‘Running Towards the Bullets’: Moral Injury in Critical Care Nursing in the COVID-19 Pandemic

The COVID-19 pandemic placed unprecedented strain on healthcare professionals around the globe, particularly those working in intensive care units. It was reported that instances of moral injury – a betrayal of what is ethically right by those in positions of power – were widespread in these organizational settings. In this paper, we explore these emerging findings to ask: What are the experiences and implications of moral injury in critical care nursing during the pandemic? Drawing on 103 interviews with 54 critical care nurses, we offer insights into the experience of moral injury in a workplace experiencing crisis, focusing on (i) unsafe staffing levels, (ii) inadequate equipment, and (iii) inability to provide patients with a dignified death. We provide accounts of the implications of moral injury ranging from debilitating anxiety to post-traumatic stress disorder and sectioning, as well as widespread feelings of anger and guilt leading to an intention to leave the profession

Toxic Absence: Why Leader Presence Matters in Times of Crisis

Aims. This study examines the importance of senior-leader presence on the “frontline” in times of crisis. Background. The COVID-19 pandemic placed unprecedented demands on nurses charged with delivering critical care. Extant research suggests that the active presence of ward-level leaders has an important role to play in supporting frontline staff and mediating the negative impacts of stress and burnout. There is little evidence on the impact of senior leader presence or absence on the experience of frontline critical care nurses, particularly at times of crisis. Methods. A three-phase qualitative interview study of critical care nurses in the UK and Ireland. A total of 107 semistructured interviews with 54 nurses representing 38 different healthcare units. Results. Senior-leader presence at the time of crisis serves as an important symbol of organisational support. Where senior leaders are not meaningfully present, they risk allowing the necessary pain of difficult work situations to become toxic. Toxicity is manifested with increased staff stress, emotional ills, absence, and turnover. Conclusions. Senior leaders must balance their responsibilities for strategy and structures with the frontline presence required to shape a positive emotional climate. Implications for Nursing Management. Senior managers should consider supplementing their strategic focus with punctuated returns to the floor. Symbolically, leaders who get their hands dirty embody a sense of mutual struggle and practical support. Managerially, time on the floor increases the opportunities for collecting primary data to improve decision-making and support

Surgical and Oncological Outcomes After Preoperative FOLFIRINOX Chemotherapy in Resected Pancreatic Cancer : An International Multicenter Cohort Study

Background. Preoperative FOLFIRINOX chemotherapy is increasingly administered to patients with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) to improve overall survival (OS). Multicenter studies reporting on the impact from the number of preoperative cycles and the use of adjuvant chemotherapy in relation to outcomes in this setting are lacking. This study aimed to assess the outcome of pancreatectomy after preoperative FOLFIRINOX, including predictors of OS.Methods. This international multicenter retrospective cohort study included patients from 31 centers in 19 European countries and the United States undergoing pancreatectomy after preoperative FOLFIRINOX chemotherapy (2012-2016). The primary end point was OS from diagnosis. Survival was assessed using Kaplan-Meier analysis and Cox regression.Results. The study included 423 patients who underwent pancreatectomy after a median of six (IQR 5-8) preoperative cycles of FOLFIRINOX. Postoperative major morbidity occurred for 88 (20.8%) patients and 90-day mortality for 12 (2.8%) patients. An R0 resection was achieved for 243 (57.4%) patients, and 259 (61.2%) patients received adjuvant chemotherapy. The median OS was 38 months (95% confidence interval [CI] 34-42 months) for BRPC and 33 months (95% CI 27-45 months) for LAPC. Overall survival was significantly associated with R0 resection (hazard ratio [HR] 1.63; 95% CI 1.20-2.20) and tumor differentiation (HR 1.43; 95% CI 1.08-1.91). Neither the number of preoperative chemotherapy cycles nor the use adjuvant chemotherapy was associated with OS.Conclusions. This international multicenter study found that pancreatectomy after FOLFIRINOX chemotherapy is associated with favorable outcomes for patients with BRPC and those with LAPC. Future studies should confirm that the number of neoadjuvant cycles and the use adjuvant chemotherapy have no relation to OS after resection.Peer reviewe

Obesity in adults: a 2022 adapted clinical practice guideline for Ireland

This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity. It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients' lived experiences; move beyond simplistic approaches of "eat less, move more" and address the root drivers of obesity. People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay

Investigating the impact of body composition and nutritional intervention strategies in pancreatic cancer

Introduction: Pancreatic adenocarcinoma (PDAC), while often described a rare or neglected cancer, is the fourth cause of cancer-related mortality in the US and Europe. Unintentional weight loss is a prominent feature of PDAC; over 80% of patients report weight loss at the time of their diagnosis. Persistent weight loss during treatment has been shown to be an adverse prognostic factor impacting both overall survival and patient-reported quality of life. Aim: The aims of this thesis were to investigate the prevalence and impact of sarcopenia or low muscle mass in patients with pancreatic cancer, and to explore the feasibility of a multi-modal intervention (designed to address weight and muscle loss) for patients undergoing neoadjuvant chemotherapy. Methods: Four interrelated studies were designed. A systematic review and meta-analysis were conducted to investigate the prevalence of sarcopenia in patients with resectable and/or borderline resectable pancreatic cancer. Following on from this, two retrospective cohort studies were designed using CT-based body composition analysis. The first study looked at the impact of sarcopenia on post-operative morbidity and mortality, while the second study characterised body composition change experienced by patients who received neoadjuvant chemotherapy. Lastly a prospective multi-modal nutritional intervention study was designed and evaluated in patients undergoing neoadjuvant chemotherapy Results: The systematic review and meta- analysis determined that 40% of patients with pancreatic cancer had low muscle mass at diagnosis, but heterogeneity was significant, limiting the ability to evaluate the impact it had on outcome Examination of the surgical cohort revealed that half of patients had sarcopenia and low /or muscle attenuation prior to surgery. Both factors impacted overall survival, while low muscle attenuation was associated with an increased risk of major post-operative morbidity. Sarcopenia and low muscle attenuation were equally prevalent among patients undergoing neoadjuvant chemotherapy. Low muscle attenuation at diagnosis, and muscle loss during chemotherapy, were independently associated with increased mortality risk. A multi-modal nutritional intervention was designed, comprising a fish-oil enriched supplement, pancreatic enzyme replacement therapy, individualised exercise advice, and intensive dietary counselling. Twenty patients enrolled in the 12-week study, and the majority found that the intervention was feasible as designed. Most patients demonstrated weight gain and functional improvements, highlighting anabolic potential exists in this patient group. Conclusion: These results highlight the significance of body composition in pancreatic cancer, and suggest intensive nutritional interventions, delivered concurrently to chemotherapy, can improve nutritional status and functional assessment parameters

Life during furlough: Challenges to dignity from a changed employment status

In response to the COVID-19 virus, the UK government introduced the Job Retention Scheme in March 2020. The scheme, a novelty in the United Kingdom, provided income support to those furloughed from work. In this paper, we examine how individuals in several occupations and organisations experienced furlough and how they were treated during this enforced period of work absence. Beyond describing their experiences during the furlough, we examine how these experiences threatened and challenged their sense of dignity. Experientially we report on furlough as a time that elicited both delight and despair. The analysis of dignity relates to how treatment based on their employment status rendered many employees marginalised and cast adrift

The impact of COVID‐19 on mental health and well‐being in critical care nurses – a longitudinal, qualitative study

BackgroundThe COVID-19 pandemic has had both a psychological and physiological effect on the human race. For those working in health care, particularly in critical care, the pandemic has put unprecedented strain on staff. Witnessing suffering during crisis in an organizational setting can be a traumatic experience and critical care nurses often risked, not only their own lives, but their psychological well-being, so that those infected with the virus might have a better chance at survival.AimsThe aim of this study was to explore the challenges to mental health and psychological well-being experienced by Critical Care Nurses during the COVID-19 pandemic.Study DesignA longitudinal, qualitative study involving semi-structured interviews with 54 critical care nurses across 38 hospitals in the United Kingdom and Ireland. Interviews were transcribed verbatim and analysed using thematic analysis.ResultsFour key themes were identified which represent the challenges faces by critical care nurses during the COVID-19 pandemic: Lack of control, Psychological trauma, Unexpected leadership, Public-political betrayal.ConclusionWhile public-political praise may lead to a short-term lift in morale for front line workers; where it is not accompanied by practical support in terms of appropriate equipment, leadership, emotional support and renumeration it is likely to be damaging in the longer term.Relevance to Clinical PracticeThis study has provided a greater understanding of the factors which affected the well-being and mental health of critical care nurses during a global pandemic

Emotional Labor: Concept and Practical Categorizations in Light of COVID Critical Care Nursing

This chapter considers the changing nature and recognition of emotional labor as a category of work. Over 40 years of scholarship have tracked and conceptualized emotion at work; marking those features that link or delineate one occupation from another according to task, performance and context. Utilizing research with Critical Care Nurses in the UK, this chapter illuminates the changing face of emotional labor. We show how and why emotional labor has come to be recognized, the different forms that it takes, its relation to reason and its impact on workers. We pay particular attention to the ways in which emotional labor is altered by contextual factors such as the site of enactment, temporality and embodied verses virtual encounters. In terms of its affects, we consider the ways in which emotional labor can act as a source of professional pride and occupational virtue, while also carrying the threat of dissonance, burnout and alienation. These affects draw attention to the obligations that might attend such categories of work. We conclude by noting that responsibilities for these affects are likely diffused, touching upon individuals, educators, occupational bodies and, perhaps most importantly, the managers, leaders and systems that constitute employers

The impact of COVID-19 on mental health and well-being in critical care nurses – a longitudinal, qualitative study

Background: The COVID-19 pandemic has had both a psychological and physiological effect on the human race. For those working in health care, particularly in critical care, the pandemic has put unprecedented strain on staff. Witnessing suffering during crisis in an organizational setting can be a traumatic experience and critical care nurses often risked, not only their own lives, but their psychological well-being, so that those infected with the virus might have a better chance at survival. Aims: The aim of this study was to explore the challenges to mental health and psychological well-being experienced by Critical Care Nurses during the COVID-19 pandemic. Study design: A longitudinal, qualitative study involving semi-structured interviews with 54 critical care nurses across 38 hospitals in the United Kingdom and Ireland. Interviews were transcribed verbatim and analysed using thematic analysis. Results: Four key themes were identified which represent the challenges faces by critical care nurses during the COVID-19 pandemic: Lack of control, Psychological trauma, Unexpected leadership, Public-political betrayal. Conclusion: While public-political praise may lead to a short-term lift in morale for front line workers; where it is not accompanied by practical support in terms of appropriate equipment, leadership, emotional support and renumeration it is likely to be damaging in the longer term. Relevance to clinical practice: This study has provided a greater understanding of the factors which affected the well-being and mental health of critical care nurses during a global pandemic.</p

Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required