Challenges to well-being in critical care.

BACKGROUND: Paediatric critical care (PCC) is a high-pressure working environment. Staff experience high levels of burnout, symptoms of post-traumatic stress, and moral distress. AIM: To understand challenges to workplace well-being in PCC to help inform the development of staff interventions to improve and maintain well-being. STUDY DESIGN: The Enhanced Critical Incident Technique (ECIT) was used. ECIT encompasses semi-structured interviews and thematic analysis. We identified 'critical incidents', challenges to well-being, categorized them in a meaningful way, and identified factors which helped and hindered in those moments. Fifty-three nurses and doctors from a large UK quaternary PCC unit were consented to take part. RESULTS: Themes generated are: Context of working in PCC, which examined staff's experiences of working in PCC generally and during COVID-19; Patient care and moral distress explored significant challenges to well-being faced by staff caring for increasingly complex and chronically ill patients; Teamwork and leadership demonstrated the importance of team-belonging and clear leadership; Changing workforce explored the impact of staffing shortages and the ageing workforce on well-being; and Satisfying basic human needs, which identified absences in basic requirements of food and rest. CONCLUSIONS: Staff's experiential accounts demonstrated a clear need for psychologically informed environments to enable the sharing of vulnerabilities, foster support, and maintain workplace well-being. Themes resonated with the self-determination theory and Maslow's hierarchy of needs, which outline requirements for fulfilment (self-actualization). RELEVANCE TO CLINICAL PRACTICE: Well-being interventions must be informed by psychological theory and evidence. Recommendations are flexible rostering, advanced communication training, psychologically-informed support, supervision/mentoring training, adequate accommodation and hot food. Investment is required to develop successful interventions to improve workplace well-being.

How the COVID-19 crisis affected the well-being of nurses working in paediatric critical care: A qualitative study.

OBJECTIVES: Evidence shows paediatric critical care (PCC) nurses display high rates of burnout, moral distress, symptoms associated with post-traumatic stress disorder (PTSD) and poor well-being. The COVID-19 pandemic magnified these pressures producing extremely challenging working conditions. The objective was to understand PCC nurses' lived experience of working during COVID-19 to determine the impact it had on their well-being. DESIGN: A qualitative design was used with individual, semi-structured online interviews analysed using thematic analysis. RESULTS: Ten nurses from six PCC units in England participated. Five themes were generated: (i) Challenges of working in Personal Protective Equipment (PPE), (ii) Adapting to redeployment to adult intensive care, (iii) Changes to staff working relationships, (iv) Being unable to attain work-life balance and (v) Unprocessed traumatic experiences of working in COVID-19. It was clear COVID-19 presented novel challenges to PCC nurses' well-being. With those came enforced changes in practice; some were temporary, for example use of PPE and redeployment, but others provided insight into the prerequisites for good staff well-being, for example strong professional relationships, work-life balance and managing one's psychological health. CONCLUSIONS: Findings show authentic connections between peers, verbal and non-verbal communication and a sense of belonging were crucial to nurses' well-being. A dent in PCC nurses' perceived competence significantly affected their well-being. Finally, staff need a psychologically safe space to process distress and trauma experienced during COVID-19. Future research needs to test evidence-based, theoretically-informed well-being interventions to improve and maintain PCC nurses' well-being.

Qualitative study exploring the well-being experiences of paediatric critical care consultants working in the UK during the COVID-19 pandemic.

OBJECTIVES: The aim of this study was to examine the well-being experiences of consultants working in paediatric critical care (PCC) settings in the UK during the COVID-19 pandemic. DESIGN: Qualitative design using individual interviews and thematic analysis. SETTING: PCC. PARTICIPANTS: Eleven medical consultants working in PCC in a range of PCC settings/transport teams in the UK from nine units participated. Participants ranged in years of experience as a consultant from four to 23 years. METHODS: A set of open semistructured questions were used to elicit information about participants' experiences of workplace well-being. Interviews were audiorecorded and transcribed. FINDINGS: Thematic analysis identified six themes and data saturation was reached. These were as follows: (1) positive and negative impact of working during COVID-19, (2) job satisfaction and public scrutiny in the unique environment of PCC, (3) supporting the workforce through modified shift work, (4) perceptions of support and recognition offered from the hospital management, (5) successful coping strategies are personal and adaptive, and (6) importance of civility and good teamwork CONCLUSION: Findings show that consultants' well-being is challenged in a number of ways and that the solutions to the problem of burn-out are multifaceted. Action is required from individual consultants, clinical teams, hospital management and national regulatory bodies. Our work corroborates the recent General Medical Council report highlighting doctors' core needs for well-being: autonomy, belonging, competence. Burn-out is a long-term problem, requiring sustainable solutions. Future research needs to develop and evaluate the effectiveness of evidence-based interventions to improve consultants' well-being. Trials of effectiveness need to present evidence that will persuade hospital management to invest in their consultants' well-being within the economic context of reduced budgets and limited PCC workforce.

Understanding what wellbeing means to medical and nursing staff working in paediatric intensive care: an exploratory qualitative study using appreciative inquiry.

AIMS AND OBJECTIVES: To explore what wellbeing means to medical and nursing staff working in a large paediatric intensive care (PIC). DESIGN: Exploratory qualitative design using an appreciative inquiry framework. SETTING: PIC unit; primary, secondary and tertiary. PARTICIPANTS: 46 nurses and doctors working on PIC. INTERVENTIONS: A set of images were used together with open-ended questions to prompt staff to discuss what wellbeing means to them. Interviews were audiorecorded and transcribed. Data were analysed thematically. RESULTS: Images depicting nature, children and groups of adults were selected most. Meanings of wellbeing for PIC staff can be understood through three themes: (1) Being nurtured and supported at work, (2) Importance of nature and (3) Social support independent of work. The first theme considered the importance of being listened to at work as well as staff highlighting the value of being in control at work. Within the second theme, being active in nature and outdoors as well as the importance of being in the present moment was illustrated. Within the final theme, staff expressed the value of having support independent of work and highlighted the importance of spending time with family. CONCLUSIONS: This study provides a unique insight into how individuals working in PIC experience wellbeing and what wellbeing means to them. Understanding how healthcare professionals in PIC settings experience wellbeing and what wellbeing means to them will enable researchers to develop interventions designed to enhance staff wellbeing based on lived experience.

Is the strong desire to void a source of diverted attention in healthy adult volunteers?

AIMS: The strong desire to void (SDV) induces changes in both cognition and gait. This may be due to the sensation of urinary urge acting as a source of diverted attention. This exploratory study examined the influence of SDV and a standardized distracting task on the performance of two measures of cognition, a simple reaction time (SRT) test and the trail making B test (TMT-B). METHODS: 18 volunteers, 8 male and 10 female, without lower urinary tract symptoms (LUTS) (mean age: 20.5, range: 20-47), performed a test of SRT and the TMT-B under three conditions; undistracted with an empty bladder, while experiencing SDV, and when performing a simultaneous distracting task, the auditory n back test. RESULTS: A statistically significant increase in SRT was found when experiencing SDV and when distracted compared with the undistracted, bladder empty condition. The time taken to compete the TMT-B significantly increased with distraction but was not affected by SDV. CONCLUSION: SDV induced a similar but smaller change in reaction time when compared with a distracting task, suggesting that SDV may act as a source of diverted attention in continent, healthy volunteers.

Psychological impact of working in paediatric intensive care. A UK-wide prevalence study.

OBJECTIVE: To determine the prevalence of work-related psychological distress in staff working in UK paediatric intensive care units (PICU). DESIGN: Online (Qualtrics) staff questionnaire, conducted April to May 2018. SETTING: Staff working in 29 PICUs and 10 PICU transport services were invited to participate. PARTICIPANTS: 1656 staff completed the survey: 1194 nurses, 270 physicians and 192 others. 234 (14%) respondents were male. Median age was 35 (IQR 28-44). MAIN OUTCOME MEASURES: The Moral Distress Scale-Revised (MDS-R) was used to look at moral distress, the abbreviated Maslach Burnout Inventory to examine the depersonalisation and emotional exhaustion domains of burnout, and the Trauma Screening Questionnaire (TSQ) to assess risk of post-traumatic stress disorder (PTSD). RESULTS: 435/1194 (36%) nurses, 48/270 (18%) physicians and 19/192 (10%) other staff scored above the study threshold for moral distress (≥90 on MDS-R) (χ2 test, p<0.00001). 594/1194 (50%) nurses, 99/270 (37%) physicians and 86/192 (45%) other staff had high burnout scores (χ2 test, p=0.0004). 366/1194 (31%) nurses, 42/270 (16%) physicians and 21/192 (11%) other staff scored at risk for PTSD (χ2 test, p<0.00001). Junior nurses were at highest risk of moral distress and PTSD, and junior doctors of burnout. Larger unit size was associated with higher MDS-R, burnout and TSQ scores. CONCLUSIONS: These results suggest that UK PICU staff are experiencing work-related distress. Further studies are needed to understand causation and to develop strategies for prevention and treatment.

Bacterial screening of platelet components by National Health Service Blood and Transplant, an effective risk reduction measure.

BACKGROUND: Bacterial contamination of blood components remains a major cause of sepsis in transfusion medicine. Between 2006 and 2010 in the 5 years before the introduction of bacterial screening of platelet (PLT) components by National Health Service Blood and Transplant (NHSBT), seven cases of PLT component-associated transmission of bacterial infection were recorded for 10 patients, three of which were fatal. STUDY DESIGN AND METHODS: Sampling of individual PLT components was undertaken at 36 to 48 hours after donation and tested in the BacT/ALERT system with 8 mL inoculated into each of aerobic and anaerobic culture bottles. Bottles were incubated until the end of the 7-day shelf life and initial reactive bottles were examined for contamination. Bacterial screened time-expired PLTs were tested as in the screen method. RESULTS: From February 2011 to September 2015, a total of 1,239,029 PLT components were screened. Initial-reactive, confirmed-positive, and false-positive rates were 0.37, 0.03, and 0.19%, respectively. False-negative cultures, all with Staphylococcus aureus, occurred on four occasions; three were visually detected before transfusion and one confirmed transmission resulted in patient morbidity. The NHSBT screening protocol effectively reduced the number of clinically adverse transfusion transmissions by 90% in this reporting period, compared to a similar time period before implementation. Delayed testing of 4515 time-expired PLT units after screening revealed no positives. CONCLUSION: The implementation of bacterial screening of PLT components with the NHSBT BacT/ALERT protocol was an effective risk reduction measure and increased the safety of the blood supply.