Cancer patients' care at the end of life in a critical care environment: perspectives of families, patients and practitioners

Innovations in cancer care requiring intensive support, and improved cancer patient survival in and out of critical care, have led to greater numbers of cancer patients than ever accessing critical care. Of these, however, a fair proportion will die. Current research points to around one in six patients dying in general critical care units and even higher numbers for cancer patients. End-of-life care (EOLC) for critically ill patients is problematic and rarely addressed beyond satisfaction or chart review studies, while palliative care is an established domain in cancer. It is not known whether dying, critically ill cancer patients experience good EOLC. In the context of a cancer critical care unit, this thesis explores the provision of EOLC for cancer patients in a critical care unit. Exploring measures for comfort care and palliative principles of care helped identify what is important for patients and families, and what those measures meant for all participants. The diagnosis of cancer and how it impacts on EOLC provision for critically ill cancer patients was also explored from the perspective of patients, families, doctors and nurses. A Heideggerian phenomenological interview approach was undertaken, in order to gain personal experiences. Families of those patients who died after decisions to forgo life-sustaining treatment (DFLSTs) were interviewed. Patients who have experienced critical care were also interviewed, since patients‘ views about EOL care provision are very rarely explored. Doctors and nurses also contribute their vision for, and experiences of, EOL care in a cancer critical care unit. Thirty one interviews with 37 participants were carried out. Cancer prognosis together with critical illness prognosis contributed to difficulties in deciding to move to, and enact EOLC. The nursing voice in DFLSTs was minimal and their role in EOLC depended on experience and confidence. Achieving a good death was possible through caring activities that made best use of technology to prevent prolonged dying. EOLC was an emotive experience. Decision-making and EOLC could be difficult to separate out which, in turn, affects prospects for EOLC. A continuum of dying in cancer critical illness is presented with different participants‘ experiences along that continuum. Three main themes included: Dual Prognostication; The Meaning of Decision-Making; and Care Practices at EOL: Choreographing a Good Death with two organising themes: Thinking the Unthinkable and Involvement in Care. These themes outlined the essence of moving along a continuum toward patients‘ deaths and the impact that had on opportunities for care and a good death. Nurses could use the care of patients dying in critical care as an opportunity to develop specialist knowledge and lead in care, but this requires mastery and reconciliation of both technology and EOLC. This work builds on Seymour‘s (2001) theory of a negotiated and natural death related to achieving a good death in critical care. Trajectories of dying, part of Seymour‘s (2001) theory, are extrapolated on with reference to Glaser and Strauss (1965) and Lofland (1978)‘s theories on dying trajectories. Nursing theory is developed through examination of Falk Rafael‘s (1996) and Locsin‘s (1998) theories of empowered caring. Implications and propositions are presented for nursing and wider practice around EOL care for critically ill cancer patients

Compassionate, collective or transformational nursing leadership to ensure fundamentals of care are achieved: A new challenge or non‐sequitur?

© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, https://creativecommons.org/licenses/by/4.0/Aims: This discursive paper draws on three key leadership theories with the aim of outlining how styles of leadership impact the provision of fundamentals of care. Design: Discussion paper. Data sources: key leadership theories, leadership and fundamentals of care literature. Implications for Nursing: The conceptualization of fundamentals of care is viewed through the lens of nursing leadership, and collective, compassionate and transformational leadership theory. The cognitive dissonance that nursing leaders encounter when trying to reconcile organizational, patient and nurses' needs is considered, and the pressure to deliver high‐quality fundamentals of care presents a challenge to nurse leaders. Conclusion: Leaders must align nursing and patient outcome data to drive forward and prioritize fundamental care. Focusing on key elements of relational leadership styles will ensure a workforce fit to provide fundamental care, which in the current climate must be an organizational and global nursing priority. Impact: This discussion attempts to draw together overlapping leadership theories, emphasizes the importance of relational leadership in ensuring the provision of the fundamentals of care and acknowledged the impact of the COVID‐19 pandemic on nurses and nursing care, with leadership implications outlined, such as a need for role‐modelling, understanding shared values and giving nurses a voice. It will have an impact on nurse leaders, but also on those nurses providing direct care by issuing a challenge for them to confront their own nurse leaders, and to ask that they better resolve competing needs of both the nursing workforce and patients.Peer reviewedFinal Published versio

Managing clinical uncertainty: an ethnographic study of the impact of critical care outreach on end‐of‐life transitions in ward‐based critically ill patients with a life‐limiting illness

© 2018 Crown copyright. Journal of Clinical Nursing © 2018 John Wiley & Sons LtdRapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment. Aims and objectives: To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness. Methods: An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis. Findings: Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions. Conclusions: Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency. Relevance to practice: There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.Peer reviewe

A protocol for a scoping review of the use of mental simulation and full-scale simulation in practising healthcare decision-making skills of undergraduate nursing students

© 2023 University of Hertfordshire. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Aim This scoping review aims to explore the effect of FSS and mental simulation on the decision-making skills of nursing students. Background Full-scale simulation (FSS) has been the most used simulation modality in nursing education due to its applicability to enhance both technical and non-technical skills. However, FSS can be excessively costly and other factors such as technophobia and lack of trained staff and support make FSS less accessible, especially for nursing education. Therefore, a novel mental simulation that is interactive and supported by visual elements can be a substitute for FSS, at least for some of the skills, such as clinical decision-making. Reviews comparing the effectiveness of FSS and mental simulation on decision-making skills in nursing students are lacking. Further knowledge on the effectiveness of these two modalities on decision-making skills for nursing students is needed to inform the nursing education curriculum and to decide between the two modalities. Design This protocol adheres to the guidelines outlined in the PRISMA extension for scoping reviews (PRISMA-scr) checklist. Method The methodological framework for scoping reviews will be followed for this scoping review. Scopus, EBSCOhost the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and for the grey literature ERIC and BASE will be searched for related studies. The search will be limited to January 2008 and April 2023 (up-to-date) and English. A detailed search strategy was developed with an experienced research information manager and this strategy will be adapted to each database. A single screening will be performed by an author who will screen all abstracts and titles and full-text publications. After the study selection step of the framework, the data from the included studies will be charted using a data extraction form. The data will be synthesised by comparing the effect of FSS and mental simulation on decision-making skills. Conclusion A synopsis of the publication on FSS and mental simulation on nurse students’ decision-making skills will be useful for stakeholders when choosing between two modalities to deliver decision-making skills to nursing students and also help to inform the nursing education and simulation practice. Scoping Review Registration Protocols.io (doi: 10.17504/protocols.io.e6nvw57y7vmk/v1)Peer reviewe

A form of mental simulation with significant enhancements enabling teamwork training

© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution-Share Alike 4.0 International License (https://creativecommons.org/licenses/by-sa/4.0/).Mental simulation is a type of simulation in which the clinician mentally practices a task without physically doing it. With mental simulation, the clinician can individually go through all the steps of technical and behavioural skills, such as decision-making skills, that they would apply in a particular situation. However, since this activity is individual-based, it does not lend itself to practising interprofessional or team-working skills. Moreover, users of this approach cannot get feedback from their colleagues or educators. Therefore, we claim that an interactive mental simulation approach using the representation of a patient and equipment combined with thinking aloud could help to rehearse behavioural skills in a classroom-based environment with other team members but without the need for a manikin or advance simulation suits. We call this approach Visually Enhanced Mental Simulation (VEMS). VEMS can also be delivered remotely using online platforms while addressing the same learning objectives. In this article, it is argued that VEMS can be an interactive way of undertaking a simulation-based activity with limited resources yet in a very interactive manner to engage a team of learners from the same or different professions. Explanations regarding how it can be delivered face-to-face, as well as using an online platform, are provided.Peer reviewe

Synthesis of qualitative research studies regarding the factors surrounding UK critical care trial infrastructure

© 2019 Author(s). Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJConducting clinical trials in critical care is integral to improving patient care. Unique practical and ethical considerations exist in this patient population that make patient recruitment challenging, including narrow recruitment timeframes and obtaining patient consent often in time-critical situations. Units currently vary significantly in their ability to recruit according to infrastructure and level of research activity. Aim : To identify variability in the research infrastructure of UK intensive care units (ICUs) and their ability to conduct research and recruit patients into clinical trials. Design: We evaluated factors related to intensive care patient enrolment into clinical trials in the UK. This consisted of a qualitative synthesis carried out with two datasets of in-depth interviews (distinct participants across the two datasets) conducted with 27 intensive care consultants (n=9), research nurses (n=17) and trial coordinators (n=1) from 27 units across the UK. Primary and secondary analysis of two datasets (one dataset had been analysed previously) was undertaken in the thematic analysis. Findings: The synthesis yielded an overarching core theme of Normalising Research, characterised by motivations for promoting research and fostering research-active cultures within resource constraints, with six themes under this to explain the factors influencing critical care research capacity: Organisational, Human, Study, Practical resources, Clinician, and Patient/family factors. There was a strong sense of integrating research in routine clinical practice, and recommendations are outlined. Conclusions: The central and transferable tenet of Normalising Research advocates the importance of developing a culture where research is inclusive alongside clinical practice in routine patient care and is requisite for all healthcare individuals from organisational to direct patient contact level.Peer reviewedFinal Published versio

COVID-19: Moving beyond the pandemic

Severe acute respiratory syndrome Coronavirus 2 (SARS‐CoV‐2) is the cause of COVID‐19. As of June 1st 2020, there were over 6 million cases of COVID‐19 internationally and over 370,000 deaths (John Hopkins University, 2020). There has been significant effort to increase hospital and healthcare capacity to reduce the number of fatalities associated with this global pandemic (Choi & Logsdon, 2020). Public health measures have been universally enforced, including the use of social distancing and self‐isolation for those most at risk. Due to this appropriate high demand in the acute phase of this pandemic, the long‐term sequalae of COVID‐19 has had less attention, and clinically much less focus

Characterising the research profile of the critical care physiotherapy workforce and engagement with critical care research: a UK national survey

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/Objective: To characterise the research profile of UK critical care physiotherapists including experience, training needs, and barriers and enablers to engagement in critical care research. 'Research' was defined broadly to encompass activities related to quantitative and qualitative studies, service evaluations, clinical audit and quality improvements. Design: Closed-question online survey, with optional free-text responses. Setting: UK critical care community. Participants: UK critical care physiotherapists, regardless of clinical grade or existing research experience. Results: 268 eligible survey responses were received during the 12-week study period (21 incomplete, 7.8%). Respondents were based in university-affiliated (n=133, 49.6%) and district general (n=111, 41.4%) hospitals, and generally of senior clinical grade. Nearly two-thirds had postgraduate qualifications at master's level or above (n=163, 60.8%). Seven had a doctoral-level qualification. Respondents reported a range of research experience, predominantly data acquisition (n=144, 53.7%) and protocol development (n=119, 44.4%). Perceived research training needs were prevalent, including topics of research methods, critical literature appraisal, protocol development and statistical analysis (each reported by ≥50% respondents). Multiple formats for delivery of future research training were identified. Major barriers to research engagement included lack of protected time (n=220, 82.1%), funding (n=177, 66.0%) and perceived experience (n=151, 56.3%). Barriers were conceptually categorised into capability, opportunity and motivation themes. Key enabling strategies centred on greater information provision about clinical research opportunities, access to research training, secondment roles and professional networks. Conclusions: UK critical care physiotherapists are skilled, experienced and motivated to participate in research, including pursuing defined academic research pathways. Nonetheless wide-ranging training needs and notable barriers preclude further involvement. Strategies to harness the unique skills of this profession to enhance the quality, quantity and scope of critical care research, benefiting from a multiprofessional National Clinical Research Network, are required.Peer reviewedFinal Published versio

The organisation of nurse staffing in intensive care units: a qualitative study

© 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License. https://creativecommons.org/licenses/by/4.0/Aims: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates. Background: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence. Methods: Focus groups with intensive care health care professionals (n= 52 participants) and individual interviews with critical care network leads and policy leads (n= 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis. Findings: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes. Conclusions: Whilst nurse: patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff wellbeing, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies. Implications for Nursing Management in order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket ‘ratio’ approach to nurse staffing, intended to apply uniformly across health services.Peer reviewe

Physical Rehabilitation Core Outcomes In Critical illness (PRACTICE): protocol for development of a core outcome set

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: Existing data on physical rehabilitation interventions in critical illness are challenged by outcome heterogeneity that limits data synthesis and translation of research findings into clinical practice. This protocol describes the PRACTICE study to develop a core outcome set (COS) for trials of physical rehabilitation interventions delivered across the continuum of a patient's recovery from the intensive care unit until reintegration in the community following hospital discharge. Methods: Mixed methods will be used including: systematic reviews of quantitative and qualitative literature; qualitative interviews with patients and caregivers; a modified Delphi consensus process with researcher, clinician and patient/caregiver stakeholder groups; and consensus meetings for ratification of findings, resolving uncertainty, or developing an action plan for COS implementation. Discussion: The PRACTICE COS will inform relevant stakeholders about important outcomes regarding physical rehabilitation in critical illness, and may enhance the future design and conduct of trials in this area.Peer reviewe