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.

A research internship scheme for nurses and its wider implications for clinical managers.

There is growing evidence that clinical research activity is linked to better patient outcomes and that staff involvement in research is linked to enhanced morale and retention. Clinical managers have a pivotal role in supporting staff to engage with research, but they are not always given the means to do so and are not always aware of the benefits. In 2021 a research internship scheme was set up as a collaboration between two London NHS trusts and a university, enabling nurses and midwives to undergo training and undertake a range of research activities. Some participants experienced challenges in fitting internship activities around clinical duties despite the fact that the scheme was planned to give them protected time. This article describes the scheme, reports the findings of its evaluation at one of the two trusts, and discusses its implications for clinical managers in terms of how they can be supported to contribute to the development of a research culture.

Interventions to support critical care nurse wellbeing: A scoping review.

INTRODUCTION: Recruitment and retention of qualified nurses in critical care is challenging and has been further exacerbated by the COVID-19 pandemic. Poor staff wellbeing, including sickness absence and burnout contribute to a high staff turnover and staff shortages. This scoping review charts wellbeing interventions targeting nurses who work in adult critical care. METHODS: Following the Joanna Briggs Institute scoping review methodology, five databases were searched: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Embase, Ovid PsycINFO, and the Cochrane Library alongside a search for grey literature targeting national and international critical care nurse organisations. Primary research studies (qualitative, quantitative and mixed methods), as well as quality improvement studies and policy frameworks published from January 1997 to September 2022 were included. Studies conducted outside an adult critical care setting or not including adult critical nurses were excluded. Extracted data were charted using a series of tables. RESULTS: 26 studies met the inclusion criteria. Most of the interventions targeted personal rather than organisational strategies, focusing on resilience training, mindfulness-based interventions, and other psychological approaches. One intervention was not evaluated. Most of the rest of the studies reported their interventions to improve wellbeing. However, only one study evaluated the intervention for longer than six months. CONCLUSION: Current evidence identified that critical care nurse wellbeing is an international concern affecting recruitment and retention. Most available wellbeing interventions take a psychological, personal approach. However, these may not address the complex interaction of organisational factors which impact adult critical care nurses. IMPLICATIONS FOR CLINICAL PRACTICE: Further work is needed to identify and evaluate organisational approaches to improving wellbeing and to evaluate wellbeing interventions over a longer period of time. Critical care nurses should be included in the design of future wellbeing interventions.

Increasing nursing and midwifery research leadership: impact evaluation of the National Institute for Health and Care Research Senior Nurse and Midwife Research Leader Programme at 1 year.

Background: Although nurses and midwives make up the largest sector of the National Health Service (NHS) workforce, studies have identified a lack of knowledge, skills and confidence to engage and lead research. In 2018, the National Institute for Health and Care Research (NIHR) invested in the development of a 3-year Senior Nurse Midwife Research Leader (SNMRL) Programme aimed at developing nursing and midwifery research capacity and capability. This review was conducted at the end of year one as part of an ongoing impact evaluation of the programme. Aim: To evaluate the impact of activities undertaken by NIHR SNMRL at the end of year one of the programme. Method: The content of anonymised end-of-year one activity, self-reported by SNMRL, was coded independently and deductively analysed by a project team using the modified Visible ImpaCT Of Research framework (VICTOR). Exemplar case studies were selected by the team to illustrate activity within domains. Working group members coded two reports independently then compared them in pairs to increase inter-rater reliability and the quality and consistency of coding. Results: Reports from 63 of 66 SNMRL were submitted and included for analysis. Reporting reflected progress towards NIHR programme objectives. These included acting as a programme ambassador, creating a vibrant research culture, supporting staff recruitment and retention, enhancing organisational reputation and clinical academic outputs. Networking and collaboration locally, regionally and nationally were widely reported. Conclusions: The SNMRL cohort reported initiating multiple initiatives aimed at influencing organisational research culture, service provision and supporting nursing/midwifery engagement with research. Evaluation indicated progress to address barriers to research engagement within NHS Trusts.

Overcoming the challenges of recruiting and interviewing patients following critical illness.

BACKGROUND: The strict restrictions implemented in England during the COVID-19 pandemic meant it was no longer possible to recruit or interview participants in person. However, virtual recruitment and interviews are not without their challenges, particularly when exploring sensitive topics. AIM: To discuss how to overcome some of the challenges involved in recruiting and interviewing participants who have been critically ill with COVID-19. DISCUSSION: An exploratory, descriptive study was conducted involving interviews with 20 people who had been critically ill with COVID-19 and had been discharged from two community-based healthcare settings in London, England. Participants were interviewed at home after being discharged from hospital after at least one month. The sensitivity of the research topic meant strategies for recruiting and interviewing needed to be adapted, including involving patient experience facilitators, using virtual interviews, managing the distress of participants and self-care for the researchers. CONCLUSION: The adaptations used in this study can be used in research involving people who have been critically ill. IMPLICATIONS FOR PRACTICE: Researchers can explore innovative ways to recruit participants using hospital or community staff who are not usually involved in research. Virtual interviews require additional skills, such as building rapport with participants, so may require additional training. A distress protocol for participants should always be considered when discussing sensitive topics. Self-care and debrief strategies for interviewers are also critical.

Implementing a discharge process for patients undergoing elective surgery: Rapid review.

BACKGROUND: Hospital discharge is a 'vulnerable stage' in care. A delayed, inappropriate or poorly planned discharge increases hazards and costs, inhibiting recovery, and often leading to unplanned readmission. New discharge processes could boost practice, reduce the length of stay, and, consequently, reduce costs and improve patients' quality of life. AIM: To identify technology based interventions that have been implemented to facilitate a safe and timely discharge procedure after elective surgery, and to describe implementation barriers and facilitators and patient satisfaction. METHOD: This rapid review followed a restricted systematic review framework, searching Medline, EMBASE, CINAHL, PsychINFO, and ClinicalTrials.gov. for relevant studies published from 2015 to 2021 in English. RESULTS: Eleven studies were included. Most interventions were machine-learning-based, and only one study reported patient involvement. Effective leadership, team work and communication were stated as implementation facilitators. The main barriers to implementation were: lack of support from leaders, poor clinical documentation, resistance to change, and financial and logistical concerns. None of the studies evaluated patient satisfaction. CONCLUSIONS: Findings highlight factors that support the implementation of technology based interventions aimed at a safe and timely discharge process following elective surgery. Nurses play an important role in the provision of information, and in the development and implementation of discharge processes.

Non-pharmacological interventions for self-management of fatigue in adults: An umbrella review of potential interventions to support patients recovering from critical illness.

PURPOSE: Fatigue is a common symptom after critical illness. However, evidence-based interventions for fatigue after critical illness are lacking. We aimed to identify interventions to support self-management of fatigue caused by physical conditions and assess their effectiveness and suitability for adaptation for those with fatigue after critical illness. MATERIALS AND METHODS: We conducted an umbrella review of systematic reviews. Databases included CINAHL, PubMed, Medline, PsycINFO, British Nursing Index (BNI), Web of Science, Cochrane Database of Systematic Reviews (CDSR), JBI Evidence Synthesis Database, and PROSPERO register. Included reviews were appraised using the JBI Checklist for Systematic Reviews and Research Syntheses. Results were summarised narratively. RESULTS: Of the 672 abstracts identified, 10 met the inclusion criteria. Reviews focused on cancer (n = 8), post-viral fatigue (n = 1), and Systemic Lupus Erythematosus (SLE) (n = 1). Primary studies often did not address core elements of self-management. Positive outcomes were reported across all reviews, and interventions involving facilitator support appeared to be most effective. CONCLUSIONS: Self-management can be effective at reducing fatigue symptoms and improving quality of life for physical conditions and has clear potential for supporting people with fatigue after critical illness, but more conclusive data on effectiveness and clearer definitions of self-management are required.

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.

Patients' perspectives of recovery after COVID-19 critical illness: An interview study.

BACKGROUND: Critical illness is a traumatic experience, often resulting in post-intensive care syndrome, affecting people's physical, psychological, emotional, and social well-being. The early recovery period is associated with increased risk, negatively impacting longer-term outcomes. AIMS: The aims of this study were to understand the recovery and rehabilitation needs of people who survive a COVID-19 critical illness. STUDY DESIGN: An exploratory descriptive qualitative interview study with 20 survivors of COVID-19 critical illness from two community-based healthcare settings in London, England. Data collection took place September 2020-April 2021, at least 1 month after hospital discharge by telephone or virtual platform. Data were subjected to inductive thematic analysis and mapped deductively to the three core concepts of self-determination theory: autonomy, competence and relatedness. RESULTS: Three key themes emerged: traumatic experience, human connection and navigating a complex system. Participants described how societal restrictions, fear and communication problems caused by the pandemic added to their trauma and the challenge of recovery. The importance of positive human connections, timely information and support to navigate the system was emphasized. CONCLUSIONS: Whilst findings to some extent mirror those of other qualitative pre-pandemic studies, our findings highlight how the uncertainty and instability caused by the pandemic add to the challenge of recovery affecting all core concepts of self-determination (autonomy, competence, relatedness). RELEVANCE TO CLINICAL PRACTICE: Understanding survivors' perspectives of rehabilitation needs following COVID-19 critical illness is vital to delivery of safe, high-quality care. To optimize chances of effective recovery, survivors desire a specialist, co-ordinated and personalized recovery pathway, which reflects humanized care. This should be considered when planning future service provisions.

Research behind a webcam: an exploration of virtual interviewing with children and young people.

BACKGROUND: Societal use of digital technology rapidly increased during the COVID-19 pandemic. Face-to-face services converted to online provision where possible. This affected many nurse researchers. AIM: To explore conducting research interviews online with children and young people (CYP) about sensitive topics. DISCUSSION: This article considers digital inclusion, as well as ethical issues surrounding safety, support and consent, along with choosing tools for collecting data. It also presents a discussion of physical proximity in qualitative interviews with this population and its role in data quality. The authors investigate benefits in the context of researchers' personal experiences. They acknowledge the disadvantages of conducting interviews online and discuss ways to mitigate these. CONCLUSION: The advantages for researchers include cost-effectiveness, time-efficiency and greater geographical reach of participants. However, CYP's perspectives are unknown and the specific ethical issues of using this method with CYP need careful consideration. IMPLICATIONS FOR PRACTICE: More research is needed to examine virtual interviews from the perspectives of CYP as participants. Virtual acquisition of consent and assent should be investigated to standardise good research practices.

Nurses' perceptions of point of care testing in critical care: A cross-sectional survey.

BACKGROUND: Nurses working in critical care (intensive or high dependency care units) perform a multitude of tasks including point-of-care testing (POCT), where diagnostic tests are performed at or near a patient's bedside. POCT can speed up clinical decision-making, but errors can occur at any point in the pre-analytical phase. AIM: To investigate nurses' perceptions of current POCT practice in critical care pre and post the COVID-19 pandemic. METHODS: An online cross-sectional survey of critical care nurses undertaken 2019-2021. Nurses across Europe were invited to participate during a conference and via communication from professional organizations. RESULTS: A total of 158 critical care nurses responded to the survey. All respondents who stated their location reported being residents of the UK. Alongside challenges related to training and competence, frequency of sampling and sampling volumes were key concerns, seen to be associated with increased blood wastage and nursing workload, potentially increasing the potential for error, and leading to poorer patient and staff outcomes. CONCLUSION: Results from this study highlight the impact of POCT on nurses' workload, patient care provision and staff wellbeing. RELEVANCE TO CLINICAL PRACTICE: Alongside exploring feasible and effective training models, innovative roles, which provide technical support, including undertaking POCT could enable nurses more time to provide care to patients and families. Any future changes in workforce allocation must, however, be fully evaluated from the perspective of both patient and staff outcomes.

'Doing the best we can': Registered Nurses' experiences and perceptions of patient safety in intensive care during COVID-19.

AIMS: To explore registered nurses' experiences of patient safety in intensive care during COVID-19. DESIGN: A qualitative interview study informed by constructivism. METHOD: Semi-structured interviews were conducted and audio-recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. RESULTS: Two key themes were identified. 'On a war footing'-an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. 'Doing the best we can'-Safe Delivery of Care which describes the ramifications of the actions taken on short- and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer Support. CONCLUSION: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an understanding of the holistic and long-term impacts on patient safety and recovery from critical illness. IMPACT: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing workforce modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

Failure Mode and Effects Analysis (FMEA) at the preanalytical phase for POCT blood gas analysis: proposal for a shared proactive risk analysis model.

OBJECTIVES: Proposal of a risk analysis model to diminish negative impact on patient care by preanalytical errors in blood gas analysis (BGA). METHODS: Here we designed a Failure Mode and Effects Analysis (FMEA) risk assessment template for BGA, based on literature references and expertise of an international team of laboratory and clinical health care professionals. RESULTS: The FMEA identifies pre-analytical process steps, errors that may occur whilst performing BGA (potential failure mode), possible consequences (potential failure effect) and preventive/corrective actions (current controls). Probability of failure occurrence (OCC), severity of failure (SEV) and probability of failure detection (DET) are scored per potential failure mode. OCC and DET depend on test setting and patient population e.g., they differ in primary community health centres as compared to secondary community hospitals and third line university or specialized hospitals. OCC and DET also differ between stand-alone and networked instruments, manual and automated patient identification, and whether results are automatically transmitted to the patient's electronic health record. The risk priority number (RPN = SEV × OCC × DET) can be applied to determine the sequence in which risks are addressed. RPN can be recalculated after implementing changes to decrease OCC and/or increase DET. Key performance indicators are also proposed to evaluate changes. CONCLUSIONS: This FMEA model will help health care professionals manage and minimize the risk of preanalytical errors in BGA.

Blood sampling in adult critical care: a mixed methods study.

There are few studies exploring blood sampling practice in critical care. In particular, the views of nursing staff are missing from the literature. The aim of this mixed methods study was to understand blood sampling practice at a single centre National Specialist Orthopaedic NHS trust in London, England. Following an audit of sampling practice over a four-week period, two focus group discussions explored nurses' views and experiences. Daily blood samples were in keeping with volumes reported in other studies of a similar size and nature, with routine sampling practice common. Although we did not seek associations between data sets, the daily reported losses from blood sampling may be a contributory factor in patients' overall post-operative haemoglobin fall resulting in blood transfusion. Four key themes emerged from the qualitative focus groups: training and responsibility, influences and impacts, nursing time and errors. The routine nature of blood sampling practice may be specific to the elective setting, but raises questions around the need for a more patient centred, needs based approach. In addition to reducing the number of potentially unnecessary tests, small-volume phlebotomy tube (SVPT), closed sampling systems and increased use of Point of Care Testing (POCT) should be considered. Education and development of clear localised protocols could also help reduce the amount of unnecessary blood taken from patients in elective adult critical care settings.

Experiences of siblings of children with congenital heart disease during Coronavirus disease 2019; A qualitative interview study.

PURPOSE: To explore siblings' perceptions of having a brother or sister with congenital heart disease in the UK during the COVID-19 pandemic. DESIGN AND METHODS: Siblings of children with congenital heart disease aged 8-17 years old were interviewed via video call technology between September 2020 and February 2021. We conducted reflexive thematic analysis of these interviews to generate themes. FINDINGS: Interviews took place with 17 siblings, predominantly of white ethnicity n = 15 (86%). Most siblings interviewed were first born in the family n = 15 (88%), and most children with CHD were the youngest n = 15(88%). Four themes were generated; My sibling is vulnerable, what does this mean for my family, I have a responsibility to protect my brother or sister, our family time during the pandemic and adjustment and adaptations to pandemic life. CONCLUSIONS: Siblings identified difficult aspects of the pandemic and these related to concerns about their brother's or sister's vulnerability, family impact, and keeping their sibling safe. They also identified adjustments they made to keep their family functioning throughout the COVID-19 pandemic. Despite the worry and uncertainty siblings experienced, they valued increased family cohesion which helped to mitigate some challenges of the restrictions imposed in the UK. PRACTICE IMPLICATIONS: Honest and open communication is valued by siblings. It is vital to ensure siblings receive the support they need to ensure they keep up with their schooling and social commitments as pandemic related restrictions ease.

How COVID-19 has affected staffing models in intensive care: A qualitative study examining alternative staffing models (SEISMIC).

AIMS: To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models. DESIGN: Exploratory qualitative study. METHODS: Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England. FINDINGS: The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing. CONCLUSIONS: Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change. IMPACT: In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes.

Waiting for infected hip revision surgery; exploring patient and families' experience of waiting (PREWs).

INTRODUCTION: As a tertiary center for complex orthopedic surgery, evaluating current practice is vital to enhance pathways of care. A vital element of this is to understand service users' perspectives and experiences, yet little research to date has explored experiences of waiting for surgery in this cohort. METHODS: The aim of this mixed methods study was to understand patients' and families' experiences of waiting for hip revision surgery for joint infection and their perceptions of its impact on their quality of life. Data were collected via a survey and individual interviews with people who had experienced waiting for surgery between May 01, 2018 and April 30, 2019. Of the 54 participants invited to participate, 22 returned a questionnaire and five were interviewed. Quantitative data were analysed descriptively whilst qualitative data underwent thematic analysis. RESULTS: Although 67 % of respondents reported being satisfied with their waiting time, all reported an increase in pain whilst waiting and 60 % stated that waiting had a significant effect on their lives and those of their friends/family (85 %). Most respondents reported high levels of satisfaction with the support (89 %) and information (83 %) provided by the clinical team. CONCLUSION: Despite satisfaction with support and information being rated highly, waiting for surgery clearly has a great impact on patients and their families. A named clinician to monitor/oversee care whilst waiting and to act as contact to help them navigate services is recommended to support people during the waiting period.

Clinical academic research internships: What works for nurses and the wider nursing, midwifery and allied health professional workforce.

Nurse-led research and innovation is key to improving health experiences and outcomes and reducing health inequalities. Clinical academic training programmes for nurses to develop research and innovation skills alongside continued development of their clinical practice are becoming increasingly established at national, regional and local levels. Though widely supported, geographical variation in the range and scope of opportunities available remains. It is imperative that clinical academic opportunities for nurses continue to grow to ensure equity of access and opportunity so that the potential of nurse-led clinical academic research to improve quality of care, health experience and health outcomes can be realised. In this paper, we describe and report on clinical academic internship opportunities available to nurses to share internationally, a range of innovative programmes currently in operation across the UK. Examples of some of the tangible benefits for patients, professional development, clinical teams and NHS organisations resulting from these clinical academic internships are illustrated. Information from local evaluations of internship programmes was collated to report what has worked well alongside 'real-world' set-up and sustainability challenges faced in practice. Clinical academic internship schemes are often opportunistically developed, making use of hybrid models of delivery and funding responsive to local needs and available resources. Key enablers of successful clinical academic internship programmes for nurses were support from senior clinical leaders and established relationships with local universities and wider organisations committed to research capacity building.

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 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 1 h, 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.

Healthcare stakeholders' perceptions and experiences of factors affecting the implementation of critical care telemedicine (CCT): qualitative evidence synthesis.

BACKGROUND: Critical care telemedicine (CCT) has long been advocated for enabling access to scarce critical care expertise in geographically-distant areas. Additional advantages of CCT include the potential for reduced variability in treatment and care through clinical decision support enabled by the analysis of large data sets and the use of predictive tools. Evidence points to health systems investing in telemedicine appearing better prepared to respond to sudden increases in demand, such as during pandemics. However, challenges with how new technologies such as CCT are implemented still remain, and must be carefully considered. OBJECTIVES: This synthesis links to and complements another Cochrane Review assessing the effects of interactive telemedicine in healthcare, by examining the implementation of telemedicine specifically in critical care. Our aim was to identify, appraise and synthesise qualitative research evidence on healthcare stakeholders' perceptions and experiences of factors affecting the implementation of CCT, and to identify factors that are more likely to ensure successful implementation of CCT for subsequent consideration and assessment in telemedicine effectiveness reviews. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, and Web of Science for eligible studies from inception to 14 October 2019; alongside 'grey' and other literature searches. There were no language, date or geographic restrictions. SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis. Studies included views from healthcare stakeholders including bedside and CCT hub critical care personnel, as well as administrative, technical, information technology, and managerial staff, and family members. DATA COLLECTION AND ANALYSIS: We extracted data using a predetermined extraction sheet. We used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess the methodological rigour of individual studies. We followed the Best-fit framework approach using the Consolidated Framework for Implementation Research (CFIR) to inform our data synthesis.  We classified additional themes not captured by CFIR under a separate theme. We used the GRADE CERQual approach to assess confidence in the findings. MAIN RESULTS: We found 13 relevant studies. Twelve were from the USA and one was from Canada. Where we judged the North American focus of the studies to be a concern for a finding's relevance, we have reflected this in our assessment of confidence in the finding. The studies explored the views and experiences of bedside and hub critical care personnel; administrative, technical, information technology, and managerial staff; and family members. The intensive care units (ICUs) were from tertiary hospitals in urban and rural areas. We identified several factors that could influence the implementation of CCT. We had high confidence in the following findings: Hospital staff and family members described several advantages of CCT. Bedside and hub staff strongly believed that the main advantage of CCT was having access to experts when bedside physicians were not available. Families also valued having access to critical care experts. In addition, hospital staff described how CCT could support clinical decision-making and mentoring of junior staff.  Hospital staff greatly valued the nature and quality of social networks between the bedside and CCT hub teams. Key issues for them were trust, acceptance, teamness, familiarity and effective communication between the two teams. Interactions between some bedside and CCT hub staff were featured with tension, frustration and conflict. Staff on both sides commonly described disrespect of their expertise, resistance and animosity. Hospital staff thought it was important to promote and offer training in the use of CCT before its implementation. This included rehearsing every step in the process, offering staff opportunities to ask questions and disseminating learning resources. Some also complained that experienced staff were taken away from bedside care and re-allocated to the CCT hub team. Hospital staff's attitudes towards, knowledge about and value placed on CCT influenced acceptance of CCT. Staff were positive towards CCT because of its several advantages. But some were concerned that the CCT hub staff were not able to understand the patient's situation through the camera. Some were also concerned about confidentiality of patient data. We also identified other factors that could influence the implementation of CCT, although our confidence in these findings is moderate or low. These factors included the extent to which telemedicine software was adaptable to local needs, and hub staff were aware of local norms; concerns about additional administrative work and cost; patients' and families' desire to stay close to their local community; the type of hospital setting; the extent to which there was support from senior leadership; staff access to information about policies and procedures; individuals' stage of change; staff motivation, competence and values; clear strategies for staff engagement; feedback about progress; and the impact of CCT on staffing levels. AUTHORS' CONCLUSIONS: Our review identified several factors that could influence the acceptance and use of telemedicine in critical care. These include the value that hospital staff and family members place on having access to critical care experts, staff access to sufficient training, and the extent to which healthcare providers at the bedside and the critical care experts supporting them from a distance acknowledge and respect each other's expertise. Further research, especially in contexts other than North America, with different cultures, norms and practices will strengthen the evidence base for the implementation of CCT internationally and our confidence in these findings. Implementation of CCT appears to be growing in importance in the context of global pandemic management, especially in countries with wide geographical dispersion and limited access to critical care expertise. For successful implementation, policymakers and other stakeholders should consider pre-empting and addressing factors that may affect implementation, including strengthening teamness between bedside and hub teams; engaging and supporting frontline staff; training ICU clinicians on the use of CCT prior to its implementation; and ensuring staff have access to information and knowledge about when, why and how to use CCT for maximum benefit.