Transient Decrease in Nursing Workload in a Cardiology Intensive Care Unit During the COVID-19 Pandemic: A Brazilian Ecological Study

Abstract

The COVID-19 pandemic has led to a general increase in the workload in Intensive Care Units (ICUs). The objective here was to analyze the nursing workload in a Cardiology ICU of a tertiary and teaching inner hospital in Brazil before and during the COVID-19 pandemic. A retrospective and ecological study was conducted. Nursing Activities Score mean by month (NAS-mm) data were collected from the unit’s opening in October 2014 until May 2023. The data were divided into pre-pandemic and pandemic periods, with the pandemic further divided into three phases/years. A workload decrease was observed during the pandemic and varied across different pandemic years. In the pre-pandemic period, the mean was 53.80 points (95%CI: 52.99; 54.60; n = 65), whereas during the pandemic, it was 52.02 points (95%CI: 50.88; 53.17; n = 39). The first year had the lowest mean workload at 50.94 points, followed by the second year with 48.37 points, while the third year had the highest with 55.82 points, exceeding the pre-pandemic period’s workload. Amid the COVID-19 pandemic scenario, a decrease in nursing workload was observed in the unit, only returning to reference values in the third pandemic year, possibly associated with patient and administrative profile changes.

1. Introduction

An outbreak of pneumonia of unknown cause emerged in December 2019 in Wuhan, Hubei province, China [1]. Analysis of these cases resulted in the isolation of a novel coronavirus, which was later named SARS-CoV-2 [1]. Of zoonotic origin, SARS-CoV-2 causes severe respiratory syndromes and is often fatal. As the epidemic unfolded in December 2019, the virus spread to all continents, and in March 2020, it was considered a pandemic by the World Health Organization (WHO) [1]. Patients affected by SARS-CoV-2 may be asymptomatic or manifest a wide variety of symptoms, ranging from mild to severe manifestations [1]. Individuals who progress to acute respiratory distress syndrome can deteriorate rapidly, culminating in multiple organ failure and, consequently, requiring care in Intensive Care Units (ICUs), often progressing to death [1].

With the onset of the COVID-19 pandemic, there was a significant impact on the workload of health professionals, especially in nursing [2]. Abruptly, health units were faced with a substantial increase in the number of critically ill patients hospitalized in a scenario where a shortage of professionals was already common [2]. There was a need to change all internal flows for the prioritization and care of patients with COVID-19, with repercussions at all levels of health care and in professions such as nursing.

Along with the increase in the number of patients, ICU nurses also faced a new class of patients who required complex and unknown care. The workload for nurses caring for COVID-19 patients was considerably higher than that for typical ICU patients [2,3]. At the peak of the COVID-19 crisis, ICU nurses often found themselves responsible for caring for more than two patients per professional or above work capacity [2]. This scenario increased the possibility of risks and adverse events in the Brazilian ICUs once we expected a ratio of 1:2, or one professional for two patients, based on Brazilian legislation.

The analysis of the nursing workload in the ICU plays a crucial role in ensuring patient safety, improving the excellence of the care offered, promoting the well-being of professionals, and optimizing the use of hospital resources, as already demonstrated in the literature [4]. In addition, this assessment helps to comply with the sanitary and professional regulations and safety guidelines established for each country, such as Brazil [5].

In view of the above, this study aims to compare the nursing workload in a Cardiology Intensive Care Unit of a Brazilian teaching and tertiary hospital during the COVID-19 pandemic and the pre-pandemic period.

2. Materials and Methods

This is a retrospective, documental, and ecological study carried out at the “Hospital de Clínicas, in Portuguese” of the Federal University of Uberlândia, Uberlândia, Minas Gerais state, Brazil. Data were collected in the Cardiology Intensive Care Unit. In this study, the unit’s Nursing Activities Score mean monthly (NAS-mm) was collected from its opening (October 2014) to October 2018. We updated the data until May 2023. The NAS-mm is a public indicator, which the institution must disclose, a fact that justifies the non-submission of the present study to the Research Ethics Committee, as stated by Almeida Júnior et al. [6] and legally supported by the Brazilian regulation agency ANVISA [5]. The study was approved internally by the university and the hospital mentioned; and it does not violate any Brazilian legal or research legislation. The NAS-mm consists of the mean NAS value recorded for all occupied beds in the unit in the month evaluated. It represents the mean nursing workload and is calculated independently of the patient. No personal patient data were evaluated or treated here.

After collecting the monthly NAS-mm, the months were dichotomized as belonging or not to the pandemic period (March 2020 to May 2023). Additionally, as the data could also fluctuate during the pandemic, this period was divided into three phases, which correspond to the pandemic years and are referred to as years here, with the first two years including data for 12 months each. The first year was from March 2020 to February 2021 and the second year was from March 2021 to February 2022. In the third year, starting in March 2022, we included the remaining months until May 2023, totaling 15 months.

We used Generalized Linear Models to compare the mean between the sources of variation, adopting a Gaussian probability function and an identity-type link function. For the pairwise multiple comparisons, the least significant difference test (LSD) was used. A significance of 0.05 was adopted.

3. Results

The pandemic reduced the nursing workload, as measured by the Nursing Activities Score (Wald Chi-Square = 23536.89; p < 0.001), with the pre-pandemic period showing an average of 53.80 points (95%CI: 52.99; 54.60; n = 65) and the pandemic presenting an average of 52.02 points (95%CI: 50.88; 53.17; n = 39). To better understand the pandemic and how the NAS-mm fluctuated throughout it, we divided the pandemic into three years, the analysis was repeated, and we also observed the distinction between all phases (Wald Chi-Square = 22383.92; p < 0.001).

The pandemic decreased the workload in the first year, with a more significant drop in the second year, while the workload increased in the third year with a higher average than the pre-pandemic period. It was observed that the third year had the highest average with 55.82 points (95%CI: 55.11; 56.53; n = 15), followed by the pre-pandemic period with 53.80 points (95%CI: 52.99; 54.60; n = 65); and there was a decrease in the burden from the first year with 50.94 points (95%CI: 50.06; 51.82; n = 12) to the second year with a mean of 48.37 points (95%CI: 47.07; 49.67; n = 12). All four phases were different from each other when compared pair by pair (p < 0.001) (Figure 1). As the end of the pandemic took place in May 2023, it was not yet possible to assess whether this increase in workload observed in the third year would be maintained in the post-pandemic period. Additional analyses are still necessary.

4. Discussion

We observed a reduction in nursing workload in the Cardiology Intensive Care Unit analyzed during the COVID-19 pandemic. In the literature, we observed an increase in workload during the pandemic compared to the pre-pandemic mainly outside Brazil, reporting an average of 76.5 versus 50.0 points [2], and comparing patients with and without COVID-19, respectively, 79 versus 65 points [3]. This is related to the fact that conventional ICUs were taken over by the increase in unscheduled COVID-19-related admissions due to the pandemic, generating an intense demand for the availability of beds in the units and, consequently, a burden on the nursing team. In addition, the workload increased given the demand of the distinct care profile of COVID-19 patients [3].

Although the measurement of workload in ICUs is critical, the scarcity of related studies is remarkable, and in the case of specialized ICUs, such as cardiology, the absence of studies is even more significant. This shortage is also present in Brazilian units, and in oncology ICUs, COVID-19 patients also had higher scores, with 119.89 versus 82.16 points [7], repeating the finding in general ICUs with COVID-19 patients presenting higher averages with 87.8 versus 82.60 points [8]. Regardless, we observed the low nursing workload in the unit evaluated here without considering the phase, as previously identified, and it was related to possible differences in the unit’s care profile [6].

The reduced NAS values in the Cardiology ICU during the pandemic may be associated with the fact that there was a reduction in elective surgeries in hospitals. In some cases, elective surgeries were canceled or postponed to free up beds and relocate staff to cover and assist in the COVID-19 emergency [9]. Also carried out at the hospital that was the focus of our study, some institutions opted for the physical separation between ICUs for COVID-19 positive patients and those for patients negative for the virus to avoid contamination among hospitalized patients, as highlighted by Mauricio et al. [10], which may have had an indirect impact on reducing the workload of the nursing team.

Another factor to be considered about the decrease in workload is the substantial drop in the demand for care during the COVID-19 pandemic, soon after the implementation of social distancing measures by the federal government due to the fear of contamination, as observed in some institutions [11]. This reduction was also seen in the volume of consultations in outpatient cardiology services and the demand for care in the cardiology emergency room, showing a 45% reduction, coinciding with a 20% drop in ICU admission rates and a 36% reduction in admissions to the cardiology ward [12].

There was an increase in the average value of the NAS in the third year of the pandemic, with the highest average of all phases. The mass vaccination of the population may be correlated with this fact, beginning in 2021, which will gradually lead to social return as individuals are immunized. As stated by Almeida et al. [12], any delay and postponement in access to medical care in the early years of the pandemic is linked to deterioration in the population’s health. This may thus indirectly explain the increase in nursing workload in this third pandemic year. The most decompensated patients, whose waiting time for care is prolonged, have a higher risk of complications and increase the complexity of the care required. Although there are possible explanations, the causal and determinant factors of the nursing workload in this unit are unknown and still need to be explored.

The nursing workload and the pandemic were widely discussed topics in the literature. Despite this, there is still a lack of paired studies (COVID-19 vs. no COVID-19 in each disease and outcome), for specialized units and even for the Brazilian scenario, which does not allow many generalizations. A Brazilian study found no differences in NAS between patients admitted to COVID-19 ICUs and General ICUs (mean NAS next 70) [13]. A high workload per nursing professional was associated with the occurrence of adverse events and the deaths of patients with COVID-19 in a Brazilian General ICU, while the nursing staff sizing was not, with a higher NAS (median 72.81) than found by us [14]. Other Brazilian studies also observed an average NAS for COVID-19 patients much higher than observed by us at 84.79 [15], 86.0 [16], and 87.8 [8]. Studies such as case–control, match case–control, and those that control all possible confounders are still needed to differentiate the impact of COVID-19 on the workload of nurses, especially in Cardiology ICUs and in Brazil. Our results reinforce the need for continuous workload monitoring and future investigations that include patient profiles to define the determinants of this pattern observed in the ICU evaluated here.

Another aspect that may deserve attention is the absence of an evaluation of the time spent on standard and respiratory precautionary measures in the workload measurement instruments, which were preponderant in the pandemic. This is a limitation of almost all workload instruments, including the Nursing Activities Score. Despite this limitation, the increase in workload has been associated mainly with more intense hygienic procedures, mobilization and positioning, support and care for relatives, and respiratory care [2]. As our study was ecological, we were not able to assess whether the NAS recorded in the indicators was true and what items from NAS describe the workload, which could also justify the result found; although in the institution evaluated here, the NAS fluctuated between 50 and 70 in its five different types of ICU in the pre-pandemic period [17], demonstrating that the institution has a low NAS compared to other institutions. Associated with this limitation of the instruments, there is the mental and physical overload the professionals experienced in the pandemic, which may not have affected the workload itself but had an impact on the capacity to respond to this workload and the intention to leave nursing if there was no institutional support for these demands [18]. Quick and efficient organizational responses are essential in times of crisis, such as the pandemic. Still, for this, the knowledge and the quality of the indicators of the institution or unit are crucial. As pointed out here, following up on the NAS in ICUs is essential and should be routine in all institutions.

This study has some limitations. It is difficult to compare it with the literature since there are few specific studies on Cardiology ICUs, especially in Brazil. In addition, this is a single-center study, and it may not consider the various regions of the country and how COVID-19 has impacted them. Finally, due to its observational and ecological characteristics, it was impossible to accurately determine the genuine reasons for the decrease in nursing workload and its increase in the third year of the pandemic. Patient-level analyses are still needed to understand the determinants of this decrease in workload, compare it with other specialized units, or determine possible managerial factors that may have influenced these results. In general, this can be attributed to the decrease in scheduled elective surgeries, the reduction in the demand for health services, the allocation of beds for patients with COVID-19, and the implementation of a physical separation between ICUs (COVID-19 versus others) to prevent contamination among patients.

5. Conclusions

The COVID-19 pandemic resulted in a reduction in the nursing team’s workload in the hospital’s Cardiology ICU under analysis. This decrease was accentuated in the first and second years of the pandemic, with an increase in the third year. Although the determinants of this are unknown, they may be related to managerial actions, such as the cancellation of elective surgeries and hospitalizations and/or changes in the profiles of patients in these phases.