Work Environment and Process in Intensive Care: Safety Risks for Professionals and Patients 111

Fernanda Raphael Escobar Gimenes*

Citation: Work Environment and Process in Intensive Care: Safety Risks for Professionals and Patients. American Research Journal of Nursing. 2019; 5(1): 1-11.

Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Introduction: Risk situations are considered as being caused by the nature of the jobs and as the result of actions or external factors that increase the probability of changes in the workers’ health. Objective: To explore how healthcare professionals in an intensive care unit (ICU) experience safety issues and other safety concerns within their work environment.

Methods: The restorative approach in healthcare was used and involved joint identification of the problem and use of a set of visual methods: focus group; photo narration; and photo elicitation.

Results: A key finding was that the work conditions and processes pose threats to patients and professionals’ safety. Participants discussed risks existing in their work environment and identified solutions to promote a safer workplace for medication management and for themselves.

Conclusions: The visual methods helped participants to develop in-depth discussions on the risk factors detected and engaged them in the proposition of solutions to the problems identified in this complex environment.

Keywords: Occupational health; Intensive care units; Photographic research methods; Nursing.



Risk situations are considered as being caused by the nature of the jobs and as the result of actions or external factors that increase the probability of changes in the workers’ health. Health work settings naturally concentrate a range of hazards that entail different health problems for the professionals working there.1 The nursing workers are the largest workforce in hospitals and are therefore the professionals who are most exposed to occupational hazards and accidents, factors that influence these workers’ quality of life.2 Among the major hazards at hospitals, nurses daily face lifting and moving patients, needle sticks, slips, trips, falls, and the agitated patients – along with a dynamic environment and a specific organizational culture.3

Intensive Care Units (ICU) are intended to provide high-complexity care to severe patients, which requires very specific facilities, equipment, devices and medications; therefore, ICU nurses are exposed to different occupational risks.4

In this study, the restorative research approach granted a better understanding of the existing hazards at an ICU according to healthcare professionals. This method permits studying the complex relationships in the health processes, furthering an understanding of how people interact with the environment they work in.5

Researchers shown how the socio-ecological approach can be used in complex healthcare settings for developing practical guidance for designing, implementing, and evaluating quality improvement programs5. This approach has being used in Canada5 and Brazil6 to support the healthcare team to carry out best practices in order to improve patient safety and other quality issues. Thus, the principles of ecological restoration and its application to health care settings inspired us to engage nurses and decision-makers in the use of photo-methods to better understand the connections between people and nature.

Thus, the objective was to explore how healthcare professionals in an ICU experience safety issues and other safety concerns within their work environment.


This qualitative research was conducted in the ICU of a general hospital in the State of São Paulo, Brazil. It is part of a research on safe medication in ICU; related publication detailed the methods used and a general view of the themes resulting from the interactive data collection and analysis.6 In this article, we present the results and in-depth discussion on one of the emerging themes, which is the continuing need to cope with the threats in the ICU setting and in the work processes, which contribute to the risks for the patients and healthcare professionals.

The restorative approach in healthcare7 involved collaborative work between the lead researcher and ICU professionals, joint identification of the research problem and use of a set of visual methods adapted from ecological restoration, which are: (1) focus group (FG); (2) photo narration; and (3) photo elicitation.

Institutional Review Board approval was obtained, in compliance with Brazilian requirements, under protocol 1096/2009. Before participating in any research phase, the ICU professionals received explanations on the objectives and methods used for data collection and analysis. After accepting to participate in the research voluntarily, each participant signed the informed consent form.

All nursing professionals, pharmacists and physicians active at the ICU were considered eligible. The exclusion criteria were: professionals on holiday, leave or dismissed from the hospital during the data collection period. Twenty-seven nursing professionals, one pharmacist and five intensive care physicians were invited to participate in the research; 19 nursing technicians, four nurses and one physician accepted the invitation. The participants’ age ranged between 24 and 50 years and all of them had worked in the ICU between two and five years.

The interactive data collection and analysis took place between January 2010 and October 2011, in three phases. In all phases, the lead researcher served as a facilitator for the discussions. In Phase 1, six FGs were held in Portuguese with the help of a semi-structured guide, aiming to understand the preparation and administration of the medicines present in the ICU, as well as the positive and negative aspects involved in the safety standards, routines and culture. The participants (n = 21) were encouraged to reflect not only on the problems, but also on the strengths of the medication system and existing resources in the work setting that positively affected safe medication preparation and administration. Two trained research assistants made notes in the field diary to enhance the rigor of the observations. The data from the FGs were recorded and later fully transcribed in rich text format. The transcriptions were compared with the notes in the field diary and content analysis was applied as described by Creswell.8 The data analysis resulted in a list that covered positive and negative aspects of the processes to be captured in research Phase 2 (photo narration). This list was used as the starting point to conduct two photo narration sessions in the ICU. The lead nurse invited a nurse expert to conduct each session with a view to documenting safe and unsafe practices in the medication preparation and administration processes. The content of the recordings was literally transcribed in rich text format and the photos were numbered, labelled and stored in a computer protected with a password. These photos were transferred to Microsoft PowerPoint®; proceeding with the interactive data analysis, the narratives and photos were analyzed separately and in combination. Figure 1 exemplifies the coding process of the photographs.

In Phase 3, the themes resulting from Phases 1 and 2 were presented to the participants during the photo elicitation. At that moment, the lead researcher selected 12 photos and presented them to the participants with the help of Microsoft PowerPoint® (Figure 2). The purpose of this data collection method was to explore further details on the medication preparation and administration processes at the ICU and the strategies focused on the prevention of adverse events. All professionals (nurses, pharmacist and physicians) were invited to participate and seven accepted the invitation. In cooperation with the lead researcher, the participants reviewed the photos and shared their perceptions and histories on safe and unsafe medication–related practices in the work processes and in the ICU. To guarantee the rigor, critical discussions were held with the participants about the final theme and the categories that emerged from the interactive data analysis.