What's in this issue

Field: Health Professions (Health Sciences)

We begin this issue by wishing our readers a happy, prosperous and rewarding year. As we near the end of this decade, it is impossible to ignore that health care is entering a period of great uncertainty influenced by social, economic and political forces, which challenge those responsible for leading and organizing the delivery of patient services to ensure that quality and patient safety are maintained within existing resources. It is also recognized that working in highly complex and demanding intensive care units (ICUs) can be stressful for nurses, and their emotional well-being can be further compromised by factors including staff shortages, lack of training/development and an unsupportive culture. Yet, despite these issues, in many areas, critical care nurses continue to identify positive ways of effectively advancing the quality of patient care through innovation, service improvements and research. The collection of papers and the editorial expand further on both clinical and workforce issues that are becoming a growing concern for the discipline of critical care and suggest practical approaches on how both clinical practice and an effective workforce can be enhanced to meet the needs of patients. Highfield's (2019) guest editorial, based on a keynote paper presented at the BACCN National Conference in Bournemouth, addresses the problems currently experienced by many ICUs in terms of staff turnover, low morale and poor retention of critical care nurses. These phenomena are not particular to the UK as illustrated to varying degrees by papers of Limbu et al. (2019) and Jarden et al. (2019) below. Highfield (2019), however, does provide a helpful four-pronged strategy on how to improve the culture for staff that ensures workforce sustainability and well-being. The message behind this guest editorial is that interventions to promote staff retention and reduce turnover lie in practical activities such as creating a regular space for staff to discuss issues, providing emotional safety by active listening, include and involve staff by hearing their concerns, demonstrating fairness and valuing the contribution and efforts of co-workers. The challenge for those leading and managing critical care is to ensure that workload pressures do not exceed the emotional abilities of staff, as well as by being supportive, compassionate and demonstrating a duty of care. The application of technology to maintain, assist and support physiological functioning and optimize recovery of ICU patients is taken for granted in many countries. However, the role of critical care nurses is pivotal in humanizing the environment and in providing individualized, person-centred, high-quality care. Understanding the experiences of nurses caring for critically ill patients and the impact of staff is therefore of major concern as the challenges may vary according the socioeconomic and natural resources of individual nations. To this end, Limbu et al. (2019) undertook a phenomenological inquiry to investigate the lived experience of 13 Nepalese nurses from three ICUs. Seven categories emerged from data analysis, which related to the lifeworlds of space, time, relations and body: low technology of care and insufficient resources (lived space); physical and psychological distress and requiring competency (lived body); connecting relationships of a family, trusting technology and realizing team working (lived relationships); less time to be with patient as a whole person (lived time). While some of these themes may be familiar to our readers, one thread that comes through strongly is that caring and meeting the needs of ICU patients and families is demanding, stressful and emotionally exhausting. Providing mechanisms of regular support and debriefing is vital to promote staff well-being; in addition, providing essential resources and empowering critical care nurses through programmes of education can enable them to become more confident, resourceful and skilled to deliver the quality of care that will optimize patients' well-being and is rewarding and satisfying. Drawing on similar concerns around the potential of nursing staff to experience distress, burnout and compassion fatigue, Jarden et al. (2019) sought to explore the perceptions of the strategies that ICU nurses (n = 65) use to strengthen their workplace well-being. Data collection was through contributing free-text comments to two open-ended questions of a larger online study focused on well-being. Participants described using 69 strengthening activities or behaviours that were clustered around: personal resources – those which individuals possessed and brought to the workplace (this included being organized, setting boundaries, and engaging in mindfulness), relational (supportive team environment and supportive feedback from colleagues) and organizational (such as peer supervision and formal debriefing sessions). The study highlights that ICU nurses can be resourceful in applying individual practices to ensure their well-being, but when complemented by positive relationships with co-workers and by an institutional culture of valuing staff and providing programmes for enabling the development and growth of the workforce, this can translate to a healthy and flourishing environment that ultimately positively impacts patient care. Along a similar line, Khan et al. (2019) undertook a mixed-method literature review to examine the factors influencing nurses' intention to leave adult intensive care settings. They found three main factors: the quality of the work environment; working relationships with managers, colleagues, patients and families; and traumatic/stressful workplace experiences. The concept of moral distress is raised. This is an emotional state when the nurse knows that what she should be doing (ethically, professionally or principally) is compromised or when a nurse has to make concessions to her own moral compass because of policy or procedure. This can be associated with the ethical dilemmas that arise from intensive care practice but also from the staffing resource, staffing dynamic and individual capacity to do the job. Inclusivity, participation, respect and involvement creates an organizational climate and, thereby, a working environment in which individuals can flourish. Whilst interventions to help build resilience and support staff through stressful and traumatic experiences are reported as ways to address intentions to leave (the unit and or the profession), balanced work schedules, adequate rest (conserving), support with the physical and emotional demands of the job (and this can mean accepting that the job is emotionally and physically demanding and enlisting help from colleagues when it is needed (see Highfield editorial, this issue) and a commitment to colleagues and to learning are all factors that can build resilience (Hart et al., 2007) and help retain our valuable critical care staff. Burke et al. (2019) report on a quality initiative undertaken by a critical care outreach team (CCOT) to improve compliance with the sepsis six care bundle on the ward. Although these data are historic, collected over 18 months from 2012 to 2014, the initiative transformed compliance with the use of the sepsis six care bundle from a baseline audit, or 34%, to an outcome that achieved 84% compliance. Therefore, the processes undertaken to achieve this outcome are worthy of review. The CCOT supported ward staff through an education programme to recognize, escalate and treat sepsis to improve patient outcomes. They also provided ‘sepsis bags’ that had all the necessary equipment to initiate treatment, an issue identified in the initial audit as one cause of poor compliance with the care bundle. In this prospective observational study, all patients over 18 years old (n = 270) who presented with sepsis, confirmed with the assistance of the sepsis screening tool, received three diagnostic and three therapeutic interventions in the first hour of recognition. The sepsis six care bundle includes: titrating oxygen to a saturation target of 94%, administering intravenous antibiotics, starting intravenous fluid resuscitation, taking blood cultures and measuring serum lactates alongside accurate monitoring of urine output. The prompt treatment on the wards reduced the necessity of ICU admission but also facilitated prompt admission where it was needed. The authors' improvement in delivering intravenous antibiotics within an hour of recognition was aided by the implementation of a standardized intravenous antibiotic regime for sepsis. Of note, the authors indicate that the prevalence of sepsis on the wards may be as high as 3.6–4.2%, with only one in five patients being seen by the CCOT. Ongoing education of ward staff to facilitate recognition and intervention when early signs of sepsis are identified can be aided by tools that enable staff to take appropriate action – in this case, the sepsis six care bundle. Interaction of this type can also build confidence to escalate concerns and seek assistance from the CCOT so that interventions can start sooner and significantly improve patient outcomes. One of the questions that continue to preoccupy critical care nurses and others is the extent to which critical care outreach services impact patient mortality rates. To address this debate, Garry et al. (2019) undertook a systematic review of literature with the aim of examining the impact of Nurse-Led Critical Care Outreach (NL CCO) on patient mortality as a primary outcome, with rates of cardiac arrest and length of stay as secondary outcomes. Ten studies met the inclusion criteria for appraisal and involved approximately 72 000 patients. While eight of the studies identified that NL CCO reduced mortality rates, only two demonstrated a statistical significant p value of 0.52; thus, while there is an encouraging trend, the authors conclude that further work is required. In relation to the incidence of arrest calls, NL CCO helped reduce this with a higher level of statistically significance when compared with mortality rates. The contribution of NL CCO is attributed to the greater influence they had on the quality of monitoring and assessment of at-risk patients. Patient length of stay was only reported by three studies, of which only two demonstrated a decrease in this aspect. Not being able to reach a more objective answer lies in the fact that most studies were single-centre, limiting generalisability of the results; in addition, at least half were scored to be of poor quality and validity. Nevertheless, there is a positive trend which highlights that NL CCO is making a difference to patient outcomes, although large multi-centre studies would help validate the level of impact. Eltaybani et al. (2019) examine how learning from error can ultimately improve patient safety. Data from 112 interviews with nurses who had reported 300 errors were categorized using Benner et al.'s (2002) taxonomy of error reporting. This taxonomy includes medication and documentation error and then errors attributed to lack of: attentiveness, clinical reasoning, prevention, intervention, accurate order interpretation, responsibility and advocacy. The study, undertaken in Egyptian ICUs, was intended to understand the nature of nursing error and included a root cause analysis of why and how the error arose in the first instance. Two conditions were identified in the study: that more errors occurred in the evening shift when there was reduced supervision, fewer staff because of meal breaks and, in this locality, increased physician rounds and peaks in nursing activity. The authors found that nurses were more likely to report an error when they felt safe to do so but also where the error had the greatest impact on the patient. They urged a review of near misses and harmless error to facilitate early intervention to address risk. Learning from mistakes in an organization is a key feature of patient safety and part of the statutory duty of the National Reporting and Learning Systems (NRLS) of the National Health Service (NHS) in the UK. At this level of national reporting, errors are examined for trends, contributing factors and risks, rather than individual circumstances of any one incident. The whole thrust is to understand and learn from what goes wrong and set in place preventative measures to improve patient safety. However, where reporting becomes burdensome, lengthy and complex, error and risk reporting is likely to be reduced (Benner et al.'s (2002)). Receiving feedback on the outcome of an error investigation is more likely to improve incident reporting. Errors occur through acts of omission as well as commission. Systems to prevent error (or framed positively: to improve patient outcome) include compliance with protocols, guidelines and care bundles. Specific learning events dedicated to error reduction might include multi-disciplinary critical incident analysis whereby the team reflects on a specific and shared event, whilst learning through simulation with debriefing helps individuals review their own practice and remediate knowledge deficit or rehearse skill where it is found lacking. However, we can only learn from mistakes if we keep challenging and questioning our practice, and that requires expert facilitation, reflective space and dedicated time. We hope that the guest editorial and papers in this issue have provoked reflection on what you can do both individually and with colleagues to promote well-being. These papers give insights into positive strategies that we can use to ensure we continue to deliver high-quality care that is both sustainable at an economic, social and psychological level but also nurtures, values and considers the physical and emotional needs of critical care nurses.