Objective: To find out if non-invasive ventilation (NIV) as a ventilation modality increases the burden on nursing personnel and give suggestions how the presence of non-medical caregivers in an ICU with an extreme staff shortage can reduce nursing workload during mechanical ventilation. Background: Although the European Union offers good quality healthcare, there are middle-income countries in the alliance that suffer from nursing staff shortage. For example, Bulgaria needs two times more nurses than it has now to meet the needs of its healthcare system. This calls for strategies that reduce nursing workload as much as possible. There is a common perception that NIV is more time-consuming for nurses compared to invasive mechanical ventilation (IMV) but only a few studies discuss the matter and none of them are settled in the unique environment where medical and non-medical caregivers provide direct patient care as a team. Study design and methods: This is an observational study conducted in a specialised respiratory ICU with trained nurses, physiotherapists, and non-medical caregivers in a university hospital in Bulgaria. Ninety adult patients (43 on NIV and 47 on IMV) with acute respiratory failure that were on mechanical ventilation for at least five days were included. Nursing workload was measured via the Nursing Activities Score (NAS). Average and daily NAS were compared between groups. Then individual components of the score were analysed to determine which activities have the greatest impact on nursing workload. Results: Average (39.72 ± 6.35 vs 46.08 ± 5,66, p< 0.001) and daily NAS for the first five days of mechanical ventilation and was significantly higher in the IMV group. There was a substantial drop of nurse workload with time in both groups, more significant for the patients who ventilated invasively. It occurred on the second day in both groups (NIV: p=0.005, 95%CI: 0.88-4.52; IMV: (p<0,001, 95%CI: 2.72-7.03). NIV patients required more time for monitoring but less for hygiene, fluid administration and nutrition. IMV patients also required specific care for their artificial airway and took more time for lung function improvement procedures. Conclusion: In a setting where direct patient care is provided by both formally trained nurses and nonmedical caregivers IMV was associated with a higher nursing workload than NIV. Implications for research, policy, and practice: In a situation with an extreme staff shortage some of the non-medical nursing activities involving patients on NIV can be potentially transferred to trained nonmedical caregivers.

What is already known about the topic?

According to the World Health Organization in 2018 there was a nurse shortage of around six million and by 2030 it will increase to 36 million. This negative trend is most prominent in low- and middle-income countries.
There is a common perception that NIV is more time-consuming for nurses compared to IMV but only a few research groups address this matter.
NIV may require additional time from nursing personnel mainly because of problems with mask fit, skin breakdown and maintenance of an optimal position in bed. NIV is more time-consuming in the first 48 h but then becomes much less demanding.

What this paper adds

This is the first study where the ICU nursing workload during NIV and IMV is compared in a setting where non-medical caregivers have a substantial role in direct patient care.
In a setting where direct patient care is provided by both formally trained nurses and non-medical caregivers IMV was associated with a higher nursing workload than NIV.
In a situation with an extreme staff shortage some of the non-medical nursing activities involving patients on NIV (like help with self-hygiene, food, and water intake) can be potentially transferred to trained non-medical caregivers under supervision.