Non-medical prescribing in critical care: A mixed methods study.

BACKGROUND: Little is known about non-medical prescribers in critical care in the United Kingdom. In 2007, a small survey identified few non-medical prescribers; however, in the intervening years, there have been many changes to the Medicine Act 1968. It is likely that prescribing within the non-medical workforce in critical care has changed significantly. AIM/S: This survey aimed to explore the breadth and diversity of prescribing practices of non-medical prescribers working within the wider critical care environment in the United Kingdom. METHOD: Data were collected via an online questionnaire adapted from the 2007 version and distributed by the BACCN to their members between 26th October 2021 and 19th November 2021. Freedom of Information requests were made to the Nursing and Midwifery Council, The Health and Care Professions Council and the General Pharmaceutical Council to understand the number of non-medical prescribers. RESULTS: The survey elicited 259 responses; 105 respondents identified themselves as non-medical prescribers, and 57 used Patient Group Directions only. In the ICU/HDU, 75 respondents identified as non-medical prescribers, with an additional 45 using Patient Group Directions. CONCLUSION: Since the last survey, there has been a large increase in the number and representation across all professional groups identifying as a non-medical prescriber and/or utilising patient group directions across critical care. Many staff responded to this survey who were neither NMPs nor utilising PGDs; of these, a large proportion were interested in taking on this additional responsibility. IMPLICATIONS FOR PRACTICE: Many people working within critical care are interested in becoming non-medical prescribers. Assists with understanding characteristics of those working as non-medical prescribers within critical care. Shows variations in practice in respect to PGDs, authorising of blood products and prescribing.

Learning from COVID-19: Cross-sectional e-survey of critical care nurses' satisfaction and experiences of their role in the pandemic response across the United Kingdom.

BACKGROUND: Since the start of the global COVID-19 pandemic in 2019, critical care nurses across the world have been working under extreme levels of pressure. AIM: To understand critical care nurses' experiences of and satisfaction with their role in the pandemic response across the United Kingdom (UK). STUDY DESIGN: A cross-sectional electronic survey of critical care nurses (n = 339) registered as members of the British Association of Critical Care Nurses. Anonymous quantitative and open-ended question data were collected in March and April 2021 during the height of the second surge of COVID-19 in the UK via an online questionnaire. Quantitative data were analysed using descriptive statistics and free text responses were collated and analysed thematically. RESULTS: There was a response rate of 17.5%. Critical care nurses derived great satisfaction from making a difference during this global crisis and greatly valued teamwork and support from senior nurses. However, nurses consistently expressed concern over the quality of safe patient care, which they perceived to be suboptimal due to staff shortages and a dilution of the specialist skill mix. Together with the high volume of patient deaths, critical care nurses reported that these stressors influenced their personalwell-being. CONCLUSIONS: This study provides insights into the key lessons health care leaders must consider when managing the response to the demands and challenges of the ongoing COVID-19 pandemic. COVID-19 is unpredictable in its course, and what future variants might mean in terms of transmissibility, severity and resultant pressures to critical care remains unknown. RELEVANCE TO CLINICAL PRACTICE: Future responses to the challenges that critical care faces must consider nurses' experiences and create an environment that engenders supportive teamwork, facilitates excellent nursing practice and effective safe patient care where critical care nursing may thrive.

Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: Descriptive comparative study.

OBJECTIVE: Comparison of nurse involvement in end of life decision making in European countries participating in ETHICUS I- 1999 and ETHICUS II- 2015. METHODOLOGY: This was a prospective observational study of 22 European ICUs included in the ETHICUS-II and I. Data were collected as per the ETHICUS-I and ETHICUS-II protocols. Four questions within the ETHICUS protocols related to nurse involvement in end of life decision making were analyzed. This is a comparison of changes in nurse involvement in end of life decisions from 1999 to 2015. SETTING: International e-based questionnaire completed by an intensive care clinician when an end of life decision was performed on any patient. SUBJECTS: Intensive care physicians and nurses, no interventions were performed. MEASUREMENTS: A 20 question survey was used to describe the decision making process, on what basis was the decision made, who was involved in the decision making process, and what precise decisions were made. RESULTS: A total of 4592 cases from 22 centres are included. While there was more agreement between nurses and physicians in ETHICUS-I compared to ETHICUS-I, fewer discussions with nurses occurred in ETHICUS-II. The frequency of end of life decisions that were discussed with nurses decreased in all three regions between ETHICUS-I and ETHICUS-II. CONCLUSION: Based on the results of the current study, nurses should be further encouraged to increase their involvement in end of life decision-making, especially those in southern Europe.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units.

BACKGROUND: Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection. AIM: To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients. DESIGN: A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion. METHODS: The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable. RESULTS: The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use. CONCLUSION: Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort. RELEVANCE TO CLINICAL PRACTICE: Effective oral care is integral to safe patient care in critical care.

Floral guidance of learning a preference for symmetry by bumblebees.

This study examines the mechanism underlying one way in which bumblebees are known to develop a preference for symmetric patterns: through prior non-differential reinforcement on simple patterns (black discs and white discs). In three experiments, bees were given a choice among symmetric and asymmetric black-and-white non-rewarding patterns presented at the ends of corridors in a radial maze. Experimental groups had prior rewarded non-discrimination training on white patterns and black patterns, while control groups had no pre-test experience outside the colony. No preference for symmetry was obtained for any of the control groups. Prior training with circular patterns highlighting a horizontal axis of symmetry led to a specific subsequent preference for horizontal over vertical symmetry, while training with a vertical axis abolished this effect. Circles highlighting both axes created a general avoidance of asymmetry in favour of symmetric patterns with vertical, horizontal or both axes of symmetry. Training with plain circles, but not with deformed circles, led to a preference for symmetry: there was no evidence that the preference emerged just by virtue of having attention drawn away from irrelevant pattern differences. Our results point to a preference for symmetry developing gradually through first learning to extract an axis of symmetry from simple patterns and subsequently recognizing that axis in new patterns. They highlight the importance of continued learning through non-differential reinforcement by skilled foragers. Floral guides can function not only to guide pollinators to the source of reward but also to highlight an axis of symmetry for use in subsequent floral encounters.

Learned Use of Picture Cues by Bumblebees (Bombus impatiens) in a Delayed Matching Task.

Picture-object correspondence provides an alternate method of investigating delayed matching by providing a cue (picture) which may be spontaneously perceived as similar but different from a corresponding target. Memory for, and corresponding choice of, a target corresponding to a cue could be facilitated by the use of a picture. Bumblebees have been found to both easily differentiate images from corresponding objects but also spontaneously perceive a similarity between the two. Herein, an approach was designed to test the possible use of picture cues to signal reward in a delayed matching task. Target choice preference corresponding to picture cues was tested among three bumblebee (Bombus impatiens) colonies using photograph cues (presented prior to target stimuli) corresponding to one of four target stimuli. Photograph cues were the only predictor of corresponding target reward, presented in stable locations. Rewarded and unrewarded tests show a choice preference significantly higher than chance for targets matching the cue. Results suggest that bumblebees can learn to use picture cues in a delayed matching task. Furthermore, experience, conditions of reward inconsistency and location, are discussed as possible contributing factors to learning in a delayed matching task.

Gaps and improvement in management of sepsis.

Sepsis can be fatal if not identified early. If health professionals know what to look out for, more patient deaths resulting from sepsis could be prevented. In November 2015, the National Confidential Enquiry into Patient Outcome and Death reviewed the subject of sepsis. This article discusses its findings and the implications for nurses.

Visual choice behavior by bumblebees (Bombus impatiens) confirms unsupervised neural network's predictions.

The behavioral experiment herein tests the computational load hypothesis generated by an unsupervised neural network to examine bumblebee (Bombus impatiens) behavior at 2 visual properties: spatial frequency and symmetry. Untrained "flower-naïve" bumblebees were hypothesized to prefer symmetry only when the spatial frequency of artificial flowers is high and therefore places great information-processing demands on the bumblebees' visual system. Bumblebee choice behavior was recorded using high-definition motion-sensitive camcorders. The results support the computational model's prediction: 1-axis symmetry influenced bumblebees' preference behavior at low and high spatial frequency patterns. Additionally, increasing the level of symmetry from 1 axis to 4 axes amplified preference toward the symmetric patterns of both low and high spatial frequency patterns. The results are discussed in the context of the artificial neural network model and other hypotheses generated from the behavioral literature.

Radio Frequency Identification and motion-sensitive video efficiently automate recording of unrewarded choice behavior by bumblebees.

We present two methods for observing bumblebee choice behavior in an enclosed testing space. The first method consists of Radio Frequency Identification (RFID) readers built into artificial flowers that display various visual cues, and RFID tags (i.e., passive transponders) glued to the thorax of bumblebee workers. The novelty in our implementation is that RFID readers are built directly into artificial flowers that are capable of displaying several distinct visual properties such as color, pattern type, spatial frequency (i.e., "busyness" of the pattern), and symmetry (spatial frequency and symmetry were not manipulated in this experiment). Additionally, these visual displays in conjunction with the automated systems are capable of recording unrewarded and untrained choice behavior. The second method consists of recording choice behavior at artificial flowers using motion-sensitive high-definition camcorders. Bumblebees have number tags glued to their thoraces for unique identification. The advantage in this implementation over RFID is that in addition to observing landing behavior, alternate measures of preference such as hovering and antennation may also be observed. Both automation methods increase experimental control, and internal validity by allowing larger scale studies that take into account individual differences. External validity is also improved because bees can freely enter and exit the testing environment without constraints such as the availability of a research assistant on-site. Compared to human observation in real time, the automated methods are more cost-effective and possibly less error-prone.

Safe care of patients with tracheostomies.

The National Confidential Enquiry into Patient Outcome and Death has reviewed the care of patients undergoing a tracheostomy or laryngectomy, what happened to them in hospital and potential problems. This article discusses the findings and nursing implications.

How images may or may not represent flowers: picture-object correspondence in bumblebees (Bombus impatiens)?

Studies of bee cognition frequently use two-dimensional stimuli referred to as floral patterns, and yet how bees perceive pictorial representations is not known. An investigation of bumblebee (Bombus impatiens) picture-object correspondence was undertaken according to the theory of Fagot et al. (Picture perception in animals. Psychology Press Ltd, East Sussex, pp 295-320, 2000) that pictures and objects may be confused, perceived as independent or equivalent. In three experiments, bumblebees were given discrimination training and unrewarded testing in a radial maze. In the first experiment, preferences between artificial flowers and photographs of those flowers revealed a significant learned preference for the stimulus rewarded during training: no confusion following training. In the second experiment, bees did transfer learning from artificial flowers to photographs: some commonality between an object and photograph was perceived. In the third experiment, bees spontaneously generalized a learned preference for one artificial flower to its silhouette, but only for one of two flowers used in training. No generalization was obtained to drawn images. Some transfer between image and object is exhibited, likely by low-level feature matching, but transfer is poor with degraded images, cautioning against extrapolation of picture-based responding to natural correspondents. Despite evidence that bees exhibit some transfer while retaining discrimination, it is likely that the observed response is due to generalization more akin to confusion than true equivalence. Furthermore, although 2D patterning cues (line, edge and shade) provide discriminable cues for bees between 2D stimuli, it is not here supported that such features are perceived as equivalent to the intended floral structures.

Are visitors beneficial to patients in adult ICUs?

Despite their benefits, visits are limited in critical or intensive care settings. The British Association of Critical Care Nurses commissioned a position statement using evidence-based literature on visiting practices in adult ICUs. This article Thexamines the evidence, the benefits and drawbacks of visiting.

Patients' and relatives' experiences of transfer from intensive care unit to wards.

AIMS: This literature review looks at the evidence around transferring patients from intensive care units (ICU) to wards. The literature informs us that patients and their families experience problems when being transferred from an ICU environment and that this increases overall anxiety. BACKGROUND: The effects of surviving critical illness often have a profound psychological impact on patients and families This study examines the experiences of adult patients, and their families, following their transfer from the ICU to the ward. FINDINGS: Five themes emerged from this literature review: physical responses, psychological responses, information and communication, safety and security, and the needs of relatives. CONCLUSIONS: This review reminds us that these problems can be reduced if information and communication around time of transfers were improved. RELEVANCE TO CLINICAL PRACTICE: As critical care nurses it is essential that we prepare patients and families for transfer to wards.

The effect of flower-like and non-flower-like visual properties on choice of unrewarding patterns by bumblebees.

How do distinct visual stimuli help bumblebees discover flowers before they have experienced any reward outside of their nest? Two visual floral properties, type of a pattern (concentric vs radial) and its position on unrewarding artificial flowers (central vs peripheral on corolla), were manipulated in two experiments. Both visual properties showed significant effects on floral choice. When pitted against each other, pattern was more important than position. Experiment 1 shows a significant effect of concentric pattern position, and experiment 2 shows a significant preference towards radial patterns regardless of their position. These results show that the presence of markings at the center of a flower are not so important as the presence of markings that will direct bees there.

Position statement on visiting in adult critical care units in the UK.

To provide nurses with an evidence-based Position Statement on the standards patients and visitors should expect when visiting an adult critical care unit in the 21st century in the UK. The British Association of Critical Care Nurses (BACCN) is a leading organization for critical care nursing in the UK and regularly receives enquiries about best practice regarding visiting policies. Therefore, in keeping with the BACCN's commitment to provide evidence-based guidance for nurses, a Position Statement on visiting practices in adult critical care units was commissioned. This brought together experts from the field of critical care nursing and representatives from patient and relatives' groups to review visiting practices and the literature and produce a Position Statement. An extensive search of the literature was undertaken using the following databases: Blackwell Synergy, CINAHL, Medline, Swetswise, Cochrane Data Base of Systematic Reviews, National Electronic Library for Health, Institute for Healthcare Improvement and Google Scholar. After obtaining selected articles, the references from these articles were then evaluated for their relevance to this Position Statement and were retrieved. The evidence suggests a disparity between what nurses believe is best practice and what patients and visitors actually want. Historically, visitors have been perceived as being responsible for increasing noise, taking up space, taking up nursing time, hindering nursing care and spreading infection. The evidence reviewed for this Position Statement suggests there are many benefits to patients and nurses from visitors. There was no evidence to suggest that visitors pose a direct infection risk to patients. Clear visiting policies based on evidence will negate arbitrary decisions by nurses regarding who can visit and will lessen confusion and dispel myths which can only bring benefits to patients, staff and organizations. To make nurses aware of the physical and psychological benefits of visiting to patients. Visitors bring a positive energy to patients and can act as advocates. They can supply nurses with vital information about patients which will enable the nurse to provide more individualized care. Being cognizant of the evidence will help nurses develop policies on visiting which are up to date for the 21st century.

British Association of Critical Care Nurses position statement on prescribing in critical care.

BACKGROUND: Nurses in the UK are now one group of non-medical staff who can prescribe. This practice is evolving for critical care nursing staff who care for critically ill patients during their stay in hospital through ward and outpatient follow-up after admission to critical care. AIM: The purposes of this paper were to present existing information regarding prescribing to support nurses in critical care currently prescribing and to inform those who are intending to prescribe. METHODS: To develop the position statement, a search of the literature was conducted using key databases. To ascertain the current level and type of prescribing in critical care, a short questionnaire was sent by email to British Association of Critical Care Nursing members, and the results of this are presented in Appendix A. OUTCOMES/RESULTS: Evidence was found in relation to the history, context in critical care, educational requirements and issues of consent related to non-medical prescribing. CONCLUSIONS: The position statement is based upon evidence from the literature, National Health Service policy and the Nursing and Midwifery Council regulations. It takes account of the critical care patient pathway before, during and after an admission to critical care.

Using a high-flow respiratory system (Vapotherm) within a high dependency setting.

BACKGROUND: Vapotherm 2000i is a non-invasive high-flow respiratory support system used mainly in the treatment of type 1 respiratory failure. It uses a mixture of oxygen and air to deliver a set concentration via nasal cannula (or tracheostomy mask). The advantage of this system is the high humidity achieved using the integral heated water system. The system has been used in neonatal practice as a replacement for conventional continuous positive airway pressure (CPAP) but there is little published research within the adult setting about its use. AIM: This study discusses the indications for the use of this non-invasive high-flow respiratory support system, the system set up, the benefits and complications of the system. AUDIT DESIGN: An audit of 72 patients was undertaken within the Surgical High Dependency Unit that collected data on the types of patient receiving the therapy, its effectiveness and patient experience. AUDIT FINDINGS: The audit demonstrated reduced respiratory rate and improvement in oxygenation for treated patients. CONCLUSION: A non-invasive high-flow respiratory support system can be effective at improving oxygenation in hypoxic patients. Patients were generally satisfied with the system and the system seems suitable for use in an adult surgical high dependency setting.