Understanding burnout and moral distress to build resilience: a qualitative study of an interprofessional intensive care unit team.

OBJECTIVE: The purpose of this study was to explore personal and organizational factors that contribute to burnout and moral distress in a Canadian academic intensive care unit (ICU) healthcare team. Both of these issues have a significant impact on healthcare providers, their families, and the quality of patient care. These themes will be used to design interventions to build team resilience. METHODS: This is a qualitative study using focus groups to elicit a better understanding of stakeholder perspectives on burnout and moral distress in the ICU team environment. Thematic analysis of transcripts from focus groups with registered intensive care nurses (RNs), respiratory therapists (RTs), and physicians (MDs) considered causes of burnout and moral distress, its impact, coping strategies, as well as suggestions to build resilience. RESULTS: Six focus groups, each with four to eight participants, were conducted. A total of 35 participants (six MDs, 21 RNs, and eight RTs) represented 43% of the MDs, 18.8% of the RNs, and 20.0% of the RTs. Themes were concordant between the professions and included: 1) organizational issues, 2) exposure to high-intensity situations, and 3) poor team experiences. Participants reported negative impacts on emotional and physical well-being, family dynamics, and patient care. Suggestions to build resilience were categorized into the three main themes: organizational issues, exposure to high intensity situations, and poor team experiences. CONCLUSIONS: Intensive care unit team members described their experiences with moral distress and burnout, and suggested ways to build resilience in the workplace. Experiences and suggestions were similar between the interdisciplinary teams.

RéSUMé: OBJECTIF: L'objectif de cette étude était d'explorer les facteurs personnels et organisationnels contribuant à l'épuisement professionnel et à la détresse morale dans une équipe de soins de santé d'une unité de soins intensifs (USI) universitaire canadienne. Ces deux problèmes ont un impact significatif sur les fournisseurs de soins de santé, sur leurs familles, et sur la qualité des soins aux patients. Ces thèmes seront utilisés pour concevoir des interventions afin de développer la résilience d'équipe. MéTHODE: Nous avons réalisé une étude qualitative utilisant des groupes de réflexion afin de mieux comprendre les perspectives des personnes concernées par l'épuisement professionnel et la détresse morale dans l'environnement des équipes d'USI. L'analyse thématique des transcriptions des groupes de réflexion, composés d'infirmières et infirmiers, d'inhalothérapeutes et de médecins intensivistes, prenait en considération les causes d'épuisement professionnel et de détresse morale, leur impact, les stratégies d'adaptation, ainsi que les suggestions pour développer la résilience. RéSULTATS: Six groupes de réflexion, chacun comptant quatre à huit participants, ont été créés. Au total, 35 participants (six médecins, 21 infirmières et infirmiers, et huit inhalothérapeutes), représentant 43 % des médecins, 18,8 % des infirmières et infirmiers, et 20,0 % des inhalothérapeutes, ont pris part à nos groupes de réflexion. Les thèmes concordaient entre les professions et comprenaient : 1) les problèmes organisationnels, 2) l'exposition à des situations de stress élevé, et 3) les mauvaises expériences d'équipe. Les participants ont rapporté des impacts négatifs sur leur bien-être émotionnel et physique, les dynamiques familiales, et les soins aux patients. Les suggestions pour développer la résilience étaient catégorisées en trois thèmes principaux : problèmes organisationnels, exposition à des situations de stress élevé, et mauvaises expériences d'équipe. CONCLUSION: Les membres des équipes de l'unité de soins intensifs ont décrit leurs expériences en ce qui a trait à la détresse morale et à l'épuisement professionnel, et suggéré des façons de développer la résilience sur le lieu de travail. Les expériences et suggestions étaient similaires dans les différentes équipes interdisciplinaires.

Does electronic medical record redesign increase screening of risk for pressure injury, falls and substance use in the Emergency Department? An implementation evaluation.

BACKGROUND: Following the provision of urgent care, screening for risks known to impact patient outcomes is an extension of safe emergency nursing care, in particular for falls, pressure injury and substance use. Screening is a process that primarily aims to identify people at increased risk for specific complications. This study aimed to describe and evaluate the implementation of a consolidated electronic checklist on the screening completion rates for falls, pressure injury and substance use in a regional health district. METHODS: This pre-post study used emergency data from four Emergency Departments (EDs) in southern NSW, Australia between November 2016 and February 2019. Patient characteristics, triage category, discharge diagnosis, arrival date and time, screening completion date and time and treatment location were extracted. Descriptive statistics were used to describe the characteristics of the presentations. Z test with adjusted p-values using Bonferroni Correction method was used to compare the characteristics of the presentations and the rates of screening completion. The Theoretical Domains Framework was used to identify any deficits in the implementation. RESULTS: There were 33,561 patients in the pre and 35,807 in the post group. There were no differences in patient characteristics between the two groups. The mean emergency department (ED) length of stay was unchanged (490.5min pre vs 489.9min post). The proportion of patients who had all three screens completed increased from 1.3% to 5.5% (p<0.001). Pressure injury risk screening increased from 46.6% (pre) to 53.1% (post) (p<0.001) as did substance use screening (1.7% vs 12.4%, p<0.001). Screening was strongly associated to which hospital the patient was admitted, their age and ED length of stay. Of the 51 mapped intervention functions, 20 (39%) were used in the implementation. CONCLUSIONS: The introduction of a consolidated electronic checklist for use by emergency nurses to complete fall, pressure injury and substance use screening resulted in an overall increase in risk screening. However screening rates remained poor. Implementation that considers the capability, opportunity and motivation of those that need to alter their behaviour would likely improve the overall compliance.

The obligate aerobe Streptomyces coelicolor A3(2) synthesizes three active respiratory nitrate reductases.

Streptomyces coelicolor A3(2) synthesizes three membrane-associated respiratory nitrate reductases (Nars). During aerobic growth in liquid medium the bacterium was able to reduce 50 mM nitrate stoichiometrically to nitrite. Construction and analysis of a mutant in which all three narGHJI operons were deleted showed that it failed to reduce nitrate. Deletion of the gene encoding MoaA, which catalyses the first step in molybdenum cofactor biosynthesis, also prevented nitrate reduction, consistent with the Nars being molybdoenzymes. In contrast to the triple narGHJI mutant, the moaA mutant was also unable to use nitrate as sole nitrogen source, which indicates that the assimilatory nitrate reductases in S. coelicolor are also molybdenum-dependent. Analysis of S. coelicolor growth on solid medium demonstrated that Nar activity is present in both spores and mycelium (hypha). Development of a survival assay with the nitrate analogue chlorate revealed that wild-type S. coelicolor spores and mycelium were sensitive to chlorate after anaerobic incubation, independent of the presence of nitrate, while both the moaA and triple nar mutants were chlorate-resistant. Complementation of the triple nar mutant with the individual narGHJI operons delivered on cosmids revealed that each operon encoded an enzyme that was synthesized and active in nitrate or chlorate reduction. The data obtained from these studies allow a tentative assignment of Nar1 activity to spores, Nar2 to spores and mycelium, and Nar3 exclusively to mycelium.

Meeting report: Convening on the influenza human viral challenge model for universal influenza vaccines, Part 1: Value; challenge virus selection; regulatory, industry and ethical considerations; increasing standardization, access and capacity.

In response to global interest in the development of a universal influenza vaccine, the Bill & Melinda Gates Foundation, PATH, and the Global Funders Consortium for Universal Influenza Vaccine Development convened a meeting of experts (London, UK, May 2018) to assess the role of a standardized controlled human influenza virus infection model (CHIVIM) towards the development of novel influenza vaccine candidates. This report (in two parts) summarizes those discussions and offers consensus recommendations. This article (Part 1) covers challenge virus selection, regulatory and ethical considerations, and issues concerning standardization, access, and capacity. Part 2 covers specific methodologic considerations. Current methods for influenza vaccine development and licensure require large costly field trials. The CHIVIM requires fewer subjects and the controlled setting allows for better understanding of influenza transmission and host immunogenicity. The CHIVIM can be used to identify immune predictors of disease for at-risk populations and to measure efficacy of potential vaccines for further development. Limitations to the CHIVIM include lack of standardization, limited access to challenge viruses and assays, lack of consensus regarding role of the CHIVIM in vaccine development pathway, and concerns regarding risk to study participants and community. To address these issues, the panel of experts recommended that WHO and other key stakeholders provide guidance on standardization, challenge virus selection, and risk management. A common repository of well-characterized challenge viruses, harmonized protocols, and standardized assays should be made available to researchers. A network of research institutions performing CHIVIM trials should be created, and more study sites are needed to increase capacity. Experts agreed that a research network of institutions working with a standardized CHIVIM could contribute important data to support more rapid development and licensure of novel vaccines capable of providing long-lasting protection against seasonal and pandemic influenza strains.

Convening on the influenza human viral challenge model for universal influenza vaccines, Part 2: Methodologic considerations.

In response to global interest in the development of a universal influenza vaccine, the Bill & Melinda Gates Foundation, PATH, and the Global Funders Consortium for Universal Influenza Vaccine Development convened a meeting of experts (London, UK, May 2018) to assess the role of a standardized controlled human influenza virus infection model (CHIVIM) towards the development of novel influenza vaccine candidates. This report (in two parts) summarizes those discussions and offers consensus recommendations. Part 1 covers challenge virus selection, regulatory and ethical considerations, and issues concerning standardization, access, and capacity. This article (Part 2) summarizes the discussion and recommendations concerning CHIVIM methods. The panelists identified an overall need for increased standardization of CHIVIM trials, in order to produce comparable results that can support universal vaccine licensure. Areas of discussion included study participant selection and screening, route of exposure and dose, devices for administering challenge, rescue therapy, protection of participants and institutions, clinical outcome measures, and other considerations. The panelists agreed upon specific recommendations to improve the standardization and usefulness of the model for vaccine development. Experts agreed that a research network of institutions working with a standardized CHIVIM could contribute important data to support more rapid development and licensure of novel vaccines capable of providing long-lasting protection against seasonal and pandemic influenza strains.

The obligate aerobic actinomycete Streptomyces coelicolor A3(2) survives extended periods of anaerobic stress.

The actinomycete Streptomyces coelicolor is an obligate aerobe that is found in soil and aqueous habitats. The levels of oxygen in these environments can vary considerably, which raises the question of how these bacteria survive during periods of anaerobiosis. Although S. coelicolor cannot grow in the complete absence of oxygen, we demonstrate here that it is capable of microaerobic growth and maintaining viability through several weeks of strict anaerobiosis. Both resting and germinated spores are able to survive abrupt exposure to anaerobiosis, which contrasts the situation with Mycobacterium species where gradual oxygen depletion is required to establish a latent state in which the bacterium is able to survive extended periods of anaerobiosis. Growth of S. coelicolor resumes immediately upon re-introduction of oxygen. Taken together these findings indicate that survival is not restricted to spores and suggest that the bacterium has evolved a mechanism to maintain viability and a membrane potential in the hyphal state. Furthermore, although we demonstrate that several members of the genus also survive long periods of anaerobic stress, one species, Streptomyces avermitilis, does not have this capacity and might represent a naturally occurring variant that is unable to adopt this survival strategy.

A response-regulator-like activator of antibiotic synthesis from Streptomyces coelicolor A3(2) with an amino-terminal domain that lacks a phosphorylation pocket.

In Streptomyces coelicolor A3(2), bldA mutants that lack the tRNA for the rare leucine codon UUA fail to make the red undecylprodigiosin antibiotic complex. To find out why, red-pigmented while bald (Pwb) derivatives of a bldA mutant were isolated. Using a cloning strategy that allowed for (and demonstrated) dominance of the mutations, they were localized to the red gene cluster. By using insert-mediated integration of a phi C31 phage-based vector, one of the Pwb mutations was more precisely located between red structural genes to a segment of approximately 1 kb about 4 kb from the known pathway-specific regulatory gene redD. The segment contained most of an ORF (redZ) encoding a protein (RedZ) with end-to-end similarity to response regulators of diverse function from a variety of bacteria. Remarkably, in RedZ hydrophobic residues replace nearly all of the charged residues that usually make up the phosphorylation pocket present in typical response regulators, including the aspartic acid residue that is normally phosphorylated by a cognate sensory protein kinase. A single TTA codon in redZ provided a potential explanation for the bldA-dependence of undecylprodigiosin synthesis. This codon was unchanged in three Pwb mutants, but further analysis of one of the mutants revealed a potential up-promoter mutation. It seems possible that a combination of low-level natural translation of the UUA codon by a charged non-cognate tRNA, coupled with increased transcription of redZ in the Pwb mutant allows the accumulation of a threshold level of the RedD protein.