Critical care nursing workforce in crisis: A discussion paper examining contributing factors, the impact of the COVID-19 pandemic and potential solutions.

AIMS AND OBJECTIVES: The critical care nursing workforce is in crisis, with one-third of critical care nurses worldwide intending to leave their roles. This paper aimed to examine the problem from a wellbeing perspective, offering implications for research, and potential solutions for organisations. DESIGN: Discursive/Position paper. METHOD: The discussion is based on the nursing and wellbeing literature. It is guided by the authors' collaborative expertise as both clinicians and researchers. Data were drawn from nursing and wellbeing peer-reviewed literature, such as reviews and empirical studies, national surveys and government and thinktank publications/reports. RESULTS: Critical care nurses have been disproportionately affected by the COVID-19 pandemic with studies consistently showing critical care nurses to have the worst psychological outcomes on wellbeing measures, including depression, burnout and post-traumatic stress disorder (PTSD). These findings are not only concerning for the mental wellbeing of critical care nurses, they also raise significant issues for healthcare systems/organisations: poor wellbeing, increased burnout and PTSD are directly linked with critical care nurses intending to leave the profession. Thus, the wellbeing of critical care nurses must urgently be supported. Resilience has been identified as a protective mechanism against the development of PTSD and burnout, thus offering evidence-based interventions that address resilience and turnover have much to offer in tackling the workforce crisis. However, turnover data must be collected by studies evaluating resilience interventions, to further support their evidence base. Organisations cannot solely rely on the efficacy of these interventions to address their workforce crisis but must concomitantly engage in organisational change. CONCLUSIONS: We conclude that critical care nurses are in urgent need of preventative, evidence-based wellbeing interventions, and make suggestions for research and practice.

A workforce survey of critical care nurses in the National Health Service.

AIM: To measure key aspects of the critical care nursing workforce across the National Health Service (NHS) and compare these with recommended standards where they exist. BACKGROUND: The provision of high-quality and safe critical care services is dependent on adequate numbers of highly skilled nurses. Understanding the issues and challenges within critical care services across the NHS is key to future planning and policy in this area. DESIGN: A stakeholder-driven consensus development approach was adopted to design a workforce survey by members of the Critical Care National Network Nurse Leads (CC3N) Forum. METHODS: The survey was conducted across all the critical care units in England, Northern Ireland, Wales, and Scotland. Data were collated to enable presentation of descriptive statistics. RESULTS: Data returns were received from 240 of the 272 units in England and Northern Ireland. Scotland and Wales data were excluded from analysis and reporting. Differences in the sample and data returns limited comparison with the previous survey in some aspects. Stability was seen in vacancy and sickness rates. Improvements were seen in safe nurse: patient ratios, supernumerary "nurse in charge," critical care outreach service cover, use of national competency framework, and agency use. Dependency on overseas nurses in some units remains high. Specialist critical care training levels in many units do not meet current required standards. CONCLUSION: Clear improvements have been made. There is significant stability. Some challenges remain. Continued review of resource allocation is important in the coming years, as is policy and strategy to ensure recruitment, appropriate training, and support for staff well-being. RELEVANCE TO CLINICAL PRACTICE: The reader will gain insight into the critical care nursing workforce in the NHS in England and Northern Ireland. The results are useful for nurses, nurse managers, and policymakers.

'You're never making just one decision': exploring the lived experiences of ambulance Emergency Operations Centre personnel.

BACKGROUND: The aim of this study was to explore the experiences of ambulance dispatch personnel, identifying key stressors and their impact on staff well-being. METHODS: Qualitative methodology was used. Nine semistructured interviews were conducted with National Health Service (NHS) ambulance Emergency Operations Centre (EOC) dispatch personnel in the UK between July and August 2014. Participants were asked about their experiences of the role, stress experienced and current strategies they use to deal with stress. Transcripts were analysed using an inductive, bottom-up thematic analysis. RESULTS: Three key themes were identified: (1) 'How dispatch is perceived by others', (2) 'What dispatch really involves' and (3) 'Dealing with the stresses of dispatch'. All participants expressed pride in their work, but felt overloaded by the workload and undervalued by others. Several sources of additional stress, not directly related to the execution of their work, were identified, including the need to mentally unwind from work at the end of a shift. Participants were able to identify a number of ways in which they currently manage work-related stress, but they also suggested changes the organisation could put in place in order to reduce stress in the working environment. CONCLUSIONS: Building on existing theory on work stress and postwork recovery, it was concluded that EOC dispatch staff require greater support at work, including skills training to promote postshift recovery, in order to reduce the likelihood of sickness absence, and prevent work-related fatigue.

Building on a novel bootstrapping modelling technique to predict region-wide critical care capacity requirements over the next decade.

We have previously described an open-source data-driven modelling technique that has been used to model critical care resource provision as well as expanded to elective surgery and even whole-hospital modelling. Here, we describe the use of this technique to model patient flow and resource use across the West Yorkshire Critical Care Network, with the advantage that recommendations can be made at an individual unit level for future resource provision, taking into account changes in population numbers and demography over the coming decade. We will be using this approach in other regions around the UK to help predict future critical care capacity requirements.

Exploring the psychological health of emergency dispatch centre operatives: a systematic review and narrative synthesis.

BACKGROUND: The study objective was to investigate and synthesize available evidence relating to the psychological health of Emergency Dispatch Centre (EDC) operatives, and to identify key stressors experienced by EDC operatives. METHODS: Eight electronic databases (Embase, PubMed, Medline, CINAHL, PsycInfo, PsycArticles, The Psychology and Behavioural Sciences Collection, and Google Scholar) were searched. All study designs were included, and no date limits were set. Studies were included if they were published in English, and explored the psychological health of any EDC operatives, across fire, police, and emergency medical services. Studies were excluded if they related solely to other emergency workers, such as police officers or paramedics. Methodological quality of included studies was assessed using checklists adapted from the Critical Appraisal Skills Programme. A narrative synthesis was conducted, using thematic analysis. RESULTS: A total of 16 articles were included in the review. Two overarching themes were identified during the narrative synthesis: 'Organisational and Operational Factors' and 'Interactions with Others'. Stressors identified included being exposed to traumatic calls, lacking control over high workload, and working in under-resourced and pressured environments. Lack of support from management and providing an emotionally demanding service were additional sources of stress. Peer support and social support from friends and family were helpful in managing work-related stress. DISCUSSION: EDC operatives experience stress as a result of their work, which appears to be related to negative psychological health outcomes. Future research should explore the long-term effects of this stress, and the potential for workplace interventions to alleviate the negative impacts on psychological health. PROSPERO REGISTRATION NUMBER: CRD42014010806.

A pilot study evaluating the use of ABCD2 score in pre-hospital assessment of patients with suspected transient ischaemic attack: experience and lessons learned.

BACKGROUND: Suspected transient ischaemic attack (TIA) is a common presentation to emergency medical services (EMS) in the United Kingdom (UK). Several EMS systems have adopted the ABCD2 score to aid pre-hospital risk stratification and decision-making on patient disposition, such as direct referral to an Emergency Department or specialist TIA clinic. However, the ABCD2 score, developed for hospital use, has not been validated for use in the pre-hospital context of EMS care. METHODS: We conducted a pilot study to assess eligibility criteria, recruitment rates, protocol compliance, consent and follow-up procedures to inform the development of a definitive study to validate the ABCD2 tool in pre-hospital evaluation of patients with suspected TIA. RESULTS: From 1st May-1st September 2013, nine patients with an EMS suspected diagnosis of TIA had the TIA diagnosis later confirmed by a specialist from five participating sites. This recruitment rate is comparable to stroke trials in the EMS setting. Bureaucratic obstacles and duplication of approval processes across participating sites took 13 months to resolve before recruitment commenced. Due to the initial difficulty in recruitment, a substantial amendment was approved to modify inclusion criteria, allowing patients with atrial fibrillation and/or taking anticoagulant therapy to participate in the study. CONCLUSIONS: It is possible to identify, recruit and follow up patients with suspected TIA in the EMS setting. Training large numbers of EMS staff is required as exposure to TIA patients is infrequent. Significant insight was gained into the complexity of NHS research governance mechanisms in the UK. This knowledge will facilitate the planning of a future adequately powered study to validate the ABCD2 tool in a pre-hospital setting.