Narratives of experience: Senior registered nurses working with new graduate nurses in the intensive care unit

The experiences and perceptions of New Graduate Nurses as they transition into professional practice and into intensive care units abounds in the literature. However, there is a dearth of literature exploring the experiences of Senior Registered Nurses who work with New Graduate Nurses in intensive care units. The aim of this inquiry was to contribute to nursing knowledge by examining Senior Registered Nurses’ stories of experience around the complexity of enabling development of New Graduate Nurses whilst working in clinical or team leading roles in the intensive care unit. Thus, allowing the Senior Registered Nurses’ voice to be heard in the literature. Narrative inquiry methodology, underpinned by Dewey’s theory of experience, was used to examine the experiences of five Senior Registered Nurses in one Level 6 intensive care unit. This was achieved by engaging Senior Registered Nurses in individual conversations then co-composing the final individual narrative accounts with participants, whilst remaining immersed in the three-dimensional space of temporality, sociality and place. Thematic analysis methods were used to actively identify two overarching threads that resonated across all five narrative accounts. The first thread, ‘Reverberations’, contained five minor threads: ‘We Carry Them’, ‘It’s Dangerous’, ‘Patrolling Like Surf Lifesavers’, ‘Enjoyable Moments’ and ‘Survival Mode’. The second thread, ‘Caring’, contained three minor threads: ‘I’ve Been There’, ‘They Must Ask Questions’ and ‘Not In My Backyard’. Analysis identified Senior Registered Nurses’ workload and level of patient surveillance increased when working with New Graduate Nurses in the intensive care unit, leading to perceptions of feeling stressed, pressured and overwhelmed. Yet an obligation prevailed to support and care for New Graduate Nurses, perceived by participant Senior Registered Nurses as not yet possessing the clinical skills to independently care for critically ill patients in the dangerous intensive care unit environment. There are significant implications for health care organisations to increase resources to alleviate Senior Registered Nurses’ substantial workload and recognise their essential role in supporting New Graduate Nurses while simultaneously sustaining quality intensive care unit patient care

Challenging tensions and contradictions: Critical, theoretical and empirical perspectives on social enterprise

Guest editoria

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

Introduction: The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. Methods: In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. Findings: Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2–6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5–5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4–10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32–4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23–11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. Interpretation: After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification

Maintaining a safe environment

INTRODUCTION Managing our own safety is thought to be a basic survival skill, which all individuals possess. We are not aware of managing our physiological homeostasis (for example, ensuring that our body cells are supplied with sufficient oxygen to produce the energy they need to function), and spend years learning to calculate and avoid risk from the external environment, The ability to control safety, including physiological homeostasis, and using physical ability and intellectual ability to manage risk, depends on a person’s stage in their lifespan development, their physical and mental wellbeing, their cognitive ability and the ability to control environmental factors such as housing, traffic, pollutants and even conflict. Throughout the world there are many differences in the types of hazards and risks that people are exposed to and just as many differences in the way that people manage their own safety. The inclusion of this AL in the Roper et al (1996, 2000) model is to draw your attention to the importance of being able to recognise the threats that exist to human survival and wellbeing and identify the impact that this may have upon any individual at any given time in their lives. In order to develop the knowledge that you need to apply it to your nursing practice, you will also need to read about the underlying physiology (how the body functions), pathophysiology (the disease process), psychology (thoughts, feelings and behaviours) and nursing practice in more depth. Several health psychology and psychology for nursing texts are referred to throughout this chapter, but physiology, pathophysiology and nursing practice are underpinned by core texts (Brooker & Nicol, 2011; Waugh & Grant, 2014). By understanding the processes involved in maintaining a safe internal and external environment for the person, you will learn to assess risk and plan care to maintain the safety of your patients. The model helps us to develop our understanding by focusing upon three key areas: • the human body's ability to protect itself and the biological mechanisms that it employs to carry this out • the ability that individuals have to make choices and take action to keep safe and free from danger • the identification and understanding of the dangers and hazards that exist in the surrounding environment (including the health care environment) and how they pose a threat to individual safety and wellbeing. These three areas will be discussed throughout this chapter within the framework of the model and will help to develop an understanding of the AL and enable nursing interventions to be as individualised and effective as possible. Often concern for our own health and safety only becomes heightened when we become ill, have an accident or hear about a tragedy or event that has had terrible human consequences. However, patient safety is essential for high quality health care, and a requirement in the United Kingdom Code for Nurses, Midwives and Health Visitors (Nursing and Midwifery Council, 2015) is to make the care and safety of people our main concern. Therefore, in nursing, we need to be able to assess and prevent risk, whether it arises from the person’s own health needs, or from the care we give and the way in which we give it. By using the framework of the Roper et al (1996, 2000) model in the following way we can begin to examine and identify how complex and varied health and safety issues really are and also identify the interrelatedness that exists between the other ALs. This chapter will therefore focus on the following: 1 The model of living • maintaining a safe environment in health and illness across the lifespan • dependence and independence in the activity of maintaining a safe environment • factors influencing the activity of maintaining a safe environment. 2 The model for nursing • the nursing care of individuals with health problems that affect their ability to undertake the activity of maintaining a safe environment • understanding of the hazards in the health care setting and how to promote patient safety effectivel

Mosaic Structure and Molecular Evolution of the Leukotoxin Operon (lktCABD) in Mannheimia (Pasteurella) haemolytica, Mannheimia glucosida, and Pasteurella trehalosi

The mosaic structure and molecular evolution of the leukotoxin operon (lktCABD) was investigated by nucleotide sequence comparison of the lktC, lktB, and lktD genes in 23 Mannheimia (Pasteurella) haemolytica, 6 Mannheimia glucosida, and 4 Pasteurella trehalosi strains. Sequence variation in the lktA gene has been described previously (R. L. Davies et al., J. Bacteriol. 183:1394–1404, 2001). The leukotoxin operon of M. haemolytica has a complex mosaic structure and has been derived by extensive inter- and intraspecies horizontal DNA transfer and intragenic recombination events. However, the pattern of recombination varies throughout the operon and among the different evolutionary lineages of M. haemolytica. The lktA and lktB genes have the most complex mosaic structures with segments derived from up to four different sources, including M. glucosida and P. trehalosi. In contrast, the lktD gene is highly conserved in M. haemolytica. The lktC, lktA, and lktB genes of strains representing the major ovine lineages contain recombinant segments derived from bovine or bovine-like serotype A2 strains. These findings support the previous conclusion that host switching of bovine A2 strains from cattle to sheep has played a major role in the evolution of the leukotoxin operon in ovine strains of M. haemolytica. Homologous segments of donor and recipient alleles are identical, or nearly identical, indicating that the recombinational exchanges occurred relatively recent in evolutionary terms. The 5′ and 3′ ends of the operon are highly conserved in M. haemolytica, which suggests that multiple horizontal exchanges of the complete operon have occurred by a common mechanism such as transduction. Although the lktA and lktB genes both have complex mosaic structures and high nucleotide substitution rates, the amino acid diversity of LktB is significantly lower than that of LktA due to a higher degree of evolutionary constraint against amino acid replacement. The recombinational exchanges within the leukotoxin operon have had greatest effect on LktA and probably provide an adaptive advantage against the host antibody response by generating novel antigenic variation at surface-exposed sites

Assessment and communication excellence for safe patient outcomes (ACCELERATE): A stepped-wedge cluster randomised trial protocol

Background: Nurses play a major role in patient safety. Poor nursing assessment and communication practices are associated with higher incidence of the adverse events of undetected deterioration, falls, and pressure injuries. Despite widespread adoption of patient safety systems, occurrence of these events continues. Aim: To implement and evaluate the feasibility and effectiveness of an organisational ward-level intervention to facilitate comprehensive systematic assessment and improved communication in clinical handover to reduce medical emergency team calls; unplanned Intensive Care Unit admissions; falls; and pressure injuries. Design: A stepped-wedge cluster randomised trial sequentially implemented over 12 months. Methods: Evidence-based implementation strategies will be employed to support implementation of an intervention focusing on comprehensive systematic patient assessment and improved nurse bedside clinical handover and multidisciplinary communication involving the patient. These are – intervention tailoring to individual wards through barrier and enabler identification; action plans; education; clinical champions; outreach visits; facilitation; clinician engagement; and reminders. Primary outcome measures will be a composite of Medical Emergency Team calls and unplanned intensive care unit admissions for deterioration. Secondary outcomes will be all categories of inpatient falls; stage 2–4 pressure injuries; nurse-reported perceptions of: teamwork; safety culture, and engagement; and patient-reported experience measures of receiving safe and patient-centred care. An a priori process evaluation will determine factors influencing intervention uptake and inform strategies for future upscale and spread. Discussion: This feasibility trial will provide evidence regarding the use of systematic comprehensive patient assessment, combined with clinical handover re-design involving patients, to reduce clinical deterioration, falls and pressure injuries

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation

Background: Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients’ bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost–benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries. Methods: A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses’ education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and ‘Code Blue’ calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses’ perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses’ and medical officers’ perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost–benefit analysis and post-trial process evaluation will also be undertaken. Discussion: If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally. Trial registration: Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022