degree, 94.3% had income equal and expenses and 59.3% of them didn’t have any children (Table 2).

Table 2.
Sociodemographic characteristics of nurses working in the ICU (n = 123).

Variables M±SD

Age (years) 30.2±5.6

n %

Sex

Female 108 87.8

Male 15 12.2

Marital status

Married 65 52.8

Single 58 47.2

Education

High school 16 13.0

Bachelor’s degree 99 80.5

Master science of nursing 8 6.5

Income Status

Less income than expense 5 4.1

Income equal to expense 116 94.3

Income more than expenses 2 1.6

Variables	M±SD
Age (years)	30.2±5.6
	n	%
Sex
Female	108	87.8
Male	15	12.2
Marital status
Married	65	52.8
Single	58	47.2
Education
High school	16	13.0
Bachelor’s degree	99	80.5
Master science of nursing	8	6.5
Income Status
Less income than expense	5	4.1
Income equal to expense	116	94.3
Income more than expenses	2	1.6

Note. M: mean; SD: Standart Deviation; n: Number; %: Percent.

Table 3 shows working conditions characteristics of nurses working in the ICU. It was found that the average total working time of the nurses who work in ICUs was 8.6±6.7 years, the average working time in the ICU was 3.7±3.1 the average number of patients in the ICU was 13.5±5.0 and 58.5% of the nurses want to work in ICUs, among those numbers 63.9% of them wants to work in ICU for the job satisfaction, 88.2% of those who didn’t want to work in ICU didn’t want to work because of the workload, 52.0% didn’t satisfied with the nursing care given to the patients in ICUs, and among those who didn’t satisfied 79.7% was stated that they can’t give sufficient care because of the large number of patients, 69.9% of them didn’t have the intensive care nurse certificate, 22.8% work in the surgical intensive care unit and 78.0% was stated that there’s no assistive staff in the ICU (Table 3).

Table 3.

Working conditions characteristics of nurses working in the ICU (n= 123).

Variables	M±SD
Total working time (year)	8.6±6.7 (1.0–30.0)
Working time in the ICU (year)	3.7±3.1 (1.0 –12.0)
Number of patients in the ICU	13.5±5.0
	n	%
Want to work in ICU
Yes	72	58.5
No	51	41.5
Reason for Requesting to Work in the ICU
Professional/job satisfaction	46	63.9
Liking to work in the intensive care unit	17	23.6
Dealing with the patient and not communicating with the caregivers	9	12.5
Reason for not wanting to work in the ICU
Workload	45	88.2
Working with inadequate personnel	6	11.8
Satisfaction of Nursing Care Given to the Patient in the ICU
Yes	59	48.0
No	64	52.0
The Reason of Not Being Satisfied With Nursing Care Given To The Patient In The ICU
High number of patient	51	79.7
Inadequate staff	7	10.9
Insufficient material	6	9.4
Having Intensive Care Nursing Certificate
Yes	37	30.1
No	86	69.9
ICU Worked
Coronary Intensive Care	10	12.2
Newborn Intensive Care	26	21.1
Internal Medicine Intensive Care	21	17.1
Surgical Intensive Care	27	22.8
Reamination Intensive Care	4	2.3
Child Intensive Care	18	10.6
Post-op Intensive Care	8	6.5
Cardiovascular Intensive Care	9	6.5
Assistive Staff in ICU
Yes	26	21.1
No	97	78.9

Note. M: mean; SD: Standart Deviation; n: Number; %: Percent.

Table 4 shows the distribution of the mean scores of nurses working in the ICU from the subscales of DT, PES-NWI, PES-NWI sub-scales, CBS-24 and CBS-24 sub-scales. It was found that the average DT of the nurses working in ICUs (n = 123) was 4.8±3.4, the average of the total score of the PES-NWI was 2.6±1.0, the nurses’ participation and representation rate in the management sub-scale score was 2.7±1.1, the average of the nursing foundations needed for quality care sub-scale score was 2.4±1.0, the average of the nurse managers’ attitudes and leadership traits sub-scale score was 2.7±1.1, the average of the adequacy of staff and other resources sub-scale score was 2.8±1.2 and the average of the communication between physicians and nurses sub-scale score was determined as 2.4±1.1 (Table 4). It was found that CBS-24 total score average was 4.7±1.1, assurance sub-scale score average was 5.3±0.8, being respectful sub-scale score average was 4.6±1.2 and knowledge and skill subscale score average was 4.6±1.2 (Table 4).

Table 4.

The distribution of the mean scores of nurses working in the ICU from the subscales of DT, PES-NWI, PES-NWI sub-scales, CBS-24 and CBS-24 sub-scales (n= 123).

	M±SD (min - max)
DT	4.8±3.4 (0.0–10.0)
PES-NWI	2.6±1.0 (1.0–4.0)
Nurses’ participation and representation rate in the management	2.7±1.1 (1.0–4.0)
Nursing foundations needed for quality care	2.4±1.0 (1.0–4.0)
Nurse Managers’ attitudes and leadership traits	2.7±1.1 (1.0–4.0)
Adequacy of staff and other resources	2.8±1.2 (1.0–4.0)
Communication between physicians and nurses	2.4±1.1 (1.0–4.0)
CBS-24	4,7±1,1 (2,7 - 6,0)
Assurance	4.5±1.3 (2.0–6.0)
Knowledge and skill	5.3±0.8 (3.0–6.0)
Being respectful	4.6±1.2 (2.0–6.0)
Loyalty	4.6±1.2 (2.0–6.0)

Note. M: mean; SD: Standart Deviation; min: Minimum; max: Maximum.

Finally, care behavior of nurses working in intensive care unit and stress predicting nurse manpower were evaluated (Table 5). The regression model, which was studied in order to analyse the care behaviours of the nurses working in the ICUs and the relationship between stress and nurse manpower, is negatively significant (F = 131.916, p < .000). As the manpower of the nurses decreases, their stress levels increase and their care behaviors decrease. For this model, care behaviours and stress were found to be a significant factor in explaining the manpower which is a dependent variable. In this model, while CBS-24 and DT variables explain 68.7% (R² = .687) of the change in nurse manpower status, it is possible to say that this value is a statistically significant contribution.

Table 5.

Care behaviour and stress of nurses working in ICU predicting nurse manpower.

Variables	Nurse Manpower
	B	SH	ß	t	p
Constant	3.810	0.581		6.555	.000*
CBS-24	.186	.031	.516	6.061	.000*
DT	–.402	.096	–.357	–4.192	.000*
R			0.829
R²			0.687
F			131.916
P			0.000
DW (1,5–2,5)			1.616
*			p < .05

Note. Regression Analyze.

4. Discussion

Care is a part of the nursing profession and is a unique function that is taking care of the individuals, being involved in the healing process and contributing to patients in gaining their independence and maintaining their well-being. A basic explanation of nursing in an adequate health care system is improving health, preventing diseases and providing care to patients and/or to people in need of care. While nurses are meeting the care needs of the individuals, certain stressors and their stress level changes affect them. Especially with the care given to the patients by the nurses who work in the intensive care units and the stress experienced in the ICUs, the workload of the nurses has an important effect. With the excessive nurse workload, the care behaviours and the stress experienced by the nurse also will be affected. In this study, it was aimed to examine the effect of the nurse manpower of the nurses working in the ICU have on care behaviours and stress level.

In this study, the attitudes of the nurses regarding the work environment, the participation of the nurses in the management and their authority, the nursing resources required for a quality care, the attitude and the leadership characteristics of the head nurses, the sufficiency of manpower and other resources and the physician-nurse-colleague communication were found to be moderate (Table 4). In the study Ulusoy and Polatkan (2016) carried out, it was found that the participation of the nurses in the management and their authority, the nursing resources required for a quality care, the attitude and the leadership characteristics of the head nurses and the physician-nurse-colleague communication were moderate, the sufficiency of manpower and other resources was found to be low [43]. In the study carried out by Bitek and Akyol (2017), it was found that while the attitudes of the nurses regarding the work environment, the participation of the nurses in the management and their authority, the nursing resources required for a quality care and the physician-nurse-colleague communication were moderate, the sufficiency of manpower and other resources and the attitude and the leadership characteristics of the head nurses were low [16]. In another study, it was concluded that the positive workload perception of the nurses working in the surgical clinics affected the patient safety attitude positively [44]. Although the findings of the study and the literature showed some similarities, some findings varied from the literature. The reason for this may be due the variation of the samples, population density of the hospitals and the variability in the number of nurses/patients. With the nurse manpower being at a moderate or low level, the quality of the care given by the nurses and the patient satisfaction levels differ.

In the study, care behaviours, assurance, knowledge and skills, respect and commitment were found to be at a high level (Table 4). In the studies of Okumus and Ugur (2017), Boğa et al. (2020), Aydin and Bjork (2019), and Erol and Turk (2019) carried out, they were determined that care behaviours, assurance, knowledge and skill, respect and commitment levels were determined to be high [12, 45–47]. In the study Gholami et al., (2019), Gulpinar et al. (2019), and Karlou et al. (2018) carried out, they were found that the care behaviours, assurance, knowledge and skill, respect and commitment levels were determined to be moderate [48 –50]. In the study in which Rostami et al. (2019) analysed perception of nursing care behaviour of the nurses working in intensive care unit it was shown that most of the nurses have the desired care behaviours to care for the patient [13]. In the study in which Keeley et al. (2015) analysed the patient satisfaction of the standard care protocol and the effectiveness of the perceived personnel care, it was found that the care behaviours were high [51]. The literature and study findings show compatibility and care behaviours of the nurses working in intensive care units are high.

The stress level of the nurses working in the intensive care unit was found to be moderate in this study (Table 4). It was determined that the stress level of the nurses was moderate in the study where Asl et al. (2022) analysed the level of and work stress, and their autonomy is a significant positive predictor of work stress [52]. In the studies of Huang et al. (2022), and Turan and Ançel (2020) carried out, they were stated that the nurses experience high levels of stress [53, 54]. In accordance with the literature and study findings, the stress level of the nurses who work in intensive care units is specified as moderate and above. Stress is an important factor for the nurses working in intensive care and care power changes in line with the responses they give to the stressors.

In the study, DT variables explain the change in the nurse manpower status, and it is seen that while the stress increases the nurse manpower decreases and as the caring behaviors increase nurse manpower increases CBS 24 (Table 5). No studies similar to the explained model were found after reviewing the national and international literature and we think that the findings of the study will provide a new perspective to the literature. As the stress, level experienced by nurses the intensive care unit increases, nurse manpower decreases. Care behaviours and nurse manpower affect each other at the same level; as the nurse manpower increases care behaviours also increase.

4.1. Limitations

As with all studies conducted, our study has several limitations. Firstly, our study was conducted in a single center. Conducting a multicenter study will provide further findings with a high level of evidence within the study’s objective. In addition, due to the limited number of samples, the level of evidence will be increased by increasing the number of samples. Since the COVID-19 pandemic occurred after the time period in which the study was conducted, the number of caregivers and their characteristics vary with the pandemic.

5. Conclusion

In conclusion, nurse manpower is an important issue for the nurses working in the ICU. This current study reveals that insufficient nurse manpower of the nurses who work in the ICU has negative effects on the stress experienced by the nurses and the care behaviors given to the patients in the ICU. With the insufficient nurse manpower, stress increases and care behaviors decrease. It is recommended to a professional member of the healthcare team, the proper evaluations should be made by increasing the number of the nurses working in ICUs, rearranging the shift systems and objectively calculating the convenient nurse numbers for optimal patient care behaviors required for the ICUs with the aim of increasing the manpower of the nurses to decrease the stress levels experienced and to increase the care behaviors of the nurses working in the ICU.

Footnotes

Acknowledgments

We would like to thank all nurses who participated in the study and for their cooperation.

ORCID iDs

Özgül Erol

Burcu Küçükkaya

Ecehan Yenici

Ethical approval (name of institute and number)

Ethical approval numbered TUTF-BAEK 2019/165 was received from the Scientific Research Ethics Committee of Trakya University.

Informed consent

The participants who wanted to participate in the research were informed about the purpose and application of the research and verbal permission was obtained.

Conflict of interest

No conflict of interest all authors.

Funding

This study was no financial supported.

References

Kokcu

Terzi

. Investigation of care nurses in the intensive work index- working environment and burnout levels. J Intensive Care Nurs. 2018;22(2):66-72.

Tokur

Ergan

Aydin

Calískan

Savran

Yaka

Koca

Comert

Gokmen

. Depression and burnout frequency in nurses working in tertiary intensive care units. J Med Surg Intensíve Care Med. 2018;9(2):25-33.

Jarden

Sandham

Siegert

Koziol-McLain

. Intensive care nurses’ well-being: A systematic review. Aust Crit Care. 2020;33(1):106-11. https://doi.org/10.1016/j.aucc.2018.11.068

Cohen

Reiser

Althouse

Resick

Chu

, et al. Burnout Among Oncology Nurses: The Effects of Providing a Primary Palliative Care Intervention Using CONNECT Protocol. Clinical Journal of Oncology Nursing. 2022;26(4):391-8.

Nergiz

Ugur

. Work Analysis of Nurses Working in Respiratory ICU at Chest Diseases Hospital. Journal of Intensive Care Nursing. 2019;23(3):140-150.

Sardo

PMG

Macedo

RPA

Alvarelhão

JJM

Simões

JFL

Guedes

JAD

Simões

Príncipe

. Nursing workload assessment inan intensive care unit: A retrospective observational study using the Nursing Activities Score. Nursing in Critical Care. 2023;28(2):288-297. https://doi.org/10.1111/nicc.12854

Robba

Poole

McNett

Asehnoune

Bösel

, et al. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Medicine. 2020;46:2397-410.

Australian College of Critical Care Nurses (ACCCN), Available at https://www.acccn.com.au/documents/item/20 (accessed 12 October 2020)

British Association of Critical Care Nurses (BACCN), Standards for Nurse Staffing in Critical Care, Available at http://icmwk.com/wp-content/uploads/2014/02/nurse_staffing_in_critical_care_2009.pdf (accessed 12 October 2020)

10.

Teker

Hidiroglu

Tepe

Surmen

, et al. A qualitative study of hand hygiene compliance among health care workers in intensive care units. The Journal of Infection in Developing Countries. 2019;13(02):111-7.

11.

Tudor Car

Dhinagaran

Kyaw

Kowatsch

Joty

Theng

Atun

. Conversational agents in health care: scoping review and conceptual analysis. Journal of Medical Internet Research. 2020;22(8):e17158.

12.

Okumus

Ugur

. The effects of nurses’ emotional intelligence levels on their caring behaviors. J Acibadem Uni Health Sci. 2017;8(2):104-9.

13.

Rostami

Esmaeali

Jafari

Cherati

. Perception of futile care and caring behaviors of nurses in intensive care units. Nurs Ethics. 2019;26(1):248-55.

14.

Vahedian-Azimi

Hajiesmaeili

Kangasniemi

Fornes-Vives

Hunsucker

Rahimibashar

Miller

. Effects of stress on critical care nurses: a national cross-sectional study. Journal of Intensive Care Medicine. 2019;34(4):311-22.

15.

Babapour

Gahassab-Mozaffari

Fathnezhad-Kazemi

. Nurses’ job stress and its impact on quality of life and caring behaviors: A cross-sectional study. BMC Nursing. 2022;21(1):1-10.

16.

Bitek

Akyol

. Evaluation of relationship between job satisfaction and perceptions relating to working environment of intensive care nurses. J Intensive Care Nurs. 2017;21(1):1-6.

17.

Pal

Taywade

Pal

Sethi

. Noise Pollution in Intensive Care Unit: A Hidden Enemy affecting the Physical and Mental Health of Patients and Caregivers. Noise and Health. 2022;24(114):130.

18.

Saygílí

Avcí

Sönmez

. Quality of work life and burnout in healthcare workers in Turkey. J Health Manag. 2020;22(3):317-29. https://doi.org/10.1177/0972063420938562

19.

Habibzadeh

Reza Masouleh

Mitra Chehrzad

Kazemnejad Leili

. Moral distress and related factors in nurses working in intensive care units. J Holist Nurs Midw. 2020;30(3):166-73.

20.

Mousazadeh

Yektatalab

Momennasab

Parvizy

. Job satisfaction challenges of nurses ín the íntensive care unit: a qualitative study. Risk Manag Healthc Policy. 2019;12:233-42. https://doi.org/10.2147/RMHP.S218112

21.

Gheidari

Adib

Mohamadii

Kazemnejad

. Knowledge, attitude and performance of nurses in intensive care units in the field of patients’ physical restraint use and their related factors. J Adv Pharm Edu Res. 2019;9(S2):109-14.

22.

Sturm

Rieger

Martus

Ueding

Wagner

Holderried

, Work Safe Med Consortium. Do perceived working conditions and patient safety culture correlate with objective workload and patient outcomes: A cross-sectional explorative study from a German university hospital. PloS One. 2019;14(1):e0209487.

23.

Colpan

Akinci

Erbay

, et al. Evaluation of risk factors for mortality in intensive care units: a prospective study from a referral hospital in Turkey. Am J Infect Control. 2005;33:42-7.

24.

Pourteimour

Yaghmaei

Babamohamadi

. The relationship between mental workload and job performance among Iranian nurses providing care to COVID-19 patients: A cross-sectional study. Journal of Nursing Management. 2021;29(6):1723-32. https://doi.org/10.1111/jonm.13305.

25.

Iordache

Elseviers

De Cock

Van Rompaey

. Development and validation of an assessment tool for nursing workload in emergency departments. Journal of Clinical Nursing. 2020;29(5-6):794-809. https://doi.org/10.1111/jocn.15106.

26.

Tuna

Kahraman

. Nursing manpower planning in a surgical unit. International Journal of Caring Sciences. 2020;13(3):2180-90. https://search.proquest.com/scholarly-journals/nursing-manpower-planning-surgicalunit/docview/2480343879/se-2?accountid=25704

27.

Faisy

Davagnar

Ladiray

Djadi-Prat

Esvan

Lenain

Durieux

Leforestier

Marlet

Seijo

Guillou

. Nurse workload and in- experienced medical staff members are associated with seasonal peaks in severe adverse events in the adult medical intensive care unit: a seven-year prospectivestudy. Int J Nurs Stud. 2016;62:60-7.

28.

Larsson

Aronsson

Norén

Wallin

. Healthcare workers’ structured daily reflection on patient safety, workload and work environment in intensive care. A descriptive retrospective study. Intensive and Critical Care Nursing. 2022;68:103122.

29.

Ramírez-Elvira

Romero-Béjar

Suleiman-Martos

Gómez-Urquiza

Monsalve-Reyes

Cañadas-De la Fuente

Albendín-García

. Prevalence, risk factors and burnoutlevels in intensive care unit nurses: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health. 2021;18(21):11432.

30.

White

Dulko

DiPietro

. The effect of burnout on quality of care using donabedian’s framework. Nursing Clinics. 2022;57(1):115-30.

31.

Rodwin

Bilan

Merchant

Steffens

Grimshaw

Bastian

Gunderson

. Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis. Journal of General Internal Medicine. 2020;35:2099-106.

32.

Bozkurt

Ören

Zengin

Ergün

Afacan

Madenoğlu Kívanç

Kíraner

. The Profile of Nurses Working in Intensive Care Units of Hospitals Affiliated to a Public University. Journal of Intensive Care Nursing. 2019;23(2):73-80.

33.

Republic of Türkiye Trakya University Hospital. 2019 Statistical Information. 2019. https://tuh.trakya.edu.tr/pages/2019-yili-istatistik-bilgileri

34.

Roth

Kornblinth

Batel-Copel

Peabody

Scher

Holland

. Rapid screening for psychologic distress in men with prostate carcinoma: A pilot study. Cancer. 1998;82:1904-8.

35.

Ozalp

Cankurtaran

Soygur

Ozdemir

Jacobsen

. Screening for psychological distress in Turkish cancer patients. Psycho-Oncology. 2007;16(4):304-11.

36.

Russin

. Effects of debriefing on nurse distress after perinatal loss. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2023;52(4):71.

37.

Cakír Özmen

Gursoy

. Can distress thermometer be used to measure anxiety induced surgery?. Journal of Anatolian Nursing and Health Sciences. 2021;24(3):318-325.

38.

Lake

. Development of the practice environment scale of the nursing work index. Res Nurs Health. 2002;25:176-88.

39.

Turkmen

Badir

Balci

Akkus-Topcu

. The adaptation of the Practice Environment Scale of the Nursing Work Index into Turkish: Reliability and validity study. J Educ Res Nurs. 2011;2:5-20.

40.

Wolf

Giardino

Osborne

Ambrose

. Dimensions of Nurse Caring. Image J Nurs Sch. 1994;26:107-11.

41.

Larrabee

Putman

. Caring Behaviors Inventory: A reduction of the 42-Item Instrument. Nurs Res. 2006;55:18-25.

42.

Kursun

Kanan

. Validity and reliability study of the Turkish Version of Caring Behaviors Inventory-24. J Anadolu Nurs Health Sci. 2012;15:229-35.

43.

Ulusoy

Polatkan

. Assessment of the nurses’ work environment using the nursing work index scale. J Cumhuriyet Med. 2016;38(4):246-57.

44.

Karahan

Çelik

Sugeçti

. Investigation of Workload Perception, Patient Safety Attitude and Affecting Factors of Nurses Working in Surgical Clinics. J Educ Res Nurs. 2021;18(1):1-9.

45.

Boğa

Aydin Sayilan

Kersu

Baydemir

. Perception of care quality and ethical sensitivity in surgical nurses. Nursing Ethics. 2020;27(3):673-85.

46.

Aydin

Bjork

Nurses′ perceptions of caring behaviors in clinical practice: A questionnaire study with nurses in Vietnam. Ersta Sköndal Bräcke University College. 2019:1-34.

47.

Erol

Turk

. Assessing the caring behaviours and occupational professional attitudes of nurses. Scanning. 2019;1(4):6-7.

48.

Gholami

Saki

Hossein Pour

. Nurses’ perception of empowerment and its relationship with organizational commitment and trust in teaching hospitals in Iran. Journal of Nursing Management. 2019;27(5):1020-9.

49.

Gulpinar

Baskaya

Yesilbudak

Boz

. Determination of the caring behaviors and affecting factors women perceived during infertility treatment. J Educ Res Nurs. 2019;16(1):21-6.

50.

Karlou

Papadopoulou

Papathanassoglou

Lemonidou

Vouzavali

Zafiropoulou-Koutroubas

Patiraki

. Nurses’ caring behaviors toward patients undergoing chemotherapy in Greece: A mixed-methods study. Cancer Nurs. 2018;41(5):399-408.

51.

Keeley

Wolf

Regul

Jadwin

. Effectiveness of standard of care protocol on patient satisfaction and perceived staff caring. Clin J Oncol Nurs. 2015;19(3).

52.

Asl

Taghinejad

Parizad

Jasemi

. The relationship between professional autonomy and job stress among intensive care unit nurses: A descriptive correlational study. Iranian Journal of Nursing and Midwifery Research. 2022;27(2):119.

53.

Huang

Xia

Zeng

Lü

. Prevalence of depression and depressive symptoms among intensive care nurses: A meta-analysis. Nursing in Critical Care. 2022;27(6):739-46.

54.

Turan

Ançel

. Examination of the psychological changes in nurses due to workload in an intensive care unit: a mixed method study. Contemporary Nurse. 2020;56(2):171-84.