Indirect Patient Care Research Articles

Advanced practice nursing in surgery: A scoping review of roles, responsibilities, and educational programs.

The increasing complexity of the healthcare sector requires an evolution in nursing education to effectively manage care in complex and interdisciplinary contexts. This review aims to analyze the role of advanced practice nurse (APN) in the surgical context within hospital settings, detailing their functions and responsibilities. It also provides an overview of the main degrees and postgraduate training programs for specialization in perioperative management in major Western countries. This scoping review followed the Arksey-O'Malley framework and Joanna Briggs Institute methodology. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to ensure rigorous and transparent reporting. Among the 3663 records analyzed, 20 were included in this review. The role of the APN spans across the preoperative, intraoperative, and postoperative phases, encompassing follow-up care as leaders, mentors, and contributors to research. APNs play a pivotal role by offering direct and indirect patient care at each stage of the surgical journey. Acting as liaisons between the healthcare team and patients, APNs enhance healthcare delivery through personalized, coordinated care, while also fostering ongoing education and research in the field. APNs enhance surgical care by providing in-depth clinical assessments, education, and support throughout the treatment process. However, the lack of standardized regulatory frameworks in some countries limits the autonomy of APNs within the healthcare system, compromising their ability to address unmet health needs and engage in international collaboration. The findings underscore the need for standardized educational pathways, roles, responsibilities, and autonomy for APNs, facilitating better international collaboration and contributing to scientific research.

A mixed-methods exploration of the Real-Time Virtual Support pathway Child Health Advice in Real-Time Electronically in Northwestern BC.

To explore the implementation of a provincial virtual paediatric consulting service, Child Health Advice in Real-Time Electronically (CHARLiE), integrated into the paediatric on-call schedule in Northwestern British Columbia. Healthcare providers in Northwestern British Columbia responded to a survey (n = 72) and participated in focus groups (n = 35) and key informant interviews (n = 4) to share their experiences engaging in a healthcare model that incorporated virtual paediatric consultants in lieu of in-person local paediatrician coverage over a 28-month period. Survey data was analyzed using descriptive statistics. Themes were generated from a qualitative descriptive approach to focus groups and key informant interview transcripts. 96.1% of survey respondents who had used CHARLiE rated it as 'good' or 'very good' in the provision of overall support, while 77.6% reported that CHARLiE improved access to paediatric care. Focus group and key informant interview participants valued CHARLiE's timely, dedicated virtual bedside assessments of patients; collegiality and professionalism; amelioration of local paediatrician burnout; prevention of unnecessary transfers; and offloading of indirect patient care tasks. Video support improved provider confidence and appeared to improve caregiver trust. Suggested improvements included addressing technological barriers, enhancing providers' knowledge of local resources, and enabling continuity of care. Participants identified that virtual care does not replace on-the-ground specialist care. Participants valued CHARLiE's 24/7, timely, and collegial video support. While maintaining a full complement of on-the-ground paediatricians remains the goal for some rural communities, dedicated virtual support provides access to paediatric care in smaller communities, thereby improving health equity for children in British Columbia.

Intensity of nursing work in a primary healthcare center: An observational study

ObjectivesIn the sphere of occupational intensity, nursing stands recognized for its inherently demanding nature, marked by a rapid succession of tasks. Our primary aim was to assess the level of job intensity within nursing by analyzing the frequency and duration of activities performed by nurses, instances of task overlap, and the distribution of break times within a primary healthcare center. MethodsThis study was conducted using a descriptive working method. Nursing activities were recorded with the observation of six nurses, each monitored for 37.5 h. We used the Maribor System for measuring Quantity in Nursing Care in Primary Health Care Settings to measure the nursing care activities about direct patient care, indirect patient care, and other unproductive aspects through direct non-participant observations. ResultsAbout 41.5% (n = 1,640) of all nursing activities involving direct contact with patients, about 38.2% (n = 1,508) was indirect patient care, where a large amount worked with paper files (n = 666, 16.9%). In addition, about 15.0% were other nursing activities (mostly computer work), and just 5.3% (n = 210) of tasks were unproductive. The observational findings indicate a pronounced level of work intensity experienced by nurses in primary health clinics. Significantly, nurses were predominantly engaged in direct patient care tasks, often managing multiple activities simultaneously. Their transitions between tasks occurred approximately every 3 min, frequently without adequate intervals for breaks. ConclusionsThis study highlights the need to shift nurses’ focus from a task-centric approach to one centered on patient care. The prevailing emphasis on tasks may contribute to enduring fatigue and professional dissatisfaction. Consequently, there is an urgent need to redefine the scope of a nurse’s role and implement a comprehensive computer information system as an integral part of this redefined approach.

Unique model for pharmacist cross‐coverage in the ambulatory care setting

AbstractClinical cross‐coverage in ambulatory care pharmacy practice is currently lacking and can lead to gaps in patient care, lost revenue generation, and pharmacist burnout due to a lack of time and support for indirect patient care and non‐clinical activities. To address this need, a cross‐coverage model for a team of ambulatory care pharmacists practicing in diverse clinical settings was developed and is primarily supported by a single broadly‐trained pharmacist known as an ambulatory care generalist. Cross‐coverage from the ambulatory care generalist includes in‐person and virtual patient care as well as in‐basket management and is available to all clinic‐based pharmacists on the specialty and primary care team with a few select clinics involving a designated collaborative practice agreement. The cross‐covering pharmacist has been shown to positively impact productivity measures and components of pharmacist burnout. Widespread implementation of this cross‐coverage model has the potential to greatly impact pharmacy practice and patient care in the ambulatory care setting and increase sources of revenue.

Time and Note Characteristic Effects of an Electronic Health Record Template for Internal Medicine Resident Notes.

Background Inpatient internal medicine (IM) residents spend most of their time on indirect patient care activities such as clinical documentation. Objective We developed optimized electronic health record (EHR) templates for IM resident admission and progress notes, with the objective to reduce note-writing time, shorten note length, and decrease the percentage of progress note text that was copy-forwarded from prior notes. Methods In 2022, a multidisciplinary team created, over an 8-month period, optimized EHR templates for IM resident admission and progress notes. A retrospective analysis was performed to assess differences in resident time spent writing notes, note length in characters, and percentage of progress note text that was copy-forwarded. All 94 residents in the IM residency program had the opportunity to use the novel templates. Results Following implementation of the novel templates, residents spent on average 3.6 minutes less per progress note compared to pre-intervention (P=.008; 95% CI of the difference: 1.1-6.0 minutes). Notes in the post-intervention period were shorter for admission notes (mean reduction of 1041 characters; P<.001; 95% CI of the difference: 448-1634 characters) and progress notes (mean reduction of 764 characters; P<.001; 95% CI of the difference: 103-1426 characters). Progress notes also saw an average 22% decrease of copy-forwarded text (P<.001, 95% CI of the difference: 18.7%-25.4%). Conclusions The optimized note templates led to a reduction in resident progress note-writing time, shortened note length, and a lower percentage of copy-forwarded text.

Defining the "ideal state": A primer on critical care pharmacy practice models.

Critical care pharmacists (CCPs) have been clearly established as value-added members of the interprofessional team, and their contributions positively impact patient outcomes in the intensive care unit (ICU). Despite this, not every critically ill patient in the US receives care from a CCP and the model through which CCPs practice is variable, which has important implications. The purpose of this primer is to review current CCP models and discuss elements of the optimal CCP practice model. Current CCP practice models are defined, including the drug processing and dispensing model, clinical pharmacy specialist model, integrated pharmacy generalist model, and hybrid model, as well as unit-based vs service-based models. The optimal CCP practice model considers the Triple Domain of CCP workload, which includes direct patient care, indirect patient care, and professional service. Elements of the ideal CCP practice model including 24/7/365 CCP services, unit- vs service-based models, prescriptive authority, operational support, and CCP-to-patient ratio are discussed. Other vital elements include dedicated offline time, use of appropriate workload metrics, development of career ladders, opportunities for professional development, and providing wellness resources. The ideal CCP practice model must also be considered through the lens of the patient and medical team, the CCP, the institution, and professional organizations. Strategies for optimizing current CCP practice models are provided, and application of optimal CCP practice model elements is explored through 5 case studies. The optimal CCP practice model includes multiple elements and incorporates the viewpoints of patients, providers, CCPs, institutions, and professional organizations; this model will increase access of all ICU patients to CCPs, enhance the scope of CCP cognitive services, and ensure the economic sustainability of CCP practice while establishing CCP involvement in activities outside of patient care and in professional service.

A multistep approach and executive summary assessing and addressing workforce satisfaction and retention of the oncology pharmacy workforce

AbstractIntroductionHematology/oncology pharmacists work in various roles in healthcare systems and represent a highly skilled and valuable resource. There remains a significant challenge in the recruitment and retention of these well‐trained pharmacists. We sought to identify key factors and propose solutions to impact the ability to recruit, promote, and retain pharmacists.MethodsAn initial survey in 2021 assessed the status of the oncology pharmacist workforce with regard to job satisfaction and attrition risk. Based on the top 5 factors identified in the Initial Survey, a Follow‐Up Survey was conducted in 2022 to further understand top dissatisfiers in the workplace. To address these factors, an in‐person collaborative workshop was conducted in 2023 with a focus on creating action plans around the practice model, professional development, well‐being, and metrics.ResultsA total of 392 individuals participated in the Follow‐Up Survey. Most were 31–40 years of age (56%), female (70%), Caucasian (78%), and from academic medical centers (68%). Of the 367 individuals who responded to factors contributing to dissatisfaction at work, 51 of the respondents selected all five factors. The most common factor was the practice model (77%), followed by burnout/well‐being (74%), leadership (62%), professional development (56%), and metrics (32%). At the workshop, teams worked collaboratively to review detailed data, evaluate root causes, define a goal future state, and build recommendations for incremental steps to pursue progress in each of these areas.DiscussionUtilizing key information learned from both the Initial and Follow‐Up Survey, the Oncology Pharmacy Workforce Collaborative demonstrated that the key themes are interconnected and institutional support is essential in modernizing practice models, revamping professional development, creating better measures of direct and indirect patient care activities, and ensuring effective support for well‐being.

Abstract WMP28: Developing a New Hospital Into a Primary Stroke Center in Just Over a Year

Background: Stroke programs are often developed and implemented in well-established health care facilities. There is little data on certified stroke programs being established in new hospitals. Our primary goal was to establish a strong culture of engagement in the care of stroke patients from the day the hospital opened. Methods: A multidisciplinary stroke oversight committee was formed, which guided development of the stroke program and integrated leaders from all areas involved with direct or indirect stroke patient care. We began trending processes and overall stroke care based on the Get with the Guidelines (GWTG) STK measures. In this study we compared data from the opening of a 160-bed hospital until achieving Primary Stroke Center (PSC) certification (October 2021 - February 2023) to after certification (March 2023 - June 2023). Our primary outcome was to examine the proportion of IV thrombolysis prior to and after PSC certification. Secondary outcomes included: proportion of door-to-needle time within 60 minutes, proportion of EMS arrival and proportion of patients transferred prior to and after PSC certification. Primary and secondary outcomes were analyzed using backwards Wald binomial logistic regression models which were adjusted for age, sex and NIHSS. Results: Among 300 patients evaluated for potential stroke symptoms, 228 (76%) were assessed prior to PSC and 72 (24%) after. Mean age was 63.15±17.37 years and median [IQR] NIHSS was 1 [0, 2]. GWTG STK measures were achieved (&gt; 85%) both before and after PSC certification. There was a higher proportion of patients treated with IV thrombolysis after PSC compared to before (9.7% versus 2.6%), adjusted Odds Ratio (aOR) = 3.66 [95% Confidence Interval (CI), 1.17 - 11.43], p = .026. There was no statistical difference in the proportion of IV thrombolysis patients treated within 60 minutes of arrival after versus before PSC, (57% versus 20%), aOR = 5.33 [95%CI, 0.38 - 75.78], p = 0.22. Additionally, there were similar proportions of EMS arrival and transfers after compared to before PSC, all p &gt; .05. Conclusions: A successful stroke program can be implemented in a new hospital within a short duration of time.

Direct and Indirect Care of Patients With Multiple Sclerosis: Burden on Providers and Impact of Portal Messages.

Multiple sclerosis (MS) indirect patient-care time is often underreported and uncompensated. Data on time spent on indirect and direct care by MS providers is lacking. A survey was designed to understand the practice patterns among MS providers in the United States, including time spent on direct and indirect patient care, as well as managing electronic medical record portal messages. The National MS Society and the American Academy of Neurology facilitated the distribution of the survey to MS providers. Most providers spent at least 1 hour on new and at least 30 minutes on follow-up direct patient care. For indirect patient care, 77% of providers spent more than 1 hour and 57% spent more than 2 hours per day. While some providers have support staff to help with portal messages, many do not have protected time or compensation for portal messages. Multiple sclerosis providers spent a higher-than-average time on direct and indirect patient care tasks, including portal messages, and most lack protected time or compensation for portal messages. These results highlight the potential impact of indirect patient care (notably portal messages) on provider workload and burnout. Better support, protected time and/or compensation for indirect patient care can help ease physician burden and decrease burnout.

Work Patterns and Intensity of Chinese Surgical Residents- A Multicenter Time-and-Motion Study

This study aimed to record and analyze surgical resident trainee time allocation among junior doctors in China in order to understand the training environment and optimize realistic training and patient care objectives. Multicenter observational time and motion study. Multicenter, carried out in 5 tier 3 public hospitals in 5 provinces across China. Surgical resident trainees at various stages of training were eligible to enter the study, total n = 44. Registered nurses were eligible to be observers, n = 4 from each hospital. An expert team comprising 4 chief surgeons and 10 surgical residents participated in establishing the clinical activity list. Participants were observed during working hours (08.00-17.00) for 10 consecutive working days and time spent on different activities were recorded. Work patterns between hospitals were often dissimilar. Most time was spent on direct patient care (34.1%; 95% CI, 28.0%-40.1%) followed by indirect patient care (24.4%; 95% CI, 15.5%-33.2%), scholarly activity (21.1%; 95% CI, 13.7%-28.5%) and other (20.4%; 95% CI, 14.1%-26.8%). Subcategory analysis showed that the amount of time spent each day performing certain tasks was 137 minutes for operating theatre tasks, 103 minutes for medical record-keeping, 25 minutes for direct patient contact, 20 minutes being taught, 12 minutes teaching others, 12 minutes hand-over time, and 0 minutes of outpatient clinic attendance. Inter-observer reliability of 96.5% was obtained prior to recordings. Chinese surgical resident work patterns fall within the range found in other international studies albeit with some exceptions. The training environment appears broadly suitable for competence-based surgical training in China. Inadequate outpatient activity has led to changes in trainee work rosters and trainer requirements. Both strengths and deficiencies were confirmed and addressed. Further audit is required.

Expanding the Role of the Surgical Preoperative Evaluation Clinic: Impact on Risk and Quality Outcome Measures

ObjectiveTo prove that inpatient-adjusted surgical risk and quality outcome measures can be considerably impacted by interventions to improve documentation in the preoperative evaluation (POE) clinic. Patients and MethodsWe designed a quality improvement project with a multidisciplinary team in our POE clinic to more accurately reflect surgical risk and impact expected surgical quality outcomes through improved documentation. Interventions included an improved patient record acquisition process and extensive POE provider education regarding patient comorbidities’ documentation. For patients admitted after their planned operations, POE clinic comprehensive evaluation notes were linked to inpatient History and Physical notes. High complexity patients seen from October 1, 2018 to December 31, 2018 were the preintervention cohort, and the patients seen from January 1, 2019 to December 31, 2019 were the postintervention cohort. ResultsThe primary outcome measures included the total number of coded diagnoses per encounter and the number of coded hierarchical condition categories per encounter. The secondary outcomes included the calculated severity of illness, risk of mortality, case-mix index, and risk-adjustment factor. Postintervention results show statistically significant increases in all primary outcomes with a P<.05. All secondary outcome measures reported positive change. ConclusionOur interventions confirm that a comprehensive POE and thorough documentation provide a more accurate clinical depiction of the preoperative patient, which in turn impacts quality outcomes in inpatient surgical settings. These results are impactful for direct and indirect patient care and publicly reported hospital and provider level performance data.

The Road to Developing Standard Time for Efficient Nursing Care: A Time and Motion Analysis.

(1) Background: The amount of time nurses spend with their patients is essential to improving the quality of patient care. Studies have shown that nurses spend a considerable amount of time on a variety of activities--which are often not taken into account while estimating nurse-to-patient care time allocation--that could potentially be eliminated, combined or delegated with greater productivity. The current study aimed to calculate standard time for each activity category by quantifying the amount of time required by nurses to complete an activity category and determine the adjustment time that can be given during work, as well as determine factors that can be altered to improve the efficiency of nursing care on inpatient general wards of a governmental hospital. (2) Method: A time and motion study was conducted over two weeks using 1-to-1 continuous observations of nurses as they performed their duties on inpatient general wards, while observers recorded each single activity, and specifically the time and movements required to complete those activities. (3) Result: There was 5100 min of observations over 10 working days. Nurses spent 69% (330 min) of time during their 8 h morning shift on direct patient care, (19.4%) ward/room activities (18%), documentation (14%), indirect patient care (12%) and professional communication (5%). Around 94 min of activities seem to be wasted and can be potentially detrimental to nurses' overall productivity and threaten patient care quality. The standard number of hours that represents the best estimate of a general ward nurse regarding the optimal speed at which the staff nurse can provide care related activities was computed and proposed. (4) Conclusions: The findings obtained from time-motion studies can help in developing more efficient and productive nursing work for more optimal care of patients.

Evaluation of the impact of technical physicians on improving individual patient care with technology

BackgroundThe rapid introduction of technical innovations in healthcare requires that professionals are adequately prepared for correct clinical use of medical technology. In response to the technological transformation of healthcare, a new type of professional, the Technical Physician (TP), was created and is trained to improve individual patient care using technology tailored to the needs of individual patients. This study investigates the TPs’ impact on patient care in terms of innovation, effectiveness, efficiency, and patient safety.MethodSemi-structured, in-depth interviews were conducted with 30 TPs and 17 medical specialists (MSs) working in academic or teaching hospitals in the Netherlands. The pre-structured and open-ended interview questions focused on: 1) the perceived impact on innovation, effectiveness, efficiency, and safety, and 2) opportunities and challenges in daily work.ResultsTPs and MSs unanimously experienced that TPs contributed to innovation. A majority indicated that effectiveness (TP 57%; MS 71%) and efficiency (TP 67%; MS 65%) of clinical practice had increased. For safety, 87% of TPs but only 47% of MSs reported an increase. The main explanation given for TPs positive impact was combining medical and technical knowledge. Mainly organizational barriers were mentioned as a potential cause for a less visible contribution of TPs.Conclusion and discussionTPs and MSs unanimously agreed that TPs contributed to innovating patient care through their integrative medical and technical competencies. Most TPs and MSs also reported increased effectiveness, efficiency, and safety of patient care due to the TPs’ work. TPs and MSs expected that the TPs’ impact on direct and indirect patient care will be enhanced once organizational barriers are removed.

Abstract TP25: Implementing Stroke Systems Of Care Within A New Hospital

Background: Stroke programs are often developed and implemented in well-established health care facilities. Stroke coordinators and nurse navigators are essential leaders to ensure success of a stroke program. We aimed to establish strong culture of engagement in the care of stroke patients from day one of a new 160-bed hospital, by hiring a stroke coordinator and navigator to assist with developing a stroke program prior to opening the hospital. Methods: Five months prior to opening a stroke coordinator was hired and navigator was assigned to coordinate post-acute stroke care. A multidisciplinary stroke oversight committee was formed, which guided development of the stroke program and integrated leaders from all areas involved with direct or indirect stroke patient care. In the months preceding go-live; policies and order sets were implemented, stroke alert processes, specific to each unit, with scenarios were reviewed. All nursing staff completed eight hours of stroke education, including NIHSS certification prior to go-live. Additionally, six mock stroke alerts were completed with the assistance of our simulation and training center. Results: One hundred twenty-two patients presented and were diagnosed with stroke between hospital opening on 09/30/2021 and 06/30/2022. The majority of patients were diagnosed with acute ischemic stroke (AIS) or transient ischemic attack 115 (94.3%), age was 69.1±14.8 years and median NIHSS was 1 [IQR, 0 - 2]. Two patients were recommended for and received AIS treatment; one IV thrombolysis and one endovascular stroke thrombectomy. Thirty four patients were added to the stroke care pathway and closely followed for 90 days. The hospital was 100% compliant with all Get with the Guidelines (GWTG) STK measures, with the exception of CSTK-01 NIHSS at 78%. Additionally, all GWTG achievement measures and quality measures achieved at least 93%, except for dysphagia screening which was at 86% compliance. Conclusions: Developing a stroke program by integrating a stroke coordinator and navigator prior to hospital opening facilitated best practices for stroke systems of care from day one. This allowed a brand-new hospital to achieve similar levels of compliance on key GWTG measures compared to other stroke certified hospitals.

Willingness of medical students to volunteer during the Covid-19 pandemic: Assessment at a tertiary care hospital in India.

Background The involvement of medical students in strategies to control Covid-19 might be considered to cope with the shortage of healthcare workers. We assessed the knowledge about Covid-19, willingness to volunteer, potential areas of involvement and reasons for hesitation among medical students towards volunteering. Methods We did this cross-sectional study among undergraduate students at a tertiary care teaching hospital in New Delhi. We used a web-based questionnaire to elicit demographic information, knowledge of Covid-19, willingness to volunteer and reasons deterring them from working during the Covid-19 pandemic, and self-declared knowledge in six domains. Results A total of 292 students participated in the study with a mean (SD) age of 19.9 (3.1) years. The mean (SD) knowledge score of Covid-19 was 6.9 (1.1) (maximum score 10). Knowledge score was significantly different among preclinical (6.5), paraclinical (7.18) and clinical groups (7.03). Almost three-fourth (75.3%) participants were willing to volunteer in the Covid-19 pandemic, though 67.8% had not received any training in emergency medicine or public health crisis management. Willingness to work was maximum in areas of social work and indirect patient care (62.3% each). Lack of personal protective equipment was cited as a highly deterring factor for volunteering (62.7%) followed by fear of transmitting the infection to family members (45.9%), fear of causing harm to the patient (34.2%) and the absence of available treatment (22.2%). Conclusions A majority of the students were willing to volunteer even though they had not received adequate training. Students may serve as an auxiliary force during the pandemic, especially in non-clinical settings.

Clinician-Designed Dashboards.

Critical care pharmacists play a crucial role in direct and indirect patient-care and professional service. Despite this, there is still an ongoing discussion on how to justify their role in the ICU and encourage the opening of more positions. A clinician-designed dashboard is an example of how to present relevant metrics to stakeholders. An example dashboard could include metrics such as pharmacist-to-patient ratio, number of interventions, and stewardship efforts. A dashboard could also convey contributions a critical care pharmacist makes outside of the ICU. This includes institutional services such as education and research. The measurement of such outcomes would justify new positions and protect current critical care pharmacists from unsustainable workloads by recognizing domains of value brought on by a pharmacist. The development of such a dashboard would be a step towards improving outcomes via interprofessional culture and patient-centered care.

Indirect Patient Care by Nurses in the Intensive Care Unit of a Hospital in Iran During the COVID-19 Pandemic

Background &amp; Aims The most important factors for the development of any society are human resources. The intensive care units (ICUs) are the most important departments in the hospitals. Considering the importance of time management for patient care, lack of human resources in this profession, and the fact that nurses spend a lot of time on indirect and non-nursing works, this study aims to investigate the time and type of indirect patient care provided by nurses in the ICU of a hospital in Iran during the COVID-19 pandemic. Materials &amp; Methods This is a descriptive, cross-sectional, and observational study that was conducted for 6 months. Participants were 42 nurses working in the ICU of Hafte Tir Hospital in Rey, Iran who were randomly selected from different shifts. Their activities were observed and their spent time was recorded by the researcher using the stopwatch mobile application. The data collection tool was the Persian version of the International Classification for Nursing Practice (ICNP) checklist with acceptable face and content validity according to opinions of a panel of experts (5 faculty members and 10 nurses). descriptive statistics (frequency, mean, standard deviation, minimum, and maximum) were used for data analysis by SPSS software, version 22. Results Most of nurses (60%) were in the age group of 30-39 years and 72% of them had a work experience of 11-20 years. Most of the nurses were female (85%) and married (80%). In each shift, nurses spent an average time of 247 minutes providing indirect care. The longest time in indirect care was related to writing nursing reports (34.9 ± 10.5 min per shift) and the shortest time were related to removing personal protective equipment (6.11±3.19 min per shift), consulting with a colleague, and wearing personal protective equipment (both with 7±3.55 min per shift). Conclusion Although patients need direct care and continuous presence of the nurse more during the COVID-19 pandemic and there are advanced equipment. To provide proper nursing care, it is important to increase the number of nurses and reduce their non-nursing activities.

Approach to advanced practice nursing student clinical during COVID-19.

Approach to advanced practice nursing student clinical during COVID-19.

Seasonal influenza vaccine uptake among healthcare workers in tertiary care hospitals, Bangladesh: Study protocol for influenza vaccine supply and awareness intervention

BackgroundHealthcare workers (HCWs), such as doctors, nurses, and support staffs involved in direct or indirect patient care, are at increased risk of influenza virus infections due to occupational exposures. Vaccination is the most effective way to prevent influenza. Despite the World Health Organization (WHO) recommendations, Bangladesh lacks a seasonal influenza vaccination policy for HCWs, and thus vaccination rates remain low. The current project aims to investigate the effect of interventions on influenza vaccine awareness and availability of vaccine supply, explore HCWs’ knowledge and perceptions about influenza vaccination, understand the barriers and motivators for influenza vaccine uptake, and understand policymakers' views on the practicality of influenza vaccination among HCWs.MethodWe will conduct the study at four tertiary care teaching hospitals in Bangladesh, using a cluster randomized controlled trial approach, with the hospital as the unit of randomization and intervention. The study population will include all types of HCWs.The four different types of intervention will be randomly allocated and implemented in four study hospitals separately. The four interventions will be: i) ensuring the availability of influenza vaccine supply; ii) developing influenza vaccine awareness; iii) both ensuring influenza vaccine supply and developing influenza vaccine awareness and iv) control arm with no intervention. Both quantitative and qualitative approaches will be applied to assess the intervention effect. We will estimate the Difference in Differences (DID) with 95% CI of the proportion of vaccine uptake between each intervention and control (non-intervention) arm, adjusting for the clustering effect. The qualitative data will be summarised using a framework matrix method.DiscussionThe results of this study will inform the development and implementation of a context-specific strategy to enhance influenza vaccination rates among Bangladeshi HCWs.Trial registrationClinicaltrials.gov NCT05521763. Version 2.0 was registered in September 2022, and the first participant enrolled in March 2022. Retrospectively registered.

Impact of workflow interruptions on baseline activities of the doctors working in the emergency department

BackgroundWorkflow interruptions are common in the emergency department (ED) of the hospitals for physicians, leading to an increased risk of errors.PurposeThis study aims to understand the baseline activities of the...