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Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care UnitsA Randomized Clinical Trial

Educational Objective
To learn about an intervention to reduce job strain among nurses working in intensive care units.
1 Credit CME
Key Points

Question  Can a multimodal program that includes education, role-play, and debriefing reduce job stress among intensive care unit (ICU) nurses?

Findings  In this randomized clinical trial including 198 ICU nurses in France, the prevalence of job strain (assessed by a questionnaire that included psychological demand and decision latitude evaluation) was significantly reduced at 6 months among nurses in the 5-day intervention group (13%) compared with those in the control group (67%).

Meaning  A multimodal program may be effective in reducing job stress among ICU nurses.

Abstract

Importance  Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover.

Objective  To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses.

Design, Setting, and Participants  Multicenter randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29, 2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018.

Interventions  The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization), which were followed by debriefing sessions on attitude and discussion of practices.

Main Outcomes and Measures  The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21 (score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover.

Results  Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]), 182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively; between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%]; P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group (between-group difference, 8% [95% CI, 0%-17%]; P = .04).

Conclusions and Relevance  Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program. Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective.

Trial Registration  ClinicalTrials.gov Identifier: NCT02672072

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Article Information

Corresponding Author: Laurent Papazian, MD, PhD, Médecine Intensive-Réanimation, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France (laurent.papazian@ap-hm.fr).

Accepted for Publication: October 2, 2018.

Published Online: October 24, 2018. doi:10.1001/jama.2018.14284

Author Contributions: Dr Baumstark had full access to all the study data and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: El Khamali, Mouaci, Valera, Cano-Chervel, Pinglis, Sanz, Allal, Attard, Malardier, Delfino, D’Anna, Rostini, Berthias, Cresta, Iride, Reynaud, Suard, Syja, Vankiersbilck, Chevalier, Inthavong, Forel, Papazian.

Acquisition, analysis, or interpretation of data: El Khamali, Mouaci, Valera, Cano-Chervel, Pinglis, Sanz, Allal, Malardier, Delfino, Aguilard, Berthias, Cresta, Iride, Reynaud, Suard, Syja, Vankiersbilck, Chevalier, Inthavong, Forel, Baumstarck, Papazian.

Drafting of the manuscript: El Khamali, Mouaci, Valera, Cano-Chervel, Pinglis, Sanz, Allal, Attard, Malardier, Delfino, D’Anna, Berthias, Cresta, Iride, Reynaud, Suard, Syja, Vankiersbilck, Chevalier, Inthavong, Forel, Papazian.

Critical revision of the manuscript for important intellectual content: El Khamali, Mouaci, Valera, Cano-Chervel, Pinglis, Sanz, Allal, Malardier, Delfino, Rostini, Aguilard, Berthias, Cresta, Iride, Reynaud, Suard, Syja, Vankiersbilck, Chevalier, Inthavong, Forel, Baumstarck, Papazian.

Statistical analysis: Baumstarck.

Obtained funding: Attard, D’Anna, Baumstarck, Papazian.

Administrative, technical, or material support: El Khamali, Mouaci, Valera, Cano-Chervel, Pinglis, Sanz, Allal, Attard, Malardier, Delfino, D’Anna, Rostini, Berthias, Cresta, Iride, Reynaud, Suard, Syja, Vankiersbilck, Chevalier, Inthavong, Forel, Papazian.

Supervision: El Khamali, Mouaci, Valera, Cano-Chervel, Pinglis, Sanz, Allal, Malardier, Delfino, Berthias, Cresta, Iride, Reynaud, Suard, Syja, Vankiersbilck, Chevalier, Inthavong, Forel, Papazian.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was funded by grant PHRIP 14-0061 from the French Ministry of Health (Programme Hospitalier de Recherche Infirmière et Paramédicale [PHRIP]) and by funding from the Assistance Publique–Hôpitaux de Marseille.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Study Group: The members of the SISTRESSREA Study Group include Valérie Reynaud and Bernard Garrigues (Réanimation Centre Hospitalier, Aix-en-Provence); Karine Berthias and Nicolas Bruder (Réanimation Polyvalente et Neurochirurgicale, Centre Hospitalier Universitaire Timone); Béatrice Cresta and Catherine Guidon (Unité de Réanimation Cardio-Vasculaire, Centre Hospitalier Universitaire Timone); Josiane Avarello, Wlady Syja, Jérémy Suard, Sandrine Wiramus, and Jacques Albanese (Réanimation Polyvalente et des Pathologies du Foie, Centre Hospitalier Universitaire Conception et Centre Hospitalier Universitaire Timone, Marseille); Frédéric Iride, Caroline Brousse, and Marc Leone (Réanimation Polyvalente et Traumatologique Centre Hospitalier Universitaire Nord, Marseille); Stéphan Aguilard and Marc Gainnier (Réanimation des Urgences et Médicale, Centre Hospitalier Universitaire Timone, Marseille); Pierre Sylla, Marièle Parra, Sophie Breuils, Catherine Moreau, Cécile Vankiersbilck, and Christine Vilagines (Réanimation des Détresses Respiratoires et Infections Sévères, Centre Hospitalier Universitaire Nord, Marseille); Anderson Loundou and Pascal Auquier (Laboratoire de Santé Publique, Faculté de Médecine de Marseille); Pierre Martinez and Elisabeth Coulomb (Direction des Ressources Humaines Assistance Publique–Hôpitaux de Marseille); and Patrick Sudour (Direction de la Recherche et de l’Innovation APHM, Marseille).

Data Sharing Statement: See Supplement 5.

Meeting Presentation: Presented in part at the 31st European Society of Intensive Care Medicine Congress; October 24, 2018; Paris, France.

Additional Contributions: We thank Justine Buand, PhD (independent contractor), for providing the English translation of this article. Dr Buand was paid for her contribution.

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