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Readiness to care and factors influencing readiness to care for patients in the intensive care units among novice nurses

Open AccessPublished:November 21, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101187

      Abstract

      Problem considered

      Nurses are the heart and soul of any healthcare institution. A skilled, qualified nurse with the readiness to care for patients in critical care setting is the dire need for today's world.

      Methods

      A cross-sectional descriptive survey was conducted among novice nurses working in the selected tertiary care hospitals to assess the readiness to care for patients in the intensive care unit (ICU) and the factors influencing readiness to care. The sample were selected using purposive sampling technique.

      Results

      The majority 157 (52.4%) had moderate readiness, 143 (47.6%) novice nurses had high readiness to care for patients in ICUs. The top six factors expressed by the participants were: knowledge of the fundamental subjects 292(97.3%), continuing nursing education 278(92.7%), feedback by peers and superiors 283(94.3%), internal motivation 277(93.3%), communication skills 277(92.3%), and proper documentation of care given 278(92.7%). There was a statistically significant association between readiness to care and gender (χ2 = 9.060; p = .011), area of work (χ2 = 10.009; p = .040), duration of clinical exposure in ICUs during the course of study (χ2 = 18.301; p = .011), duration of clinical experience during final year of training (χ2 = 10.315; p = .016), specific ICU related training (χ2 = 6.511; p = .011), and duration of induction programme (χ2 = 50.23; p= <.001)

      Conclusion

      The novice nurses had moderate readiness to practice in ICUs. The nursing educational sector and the nursing service sector can devise certain structures which can help increase the readiness of novice nurses to work in ICUs by focusing on the factors identified.

      Keywords

      1. Introduction

      Nurses are the heart and soul of any healthcare institution. With the increase in life expectancy, the burden of non-communicable disease has been increasing globally as well as nationally. They play a major role nationally as well as internationally in achieving the health targets and contributing to the universal health coverage.
      • World Health Organization
      State of the World's Nursing 2020: Investing in Education, Jobs and Leadership.
      Therefore, it comes upon the educational institution to fulfil the expectation of the healthcare sector by producing skilled nurses.
      According to the Indian Finance Commission Report in COVID Times, the nurse to population ratio is 1:670 against the norm of 1:300.
      Finance Commission of India
      Report of Fifteenth Finance Commission.
      Therefore, for meeting the health care needs, especially amid the pandemic, skilled, qualified, and motivated nurses are the dire need to bear with the increasing strain on health care services.
      The transition from a student nurse to a professional nurse has been described as a term “reality shock”.
      • Kramer Marlene
      Reality Shock: Why Nurses Leave Nursing.
      The complexities of the health care system along with the dearth of coaching and mentorship bring many challenges to the new graduate nurses during the transition period.
      • Serafin L.
      • Pawlak N.
      • Strząska-Kliś Z.
      • Bobrowska A.
      • Czarkowska-Pączek B.
      Novice nurses' readiness to practice in an ICU: a qualitative study.
      However, there are studies which highlight that induction training helps to increase job satisfaction and reduce stress and anxiety. New graduate nurses’ readiness to care has been a debatable area ever since. The theoretical knowledge along with the clinical expertise acquired through proper mentoring is essential to provide care for critically ill patients.

      Salem AH. Exploring students nurses' preparedness and readiness for to care for critically ILL patients and implication for patient's safety. Vol. 13, Int J Nurs Educ.

      With the increasing COVID 19 cases, the world plunged into an era of a public health crisis. The ripples of its effect were seen in all the spheres of life. The educational institution was also affected by these crises. A cross-sectional study was conducted among students of Bachelor of Science in Nursing (N = 286) to study the effect of COVID19 on educational performance and professional competency. The findings revealed that the students who expressed confidence in their ability for success, and patient care delivery during the pre-
      COVID pandemic, retained that confidence. However, overall, the participants felt less confident after the transition.
      • Gaffney M.K.
      • Chargualaf K.A.
      • Ghosh S.
      COVID-19 disruption of nursing education and the effects on students' academic and professional confidence.
      With the increasing adversity of the pandemic, the nursing colleges in India shifted from face-to-face classes to online mode. The clinical placement of the students was either restricted or suspended till the cases came down, which affected their clinical experience and clinical learning. This may have led to a decrease in confidence for readiness among the final year students to work in intensive care units as novice nurses.
      In the context of the above studies and the global crisis, the below-mentioned study was planned. The purpose was to assess the readiness to care for patients in intensive care units and the factors influencing readiness among novice nurses. The findings of the study may help to devise a strategy to ensure adequate retention of critical care knowledge and boost the readiness and caring attitude among novice nurses. The objectives were to assess the readiness to care for patients, determine factors influencing readiness to care for patients, and find the association between readiness to care for patients in intensive care units and the demographic variables.

      2. Methods

      A cross-sectional survey design was employed to assess the readiness to care for patients in ICU(s) and the factors influencing readiness. The study was conducted in four selected tertiary care hospitals of Karnataka from 1st February to 10th March 2022. The novice nurses working in four tertiary care hospital were the participants of the study. The inclusion criteria were nurses with less than one year of experience and nurses working in tertiary care hospitals of Karnataka. The exclusion criteria included nurses who were working in the Intensive Care Unit. The purposive sampling technique was used to select the tertiary care
      Hospitals and then enumerative sampling of the participants was undertaken to obtain the desired sample size.
      The key research variable of the study is the readiness to care, which is defined as novice nurses’ state of being ready and prepared to care for patients in intensive care units which is assessed by the Self-structured Readiness to Care Scale. The demographic variable in the study was age, gender, educational qualification, area of work, clinical experience during the final year of training, clinical exposure in ICUs during the course of study, and duration of the induction program. The sample size was estimated using the formula, (Z1-a/2)2 (p) (q)/d2 with an absolute error of 5%, confidence interval of 95% and above, and readiness to practice (77%), the estimated sample size was 270 participants and considering 10% non-respondent rate the total sample size was estimated 300.
      • Sharma S.K.
      • Arora D.
      • Belsiyal X.
      Self-reported clinical practice readiness of nurses graduating from India: a cross-sectional survey in Uttarakhand.
      Administrative permission was obtained from the head of the selected institutions. Institutional Ethics Committee clearance (IEC: 729/2021) was also obtained. For ensuring transparency and enhance visibility; the study was registered with the Clinical Trials Registry of India (CTRI/2022/01/039356). Before enrolling the participants in the study, written informed consent was ensured. Participants were briefed regarding the study objectives and provided subject information sheet.
      The data was collected by self-administering the tools to the participants after obtaining the informed consent. Structured questionnaires were used to assess the readiness and factors influencing readiness among novice nurses. The data collection instruments were, Demographic proforma, Readiness to Care Scale, and Questionnaire on factors influencing readiness to care. The demographic proforma consisted of a total of 8 items such as age, gender, educational qualification, area of work, clinical experience during the final year of training, clinical exposure in ICU's during the course of study, and duration of the induction program.
      Readiness to Care Scale is, a self-structured five-point Likert scale ranging from strongly agree to strongly disagree which consisted of 43 items, under the components of clinical knowledge, technical skills, clinical reasoning, communication skills, provision of safe care, professionalism, and management skills. A questionnaire on factors influencing readiness to care was developed to assess the factors influencing readiness to care for patients in intensive care units. It is divided into two sections: general and ICU related factors. It consisted of 24 items under the components of academic factors, organizational factors, personal factors, skill-related factors, communication factors, and work-related factors.
      For establishing the content validity all the tools were given to three experts from the Department of Nursing Services and four experts from the College of Nursing. The Content Validity Index of the three tools were 0.88, 0.97 and 0.94 respectively. The reliability was obtained using Cronbach's alpha for Readiness to Care Scale and Test- Retest method for the Questionnaire on factors influencing readiness to care. The reliability was r = 0.97 and r = 0.77 respectively for the Readiness to Care Scale and Questionnaire on factors influencing readiness to care.
      The data was analysed using Statistical Package for Social Sciences (SPSS 16.0 version). Descriptive and inferential statistics were used for data analysis. Descriptive statistics was used to present frequency and percentage of sample characteristics, readiness to care and factors affecting readiness to care for patients in ICUs. Association between selected demographic variable with readiness to care was analysed using Chi Square.

      3. Results

      The majority of 257 (85.7%) participants belonged to the age group of 20–25 years, 213 (70.3%) were females. Most 163(54.3%) of the participants were BSc(N) qualified. The majority 212 (70.7%) of the participants had the experience of working in general wards.
      About 157 (52%) participants expressed that their clinical experience during the final year of training was affected due to the COVID19 pandemic and 82 (27.3%) of them were affected in the area of clinical exposure. Most 92 (30.7%) of the participants had 1–2 weeks of clinical postings in ICUs during the study. The majority 181 (60.3) had more than 6 months of clinical experience during the final year of their training. All the participants had undergone an induction programme and the majority 152 (50.7%) of the participants had less than 1 week of induction training. The majority 211(70.1%) of the participants expressed that they had not received any special training related to ICU care (Table 1).
      Table 1Socio demographic characteristics of sample in frequency and percentage.
      VariablesFrequencyPercentage
      (f)(%)
      Age in years
       20 to 2525785.7
       25 to 304314.3
      Gender
       Female21371
       Male8729
      Educational Qualifications
       Diploma in Nursing and Midwifery11538.3
       B.Sc. Nursing16354.3
       Post Basic B.Sc. Nursing227.4
      Area of work
       General Ward21271
       Special ward5117
       Emergency186
       OBG196
      The effect of COVID-19 on clinical experience during
      the final year15752
       Yes14348
       No
      If yes, affected areas of posting
       Clinical Exposure8227.3
       Internship3712.3
       OBG237.7
       Community155.0
      The duration of clinical exposure in ICUs during the
      course of the study
       1–2 weeks9231.0
       2–3 weeks8227.3
       3–4 weeks7826.0
       More than 4 weeks4815.7
      Duration of clinical experience during the final year of training
       Nil3511.7
       1–3 months5117.0
       3–6 months3311.0
       More than 6 months18160.3
      Undergone induction programme
       Yes300100
       No00
      Duration of induction programme
       1–3 days3511.7
       4–7 days11337.7
       More than 1 week15250.6
      Specific ICU related training
       Yes8929.7
       No21170.3
      Readiness to care for patients in Intensive Care Units were analysed by using descriptive statistics. The majority 157 (52.4%) had moderate readiness, and 143 (47.6%) of the novice nurses had high readiness to care for patients in Intensive Care Units (ICUs). The overall mean score was 168.3 with SD ± 21 (Table 2).
      Table 2Levels of readiness to care for patients in intensive care units in frequency and percentage.
      Level of Readiness to Caref (%)MeanSD
      High readiness (172–215)143(47.6%)168.321.1
      Moderate readiness (86–172)157(52.4%)
      Low readiness (less than 86)0
      Maximum score: 215 Minimum score: 43.
      The top six factors expressed by the participants as factors influencing their readiness were: knowledge of the fundamental subjects 292(97.3%), continuing nursing education 278(92.7%), feedback by peers and superiors 283(94.3%), internal motivation 277(93.3%), communication skills 277(92.3%), and continuity in care provided through proper documentation of all the care given 278(92.7%). Fear of contracting COVID 19 infection 119 (39.7%) and fear of spreading it to their family members 121 (40.3%) were expressed by the novice nurses as the factors hindering their readiness to care for patients in ICUs (Fig. 1).
      Fig. 1
      Fig. 1Top six factors influencing readiness to care for patients in intensive care unit.
      There was a statistically significant association between gender (χ2 = 9.06; p = 0.011), area of work (χ2 = 10.01; p = .040), duration of clinical exposure in ICUs (χ2 = 18.30; p = .001), duration of clinical experience during final year of training (χ2 = 10.32; p = .016), duration of induction programme (χ2 = 50.23; p=<.001), specific ICU related training (χ2 = 6.51; p = .011) with readiness to care. However, the readiness to care was independent of age, educational qualification, and effect of COVID-19 on clinical experience (Table 3).
      Table 3Association between readiness to care for patients in intensive care units with selected demographic variables.
      Demographic VariablesReadiness2(df)p value
      Moderate readiness (85–168) f (%)High readiness (169–210) f (%)
      Age in years125(41.66)

      132(44)
      16(5.33)2.95 (1).086
       20 to 25
       25 to 30
      Gender118(39.33)

      34(11.33)
      94(31.33)

      53(17.66)
      9.06(2).011*
       Female
      Male
      Educational Qualifications61(20.33)

      75(25)

      16(5.33)
      54(18)

      88(29.33)

      6(2)
      5.96(2).051
       Diploma in Nursing and Midwifery
       B.Sc Nursing
       Post Basic B.Sc. Nursing
      Area of work117(39)

      17(5.66)

      10(3.33)

      8(2.66)
      95(31.66)

      34(11.33)

      8(2.66)

      11(3.66)
      10.01(3).040*
       General Ward
       Special ward
       Emergency
       OBG
      Effect of COVID 19 on clinical experience81(27)

      72(24)

      76(25.33)

      71(23.66)
      2.05(1).562
       Yes
       No
      Affected areas69(23)

      40(13.33)

      19(6.33)

      12(4)

      12(4)
      74(24.66)

      42(14)

      18(6)

      11(3.66)

      3(1)
      5.64(4).228
       Nil
       Clinical Exposure
       Internship
       OBG
       Community
      Duration of clinical exposure in ICUs40(13.33)

      50(16.66)

      48(16)

      15(5)
      52(17.33)

      32(10.66)

      30(10)

      33(11)
      18.30(4).001*
       1–2 weeks
       2–3 weeks
       3–4 weeks
       More than 4 weeks
      Duration of clinical experience16(5.33)

      22(7.33)

      10(3.33)

      104(34.66)
      19(6.33)

      29(9.66)

      23(7.66)

      77(25.66)
      10.31(3).016*
       Nil
       1–3 months
       3–6 months
       More than 6 months
      Specific ICU related training

       Yes

       No
      35(11.66)54(18)6.51(1).011*
      117(39)94(31.33)
      p < .05.

      4. Discussion

      The findings of the current study can be supported by a study conducted on the newly graduated nurses which concluded that the majority 112 (63.3%) of qualified nursing students were not ready and 64 (36.3%) of them were ready for clinical practice. Among the perceived barriers 153 (86.9%) have perceived inadequate sleep, low remuneration 145 (82.4%), insufficient time 142 (80.7%), time for documentation 125 (79%), and fear of being blamed 135 (75%).
      • Kaur V.
      • Dhama V.
      • Kaur K.
      • MK S.
      • Rawat R.
      Budding nurses readiness for clinical practice: the future is now.
      (1) Similarly, a study conducted among the final year nursing students of an Australian university identified that 259 (75%) participants were willing to work in intensive care units after attaining clinical experience as a registered nurse and 193 (54%) said that they were interested to work in critical care as new graduate nurses. Among the barriers identified three most common ones were: lack of knowledge 58 (16%), lack of psychometric skills 57 (16%), and interest in another specialty 26 (7%).
      • Halcomb E.J.
      • Salamonson Y.
      • Raymond D.
      • Knox N.
      Graduating nursing students' perceived preparedness for working in critical care areas.
      In a cross-sectional online descriptive study conducted to investigate the preparedness of nursing students to resume clinical practice after COVID 19 in Nigeria, 61.7% had high readiness and 38.3% had a low level of readiness. About 92(30.7%) responded that they were ready to work with patients infected with the coronavirus.
      • Nweke C.I.
      • Abazie O.H.
      • Adetunji A.J.
      • Okwuikpo M.I.
      Readiness for clinical practice amidst coronavirus among nursing students in southwest Nigeria.
      A study conducted in Australia showed that graduates gradually develop practice readiness, and that practice readiness is influenced by elements in both the educational and employment environments. Clinical experience in the healthcare setting that gives 'enough of practice’ was identified as the foundation for improving practice readiness. A workplace environment that helps graduates in putting their learning into practice and evolving as registered nurses were described as one that allows them to develop, demonstrate, and improve their practice.

      4.1 Readiness.
      • Harrison H.
      • Birks M.
      • Franklin R.C.
      • Mills J.
      Fostering graduate nurse practice readiness in context.

      Contradicting the present finding, the study done in Nigeria found that there was a significant difference between nursing institutions and readiness f (ꭓ2 = 21.0, p=>.001) and no significant difference between years of clinical exposure and readiness for clinical practice (ꭓ2 = 1.89, p = .594).
      • Nweke C.I.
      • Abazie O.H.
      • Adetunji A.J.
      • Okwuikpo M.I.
      Readiness for clinical practice amidst coronavirus among nursing students in southwest Nigeria.
      A study conducted on Turkish students’ preparedness to work in clinical, revealed similar findings where age (ꭓ2 = 4.286, p = .040), gender (ꭓ2 = 5.22, p = .020), and educational qualification (ꭓ2 = 14.52, p=>.001) was found to be statistically significant.
      • Güner P.
      Preparedness of final-year Turkish nursing students for work as a professional nurse.
      The purposive sampling technique used in the study limits the generalizability of the
      findings, a probability sampling technique could have yielded better representation of the
      participants and the ICU nurses were not included in the data collection.

      5. Conclusion

      The novice nurse's readiness to practice in the clinical field is an area that has not been explored, especially in the Indian context. This study has focused on novice nurses' readiness to care for critically ill patients and the factors influencing their readiness. The majority of the novice nurses had moderate readiness as revealed in this study. Understanding the factors influencing readiness will empower the nurse managers to increase job satisfaction, efficiency and in long term decrease in the nurse turnover in the clinical settings. The research in this area would help the nursing educational sector and the nursing service sector to devise certain programs which can help to increase the readiness of novice nurses to work in the Intensive Care Units thereby contribute to the quality of patient care.

      Funding source

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Declaration of competing interest

      Nil.

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