Educational Content Focusing on Basic Skills for Novice Nurses to Work Independently in Intensive Care Units in Japan: A Qualitative Study

1. INTRODUCTION

Since intensive care units (ICUs) house critically ill patients, ICU nurses should not only be familiar with advanced techniques but also possess knowledge of complex pathological conditions [1, 2]. ICUs require skilled nurses [3, 4]. For this reason, various educational programs have been established in different countries, including the American Association of Critical-Care Nurses (AACN) [5] and a ladder system for ICU nurses in Japan [6]. Based on the AACN, the basic framework comprises: (1) assessment of critically ill patients and their families; (2) planning care for critically ill patients and their families; (3) interpretation and management of basic cardiac rhythms; (4) hemodynamic monitoring; (5) airway and ventilatory management; (6) pain, sedation, and neuromuscular blockade management; (7) pharmacology; and (8) ethical and legal considerations [5]. The Australian College of Critical Care Nurses (ACCCN) recommends that appropriately qualified nurses should practice ICU nursing, emphasizing the need to provide specific education for nurses at all levels [7]. Although it varies by country, various organizations in Europe also support specialized training for ICU nurses. Improving the expertise of emergency medical care and efforts to train ICU nurses are needed so that they can care for seriously ill patients [8]. The contents of each country's educational program include items related to the knowledge and skills used in ICUs. The effects of education, such as improved knowledge, are revealed through the program [9-11]. As such, there are many programs available to help prepare nurses to work in ICUs. Conversely, in Japan, the only national qualification is “nurse,” so new graduate nurses (novice nurses) are assigned to the ICU department, which requires advanced knowledge and skills. In Japan, each facility develops its educational program and offers training in stages based on protocols. However, there are no uniform criteria for becoming independent, leading to significant differences in the time it takes novice nurses to reach a certain level. Therefore, in practice, it is the head nurse who decides. Consequently, novice nurses must be trained to work independently in the ICU within a year.

However, existing programs that cover all knowledge and skills are too comprehensive to serve as a standard for novice nurse independence. Previous research on educational programs that promote independence through early practice is scarce in Japan. Therefore, to develop an educational program suited to clinical settings in Japan, we conducted in-depth interviews with senior nurses about the behaviors they expect from novice nurses in actual clinical settings. In particular, there is no content focused on achieving independence within one year. ICU orientation increases cognitive load [12] and therefore, training novice nurses should prioritize essential content [13]. In other words, when designing training content for novice nurses in clinical settings, it is necessary to clearly define the essential skills of a long-term, comprehensive educational program. Therefore, this study aimed to identify the basic skills required for novice nurses to be considered independent by consolidating specific examples of reports, contacts, and consultations that senior nurses in the ICU expect from them. We report our findings on the content of novice nurse in-service education in Japan, specifically for ICUs.

2. MATERIALS AND METHODS

3. RESULTS

The research collaborators were two men and six women from four facilities. Their mean (standard deviation) age, years of experience, and years of ICU experience were 32.4 (8.1), 10.8 (8.5), and 7.5 (3.3) years, respectively (Table 1).

This study identified the basic skills that novice nurses without prior nursing experience should possess at the beginning of their careers. It outlined the actions necessary for novice nurses to function effectively as independent staff members before acquiring knowledge and skills. It emphasizes the importance of seeking support from senior nurses to perform their duties independently once assigned to the ICU. We extracted detailed scenarios by listening to specific examples of reports, contacts, and consultations required by senior nurses for novice nurses to work independently and be considered part of the workforce in an ICU. These matched the items listed in the Critical Care Nursing Training Skills of the Critical Care Nursing Course [14] (Table 2), revealing the following results. Since this educational program aligns with our research, we have outlined, using double quotation marks, the specific examples of reports, contacts, and consultations that senior nurses need to provide to novice nurses in order for them to work independently and be fully integrated into the ICU team.

Central line care includes “assistance with central line insertion and removal.” Central line insertion in the ICU is often an emergency requirement due to the patient's condition. This also reflects the significant responsibility of managing several drugs that need to be administered through the central line.

Invasive neuro-intervention care includes “assistance with spinal drain removal” and “changes in pupil diameter and level of consciousness.” This reflects the need to accommodate patients with diseases of the cranial nervous system and provide nursing care for those with pathological conditions that require observation for neurological symptoms.

Respiratory care and assessment include “suction” and “evaluation for suction of bloody secretions.” This reflects the need to monitor aspirated secretions during ventilator care as a part of systemic management after major surgery and when accommodating patients who require airway management due to severe respiratory disease or failure.

Assessment of critical care patients includes “evaluation of vital signs,” “urine volume management,” “evaluation of water balance,” “discovery of dangerous electrocardiogram waveforms,” and several other scenarios. Although assessing a patient's medical condition and need for nursing care may be an advanced skill for novice nurses who have just joined the workforce, it is an essential skill for ICU nurses.

Hemodynamic line care includes “assistance with arterial line insertion/removal,” “management of catecholamine dosage,” “replacing the catecholamine syringe,” and other such scenarios. Although catecholamines are associated with central line care, they are classified here because they are drugs related to hemodynamics. As circulatory agonists, they have the potential to be life-threatening. Thus, special care must be taken and safe techniques must be followed to avoid adverse effects when renewing or increasing the dose.

Pain management and sedation assessment include “pain management,” “Richmond Agitation-Sedation Scale (RASS) evaluation,” “management of patients receiving sedatives,” and so forth. Patients admitted to the ICU often require pain management and sedation and are more likely to develop delirium due to the effects of their general condition and medications.

Ventilator training includes “report and contact of extubation schedule,” “management of patients on ventilators (including leaks, settings, and weaning),” “evaluation of whether extubation is possible,” and “extubation assistance.” This means that extensive ventilator management is required in ICUs.

In addition, although they could not be classified as Critical Care Nursing Training Skills, some essential items, such as “complete bed bath,” “handling of drugs other than catecholamines,” and “correct way to double check,” among others, were also extracted. This indicates that even nursing care and procedures that are performed in general wards require careful consideration when performed on critically ill patients. The collaborators also emphasized the importance of information sharing when working in a team through items such as “coordination during break shifts” and “cooperation during busy times.”

4. DISCUSSION

ICU nurses require advanced knowledge and skills. However, in Japan, novice nurses are assigned to ICUs under the guidance of senior nurses despite the lack of preparation for practice and knowledge specific to emergency medicine [15]. For such novice nurses, imparting education on the spot while working, in parallel with the extensive existing educational programs, is essential. By conducting interviews with senior nurses about the reports, contacts, and consultations necessary for novice nurses to become independent, we clarified the practical educational content for novice nurses aiming to become independent. Furthermore, the validity of the results was evaluated, as they matched the items listed in the Critical Care Nursing Training Skills of the Critical Care Nursing Course. However, many educational programs already exist to acquire knowledge and skills, and the item itself is not a new report. In other words, this study aimed to identify the behaviors necessary for novice nurses who have not yet gained all knowledge and skills to function independently in the workforce. Previous programs focused on teaching ICU nurses the required skills but did not establish criteria for independence. Senior nurses are aware that novice nurses' knowledge and skills are immature; hence, senior nurses expect them to ask for help when needed and learn the required knowledge and skills. This helps novice nurses earn trust, which is a significant factor in working independently from senior nurses. In other words, these are skills that novice nurses must be able to perform, even with assistance, from the beginning of their assignment to be recognized as independent nurses. It is significant that we were able to identify these skills through interviews with senior nurses in the field.

For novice nurses to provide nursing care based on accurate knowledge and safe techniques, we focused on the aspects that senior nurses who provide daily guidance should first teach novice nurses in their practice.

The skills that novice nurses should acquire in the early stages include assisting with procedures related to lines and ventilator management, reflected in each category of “assistance with central line insertion and removal,” “assistance with spinal drain removal,” “assistance with drain insertion/removal,” “assistance with arterial line insertion/removal,” and “extubation assistance.” Since these represent the characteristics of patients who require ICU management and the advanced procedures performed in the ICU, the content is advanced for novice nurses and requires time to acquire relevant knowledge and skills. Therefore, support from senior nurses is essential before novice nurses can perform the procedure completely on their own. A novice nurse may lack awareness of procedures that a seasoned senior nurse would consider routine practice, including necessary precautions and potential future implications. Bedside training is essential to identify the deterioration of clinical symptoms [16, 17]. Therefore, senior nurses should provide initial guidance, allowing novice nurses to acquire skills through training [18]. For this reason, senior nurses believe that it is necessary for novice nurses to seek support independently. If novice nurses can do this, they will be able to become independent without being monitored by senior nurses.

Given that high-risk drugs are often used in ICUs, knowledge of drugs is also necessary [19]. Catecholamines are especially important among drugs used in ICUs. Because they are life-threatening drugs, they must be handled with care to ensure that their administration does not alter the patient's hemodynamics [20]. Senior nurses need to make novice nurses aware that handling high-risk drugs as they would any other regular drugs can put patients at risk. Therefore, in this study, senior nurses specifically used catecholamines as an example to explain the importance of medication management in the ICU.

The severity of the condition of patients admitted to the ICU and the urgency of treatment were high, as expressed in the content regarding nursing care and evaluation. Patients admitted to the ICU could face life-threatening danger if certain aspects of nursing care are overlooked. However, it takes time for novice nurses to notice abnormalities, assess them, and manage them on their own. Novice nurses need support from experienced nurses for complex patient situations that require several skills [21]. By first communicating with senior nurses, novice nurses can learn the aspects of nursing that require additional care and their corresponding expectations, thereby accumulating knowledge and experience that will help them become independent in the future. Communication is important not only for developing novice nurses' professional behavior but also for gaining knowledge from senior nurses [22, 23]. Effective teams and support staff are essential for novice nurses to develop as human resources [24, 25]. Factors such as the gap between theory and practice, experience, and a lack of knowledge can reduce novice nurses' confidence [26]. Young nurses are highly dependent on senior nurses with extensive work experience, consulting them and seeking advice to confirm clinical deterioration when they have doubts or lack ability [16]. Novice nurses should thus build relationships with senior nurses through which they can easily share information and collaborate.

Furthermore, patients admitted to the ICU often communicate poorly due to their critical condition and sedation. Protecting patient safety in such an environment is one of the roles of ICU nurses [27]. However, the ICU is perceived as a high-risk environment and is considered frightening by novice nurses [12]. Our interviewees explained about detecting abnormalities and the progression of treatment to save patients’ lives. To be able to do this, the knowledge and skills of nurses included in each educational program are important. The ultimate goal is for novice nurses to acquire the necessary knowledge and skills. However, before that, they must begin working as part of the workforce, where they should not hesitate to seek help and become independent in areas where they lack experience. In addition, nurses must work together as members of an organization, as effective teamwork improves performance and the quality and safety of care [28]. We believe that fostering nurses who are aware of and can implement this work approach will enhance the demand for and availability of skilled nurses [3].

In this study, we interviewed senior nurses in clinical settings who actually provide daily guidance to novice nurses. Therefore, differing from existing programs that are rich in theoretical content, we were able to highlight cases that occur more frequently in clinical settings. For novice nurses to be able to perform these tasks on their own, learning and experience are required, which take time. However, in reality, novice nurses are assigned to ICUs and provide nursing care immediately after graduation, limiting their ability to become independent immediately. Thus, specific education tailored to the needs of clinical sites should be imparted simultaneously as nurses join the medical workforce. It has been suggested that to facilitate a smooth transition to clinical practice, orientation programs should be provided that allow for a gradual deployment of skills [29, 30]. We also need to consider the extent to which novice nurses need to be able to perform tasks to be considered independent. We hope that, based on these results, an educational program that is effective in practice can be developed. Furthermore, training preceptors have been shown to help novice nurses develop their clinical skills [31, 32]. We hope the study findings underscore the role of senior ICU nurses in imparting highly specialized education to novice nurses and emphasize the importance of the role of ICU nurses.

CONCLUSION

In this study, we interviewed senior nurses about specific examples of reports, contacts, and consultations they expect from novice nurses to work independently in the ICU. Our findings-confirmed the basic skills that senior nurses believed would enable novice nurses to achieve independence while ensuring patient safety through appropriate support-seeking from senior nurses. Furthermore, although previous studies have demonstrated the effectiveness of educational programs, this study focused on clarifying the basic skills that support the independence of novice nurses, which have not been previously examined. In the ICU, where advanced knowledge and skills are required, we believe that providing focused and targeted education will expedite novice nurses’ transition to independence. This study also highlights the critical role of ICU nurses. We believe that these results may be useful in the initial education of novice nurses in the future.

REFERENCES