# Preferences of ICU Nurses for Improving Their Work System: A Sequential Exploratory Mixed‐Methods Study

## TL;DR

This study identifies ICU nurses' top priorities for improving their work system to reduce stress and turnover, using a mixed-methods approach.

## Contribution

First use of the Analytic Hierarchy Process to prioritize ICU work system interventions based on nurses' preferences.

## Key findings

- Workload and Staffing, and micro-level Support and Resources were top priorities for improvement.
- Collaboration and Support, Equipment Enhancement, and Spatial Design were also notable intervention areas.
- Mixed-methods approach identified 17 interventions to improve ICU nurse well-being and patient care.

## Abstract

Patients admitted to intensive care units (ICU) generally require expensive, advanced technological interventions as well as a high level of specialised and timely care to survive their medical crisis. Work in this setting can generate significant pressures for ICU nurses.

To understand and prioritise ICU nurses' preferences for improving their work system based on the five components of the Systems Engineering Initiative for Patient Safety (SEIPS) model.

Using a sequential exploratory mixed‐methods design, qualitative interview data were first collected from ICU nurses employed in a tertiary hospital in Iran to identify interventions for improving their work system. Data saturation guided sample size. Directed content analysis was used for extracting themes representing areas for intervention. The qualitative data were then integrated into an Analytic Hierarchy Process for weighting and prioritising the identified interventions using quantitative pairwise comparisons and mathematical calculations.

Fourteen ICU nurses were interviewed. Directed content analysis of the transcribed data yielded 17 themes impacting nurses' well‐being and performance. The Analytic Hierarchy Process indicated that the themes with the highest priority for improving the ICU work system for nurses were Workload and Staffing, and micro‐level Support and Resources—associated with SEIPS Organisation and Person components, respectively. Notable intervention importance was also found for themes Collaboration and Support, Equipment and Technology Enhancement, Culture and Management, and Spatial Design and Arrangement.

ICU nurses identified a high number of challenges in their work environment. Modern decision‐making analyses were able to quantify and prioritise their preferences. These provide direction for designing future interventions.

As technological advances continue to support patient survival, there is a need for judicious decision‐making in providing immediate and long‐term solutions for associated changes in the work system faced by critical care nurses to ensure nurse well‐being and patient care.

What is Known About This Topic
○The ICU work system is inherently stressful because it involves work with critically ill patients and life‐or‐death outcomes.○The ICU work system is dynamic and constantly evolving in terms of technical complexity, which indicates regular review of operational processes and timely intervention.○Critical care nursing has high turnover, which impacts both patient care and hospital budgets. There is a good business case for intervening to remove barriers in the work of ICU nurses.
What This Paper Adds
○Use of a robust mixed‐methods approach to identify 17 interventions across the ICU work system that warrant improvement according to ICU nurses.○First use of the Analytic Hierarchy Process method for multi‐criteria decision‐making to prioritise the identified interventions to progress an improved work system in ICU.○An approach and evidence‐based recommendations from ICU nurses to improve the work system, which can tackle high ICU nurse turnover and, in turn, improve patient care.○The work system of critical care nurses directly contributes to applying their expertise in monitoring and managing complex conditions towards patient survival and effective recovery. This article recognises that in pursuit of excellence, ICU nurses have raised issues about their work system, and working conditions are an important factor in the high turnover rates. This research sought to identify from experienced ICU nurses interventions that can improve the work system and how they can be prioritised for best effect. Application of the methodology and findings in ICU, wherever situated, can serve to support critical care nurses, and importantly, patient outcomes.

What is Known About This Topic
○The ICU work system is inherently stressful because it involves work with critically ill patients and life‐or‐death outcomes.○The ICU work system is dynamic and constantly evolving in terms of technical complexity, which indicates regular review of operational processes and timely intervention.○Critical care nursing has high turnover, which impacts both patient care and hospital budgets. There is a good business case for intervening to remove barriers in the work of ICU nurses.

The ICU work system is inherently stressful because it involves work with critically ill patients and life‐or‐death outcomes.

The ICU work system is dynamic and constantly evolving in terms of technical complexity, which indicates regular review of operational processes and timely intervention.

Critical care nursing has high turnover, which impacts both patient care and hospital budgets. There is a good business case for intervening to remove barriers in the work of ICU nurses.

What This Paper Adds
○Use of a robust mixed‐methods approach to identify 17 interventions across the ICU work system that warrant improvement according to ICU nurses.○First use of the Analytic Hierarchy Process method for multi‐criteria decision‐making to prioritise the identified interventions to progress an improved work system in ICU.○An approach and evidence‐based recommendations from ICU nurses to improve the work system, which can tackle high ICU nurse turnover and, in turn, improve patient care.○The work system of critical care nurses directly contributes to applying their expertise in monitoring and managing complex conditions towards patient survival and effective recovery. This article recognises that in pursuit of excellence, ICU nurses have raised issues about their work system, and working conditions are an important factor in the high turnover rates. This research sought to identify from experienced ICU nurses interventions that can improve the work system and how they can be prioritised for best effect. Application of the methodology and findings in ICU, wherever situated, can serve to support critical care nurses, and importantly, patient outcomes.

Use of a robust mixed‐methods approach to identify 17 interventions across the ICU work system that warrant improvement according to ICU nurses.

First use of the Analytic Hierarchy Process method for multi‐criteria decision‐making to prioritise the identified interventions to progress an improved work system in ICU.

An approach and evidence‐based recommendations from ICU nurses to improve the work system, which can tackle high ICU nurse turnover and, in turn, improve patient care.

The work system of critical care nurses directly contributes to applying their expertise in monitoring and managing complex conditions towards patient survival and effective recovery. This article recognises that in pursuit of excellence, ICU nurses have raised issues about their work system, and working conditions are an important factor in the high turnover rates. This research sought to identify from experienced ICU nurses interventions that can improve the work system and how they can be prioritised for best effect. Application of the methodology and findings in ICU, wherever situated, can serve to support critical care nurses, and importantly, patient outcomes.