Factors influencing nurses' intentions to leave adult critical care settings

© 2018 British Association of Critical Care Nurses Background: The shortage of critical care and specialist nurses has been an ongoing issue for many decades. Although all areas of nursing are affected, critical care areas are especially vulnerable to recruitment and retention problems. High nursing turnover in critical care areas is evident; however, research into the factors that influence nurses' intentions to leave adult critical care areas is limited. Aim: To explore factors that may influence nurses' intentions to leave adult critical care areas. Objectives: To appraise existing evidence and highlight gaps in knowledge regarding factors that may influence nurses' intentions to leave adult critical care areas. Methods: A systematic mixed-method literature review was conducted. The search strategy was developed using the List, Keep and Delete approach, a framework used to identify search terms for systematic health care reviews. The following key words were used: intentions to leave, nurses, adult and critical care. The databases searched were BNI, CINAHL, PubMed, PsycINFO, Embase and Health B Elite from 2005 to 2016. Primary data from non-critical care areas and neonatal and paediatric critical care areas were excluded. Comprehensive supplementary searching was performed. Papers were critically appraised using the NICE (2012) checklists. Data were analysed using the Braun and Clarke (2006) thematic framework. Results: A total of 15 studies, including 13 cross-sectional studies and 2 qualitative studies, were reviewed. Three main themes emerged following data analysis. These themes were quality of the work environment, nature of working relationships and traumatic/stressful workplace experiences. Conclusions: The literature review highlighted the need for further research and greater understanding of how these themes may impact critical care nurses. Nurse managers and leaders should consider these findings when developing strategies to improve nurse retention. Relevance to practice: The shortage of critical care nurses is currently a global issue impacting costs and quality of patient care

Fatigue After CriTical illness (FACT): Co-production of a self-management intervention to support people with fatigue after critical illness

Purpose: Fatigue is a common and debilitating problem in patients recovering from critical illness. To address a lack of evidence-based interventions for people with fatigue after critical illness, we co-produced a self-management intervention based on self-regulation theory. This article reports the development and initial user testing of the co-produced intervention. Methods: We conducted three workshops with people experiencing fatigue after critical illness, family members, and healthcare professionals to develop a first draft of the FACT intervention, designed in web and electronic document formats. User testing and interviews were conducted with four people with fatigue after critical illness. Modifications were made based on the findings. Results: Participants found FACT acceptable and easy to use, and the content provided useful strategies to manage fatigue. The final draft intervention includes four key topics: (1) about fatigue which discusses the common characteristics of fatigue after critical illness; (2) managing your energy with the 5 Ps (priorities, pacing, planning, permission, position); (3) strategies for everyday life (covering physical activity; home life; leisure and relationships; work, study, and finances; thoughts and feelings; sleep and eating); and (4) goal setting and making plans. All material is presented as written text, videos, and supplementary infographics. FACT includes calls with a facilitator but can also be used independently. Conclusions: FACT is a theory driven intervention co-produced by patient, carer and clinical stakeholders and is based on contemporary available evidence. Its development illustrates the benefits of stakeholder involvement to ensure interventions are informed by user needs. Further testing is needed to establish the feasibility and acceptability of FACT. Implications for clinical practice: The FACT intervention shows promise as a self-management tool for people with fatigue after critical illness. It has the potential to provide education and strategies to patients at the point of discharge and follow-up

Making sense of it: Intensive care patients' phenomenological accounts of story construction

Background Patients entering intensive care encounter physical and psychological stress which may lead to psychological morbidity such as depression, anxiety and post-traumatic stress. It has been suggested that constructing a story may assist psychological recovery however this has been minimally investigated in the intensive care patient. Aim The aim of this paper is to examine the process of story construction in patients’ phenomenological accounts of being a patient in the technological environment of intensive care. Study design The study design was informed by Heideggerian phenomenology. Methods Semi-structured interviews were conducted in nineteen patients who had been in intensive care for at least four days. Interviews were digitally recorded, transcribed and analysed utilising Van Manen’s framework for thematic analysis. Findings Making sense of their experiences in ICU appeared to be fundamental to story construction. Themes that arose were: “Why am I here?”, “Filling in the gaps”, “Sorting the real from the unreal” and “Searching for familiarity”. These themes describe how participants sought temporal and causal coherence in order to construct their integrated and understandable story. Families appeared to play a critical role in assisting participants in filling in the gaps, sorting the real from the unreal and their subsequent psychological recovery. Conclusions and relevance to clinical practice The importance of early support from health care professionals to facilitate patients’ story construction is highlighted. The study also emphasizes the role of families in supporting patients in making sense of their experiences and the associated psychological recovery process. Further research to evaluate methods of facilitating story construction such as nurse-led de-briefing, patient diaries, is recommended. In addition investigation of families’ perceptions of their role in assisting patients to construct their story may facilitate health care professionals in developing strategies to effectively support families in their role

Patients’ experiences of technology and care in adult intensive care

Aims To investigate patients’ experiences of technology in an adult intensive care unit Background Technology is fundamental to support physical recovery from critical illness in Intensive Care Units. As well as physical corollaries, psychological disturbances are reported in critically ill patients at all stages of their illness and recovery. Nurses play a key role in the physical and psychological care of patients, however there is a suggestion in the literature that the presence of technology may dehumanise patient care and distract the nurse from attending to patients psychosocial needs. Little attention has been paid to patients’ perceptions of receiving care in a technological environment. Design This study was informed by Heideggerian phenomenology. Methods The research took place in 2009-2011 in a university hospital in England. Nineteen participants who had been patients in ICU were interviewed guided by an interview topic prompt list. Interviews were transcribed verbatim and analysed using Van Manen’s framework. Findings Participants described technology and care as inseparable and presented their experiences as a unified encounter. The theme ‘Getting on with it’ described how participants endured technology by ‘Being Good’ and ‘Being Invisible’. ‘Getting over it’ described why participants endured technology by ‘Bowing to Authority’ and viewing invasive technologies as a ‘Necessary Evil’. Conclusion Patients experienced technology and care as a series of paradoxical relationships: alienating yet reassuring, uncomfortable yet comforting, impersonal yet personal. By maintaining a close and supportive presence and providing personal comfort and care nurses may minimise the invasive and isolating potential of technology

Recognizing and managing a deteriorating patient: a randomised controlled trial investigating the effectiveness of clinical simulation in improving clinical performance in undergraduate nursing students

Aims To report the results of a randomised controlled trial which explored the effectiveness of clinical simulation in improving the clinical performance of recognising and managing an adult deteriorating patient in hospital. Background There is evidence that final year undergraduate nurses may lack the knowledge, clinical skills and situation awareness required to competently manage a deteriorating patient in hospital. The effectiveness of clinical simulation as an educational strategy to teach the skills required to recognise and effectively manage the early signs of clinical deterioration needs to be evaluated. Method This was a two centre, randomised, controlled trial with single blinded assessments. Data were collected in July 2013. Ninety- eight first year nursing students were randomised either into a control group where they received a traditional classroom lecture, or an intervention group where they received simulation training. Participants completed a pre and post- intervention objective structured clinical examination. General Perceived Self Efficacy and Self-Reported Competency scores were measured before and after the intervention. Student satisfaction with teaching was surveyed after the teaching intervention. Results The intervention group performed significantly better in the objective structured clinical examination after their simulation training. General Perceived Self Efficacy and Self-Reported Competency were not correlated with performance. There was no significant difference in the post intervention General Perceived Self Efficacy and Self-Reported Competency scores between the control and intervention group. The intervention group were significantly more satisfied with their teaching method. Conclusion Simulation based education may be an effective educational strategy to teach nurses the necessary skills to effectively recognise and manage a deteriorating patient

Effects of a simulation-based workshop on nursing students' competence in arterial puncture

Objective: To evaluate whether a short simulation-based workshop in radial artery puncture would improve nursing students’ competence to a level in which they could practise the procedure on a live patient without compromising his safety. Methods: Quasi-experimental one-group pretest-posttest study with 111 third-year nursing students. A 1.5-hour simulation-based workshop was implemented. This included a video-lecture, live demonstrations, selfdirected simulated practice in dyads and individual intermittent feedback. Participants’ skills, knowledge and self-efficacy in arterial puncture were measured before and after attending the workshop. Results: After the intervention, a total of 61.1% of the participants showed the level of competence required to safely practice radial artery puncture on a live patient under supervision. Conclusion: Effective simulation-based training in arterial puncture for nursing students does not necessarily need to be resource-intensive. Well-planned, evidence-based training sessions using low-tech simulators could help educators to achieve good educational outcomes and promote patient safety

Implementation of the evidence for the improvement of nursing care to the critical patient's family: a participatory action research

Background: There are many descriptive studies regarding the needs of the family, as well as those regarding nursing care aimed directly at family members. However, there is no widespread application of such evidence in clinical practice. There has also been no analysis made of the evolution of patterns of knowing during the act of improving clinical practice. Therefore, the purpose of the study is to understand the change process aimed at improving care to critical patient's families, and to explore the evolution of patterns of knowing that nurses use in this process. Methods: Qualitative study with a Participatory Action Research method, in accordance with the Kemmis and McTaggart model. In this model, nurses can observe their practice, reflect upon it and compare it with scientific evidence, as well as define, deploy and evaluate improvement strategies adapted to the context. Simultaneously, the process of empowerment derived from the Participatory Action Research allows for the identification of patterns of knowing and their development over time. The research will take place in the Intensive Care Units of a tertiary hospital. The participants will be nurses who are part of the regular workforce of these units, with more than five years of experience in critical patients, and who are motivated to consider and critique their practice. Data collection will take place through participant observation, multi-level discussion group meetings and documentary analysis. A content analysis will be carried out, following a process of codification and categorisation, with the help of Nvivo10. The approval date and the beginning of the funding were December 2012 and 2013, respectively. Discussion: The definition, introduction and evaluation of care strategies for family members will allow for their real and immediate implementation in practice. The study of the patterns of knowing in the Participatory Action Research will be part of the theoretical and practical feedback process of a professional discipline. Also, the identification of the construction and evolution of knowledge will provide decision elements to managers and academics when choosing strategies for increased quality

Prevalence of bacteriuria in dogs without clinical signs of urinary tract infection presenting for elective surgical procedures

ObjectivesTo determine the frequency of bacteriuria in dogs presenting for elective surgery, to compare the frequency of bacteriuria in dogs presenting for orthopaedic (non-neurological) procedures to that of dogs presenting for soft tissue procedures and to measure the agreement of microscopic visualisation of bacteria in urine sediment with the occurrence of bacterial growth on culture.MethodsProspective cohort study of 140 client-owned dogs. Urine was collected via prepubic cystocentesis prior to or immediately after induction of anaesthesia. Urine was submitted for quantitative bacteriological culture and urinalysis. The dogs' age, sex, weight and breed were recorded, as well as the surgical procedure performed.ResultsIn total, 80 orthopaedic and 60 soft tissue surgical cases were included in the study; 3 dogs (2.1%) returned bacterial growth on culture (positive urine culture) and 19 (13.6%) recorded urine sediment with pyuria and/or bacteriuria on urinalysis (positive urinalysis). All dogs with positive urine culture were female and two of them underwent orthopaedic procedures. Each bitch had growth of Escherichia coli >10(5)CFU/mL. The agreement between positive urinalysis and positive urine culture was poor ( = 0.15).ConclusionsThe prevalence of bacteriuria in dogs without clinical signs of urinary tract infection in this population was low (2.1%). An at-risk population could not be identified because of the small number of positive outcomes. A positive urinalysis showed poor agreement with urine culture results and therefore the decision to treat without performing a urine culture is not advised

Exploring adult critical illness survivors’ experiences of fatigue; a qualitative study

Aims: To explore adult experiences of fatigue after discharge from an intensive care unit and to identify potential management strategies. Design: An exploratory qualitative study Methods: One to one audio-recorded semi-structured interviews with 17 adult survivors of critical illness in the United Kingdom, lasting up to one hour, between September 2019 and January 2020. Anonymised and verbatim-transcribed interview data underwent a standard process of inductive thematic analysis as described by Braun and Clarke. Findings: Three themes were identified: fatigue is different for everyone; complex interrelating interactions; and personalised fatigue strategies. Fatigue was described as a distressing symptom, unique to the individual that causes an array of complex, often long-term interrelating impacts on the survivor and their wider family, made worse by a lack of understanding, empathy, and support resources. Support from others, alongside interventions such as exercise, good nutrition, information, and alternative therapies are used by survivors with variable degrees of success. Conclusions: This qualitative study reports peoples’ experiences of fatigue after critical illness. Findings highlight the significant impact it has on people’s lives and those of their family and friends

Prevalence and experience of fatigue in survivors of critical illness: a mixed‐methods systematic review

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an ICU and extracted data were split into three datasets: vitality scores from the Short Form Health Survey SF-36 (n=54); other quantitative data (n=19); and qualitative data (n=9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. SF-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately one-month post-ICU discharge (Mean (SD) 56.44 (32.30); 95%CI 52.92 - 59.97), improved over time but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors’ quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific for critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed