The nursing role in ICU outreach: an international exploratory study

Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse

AIM AND OBJECTIVE

To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT).

BACKGROUND

For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction.

DESIGN

Qualitative focus group interviews.

METHODS

A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist.

RESULTS

One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'.

CONCLUSION

Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses.

RELEVANCE TO CLINICAL PRACTICE

Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.

Patient experiences of an intensive care Liaison Nurse support service

OBJECTIVES

To illuminate patients' experiences of being a part of an liaison nurse support service focused on supporting recently transferred intensive care unit patients.

RESEARCH METHODOLOGY/DESIGN

A qualitative inductive descriptive design including in-depth interviews was chosen.

SETTING

A project including an liaison nurse support service-intervention was undertaken during a 16-week period at a University hospital in Sweden. The liaison nurse support service was available Monday-Friday 10 am - 6 pm and nurses visited the patient 1-4 times after transfer to the ward.

MAIN OUTCOME MEASURES

Of the 109 patients who were visited by the liaison nurse support service, 14 agreed to be interviewed about their experiences of the transfer. Data was analysed by inductive content analysis.

FINDINGS

One overall theme, An advocate in a vulnerable situation emerged from the data. Four subthemes were identified: Ensures transfer of information between the intensive care unit and the general ward, Makes the circumstances understandable and coordinates between the care levels and Offers emotional support and stability in an uncertain situation.

CONCLUSION

The liaison nurse support service contributed to ensuring accurate transfer of information, solved problems when the patient themselves did not have control or strength and provided emotional support.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum

BACKGROUND

For over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required.

AIM

The aim of this study was to ascertain nurses' perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system.

METHODS

An exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes.

RESULTS

Seventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles.

CONCLUSIONS

A curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

The Intensive Care Unit Liaison Nurse and their value in averting clinical deterioration: A qualitative descriptive study

OBJECTIVES

Intensive Care Unit Liaison Nurse roles are associated with improved clinical outcomes for patients and financial benefits for healthcare providers. However, there is little academic exploration of the ward nurses' perspectives of the role and whether it can affect ward nurses' confidence in identifying and managing the deteriorating patient. This study addresses this gap by examining both those perspectives.

RESEARCH DESIGN

A qualitative descriptive approach was used, utilising semi-structured interviews to garner the perspectives of ward nurses.Interviewswere conducted with ward nurses who had been involved in a MedicalEmergencyTeam/Code Blue call;sought technical or clinical support;or had been at the bedside during a post intensive care unit discharge review. Data were analysed using thematic analysis.

SETTING

A private, not-for-profit, metropolitan acute care hospital.

FINDINGS

The participants identified four areas that contributed to improved patient care: reduced Medical Emergency Team/Code calls; improved ward based critical care knowledge through education; improved ward nurses' confidence in dealing with the deteriorating patient and provision of technical support.

CONCLUSION

The Intensive Care Unit Liaison Nurse role not only contributes to improved clinical patient outcomes; it also influences confidence levels of the ward nurses in managing deteriorating patients.

Insight into hospital ward nurses' concerns about patient health and the corresponding Medical Emergency Team nurse response

AIM

This study aims to understand the concerns of nurses when making MET calls which did not fulfil the vital sign criteria, and the MET nurses subsequent responses to these calls.

METHODS

This was a retrospective report-based study. Research material included nursing reports and MET forms related to MET calls made due to nurses' concern. Inductive content analysis was used to identify observations, which were then quantified based on the research material.

FINDINGS

From a total of 546 MET calls, 39 visits (7%) were due to nurses' concern. In these 39 visits, the vital sign criteria did not reach the alert threshold, but nurses made the call due to subjective worry. In 13% of visits, the alert concern was inadequate contact with the doctor. MET nurses responded to the alert by providing clinical and indirect nursing; more specifically, they performed examinations and nursing interventions and collaborated with other professionals.

CONCLUSION

A nurse's worry is influenced by subjective changes in the patient's condition or an inadequate doctor's response rather than objective physiological measurements. A MET nurse's ability to assess patient condition, respond to nurses' calls, and acknowledge justified alerts help MET nurses support concerned nurses and encourage them to contact the MET if necessary.

Ward visits- one essential step in intensive care follow-up. An interview study with critical care nurses' and ward nurses'

OBJECTIVE

The aim of this study was to describe critical care nurses' and ward nurses' perceptions of the benefits and challenges with a nurse-led follow-up service for intensive care-survivors at general wards.

BACKGROUND

Patients recently transferred from intensive care to the general ward are still vulnerable and require complex care. There are different models of intensive care follow-up services and some include ward visits after transfer from intensive care. Research methodology/design: This study had a qualitative design. Data from 13 semi-structured interviews with Swedish critical care nurses and ward nurses were analysed using qualitative content analysis.

FINDINGS

The findings consisted of one theme, namely, "Being a part of an intra-organisational collaboration for improved quality of care", and four subthemes: "Provides additional care for the vulnerable patients, "Strengthens ward-based critical care", "Requires coordination and information", and "Creates an exchange of knowledge". The nurse-led follow-up service detected signs of deterioration and led to better quality of care. However, shortage of time, lack of interaction, feedback and information about the function of the follow-up service led to problems.

CONCLUSION

The findings indicate that ward visits should be included in the intensive care follow-up service. Furthermore, intra-organisational collaboration seems to be essential for intensive care survivors' quality of care.

Physical and Mental Health of Patients Immediately After Discharge From Intensive Care Unit and 24 Hours Later

Background:

Monitoring the health status of patients discharged from intensive care units is a crucial method of service evaluation.

Objectives:

This study aimed to assess the physical and mental health status of patients immediately after discharge from the ICU and 24 hours later.

Patients and Methods:

This descriptive comparative study was conducted on 104 patients discharged from the ICUs of a referral trauma center in Shiraz, Southwest Iran. Physical parameters, including respiratory rate, need for supplemental oxygen, heart rate, blood pressure, and need for cardiac monitoring, were assessed. Hospital anxiety and depression scale (HADS) was used for mental health evaluation. The mental and physical status of patients were assessed before ICU discharge and 24 hours later; data were recorded in information forms and were analyzed using SPSS statistical software version 17.

Results:

At the time of discharge, the respiratory rate of 28% of the participants was more than 24 minutes, and 95.2% received supplemental oxygen. However, after 24 hours these values decreased to 10% and 21.6%, respectively. The mean heart rate and systolic blood pressure were within the normal range at both time points. Additionally, 63% of the patients had anxiety scores above 11 at both time points, reflecting high anxiety. The number of patients who reported depression increased from 58.7% at ICU discharge to 69.6% after 24 hours.

Conclusions:

Despite the considerable improvement in most of the patients’ physical condition in the first 24 hours after discharge from ICU, a significant number of them remain at risk for the development of adverse effects from this transition. The high prevalence of mental health disorders in these patients reveals the necessity to conduct follow-up consultations.

Intensive care survivors' experiences of ward-based care: Meleis' theory of nursing transitions and role development among critical care outreach services

AIMS AND OBJECTIVES

To explore the psychosocial needs of patients discharged from intensive care, the extent to which they are captured using existing theory on transitions in care and the potential role development of critical care outreach, follow-up and liaison services.

BACKGROUND

Intensive care patients are at an increased risk of adverse events, deterioration or death following ward transfer. Nurse-led critical care outreach, follow-up or liaison services have been adopted internationally to prevent these potentially avoidable sequelae. The need to provide patients with psychosocial support during the transition to ward-based care has also been identified, but the evidence base for role development is currently limited.

DESIGN AND METHODS

Twenty participants were invited to discuss their experiences of ward-based care as part of a broader study on recovery following prolonged critical illness. Psychosocial distress was a prominent feature of their accounts, prompting secondary data analysis using Meleis et al.'s mid-range theory on experiencing transitions.

RESULTS

Participants described a sense of disconnection in relation to profound debilitation and dependency and were often distressed by a perceived lack of understanding, indifference or insensitivity among ward staff to their basic care needs. Negotiating the transition between dependence and independence was identified as a significant source of distress following ward transfer. Participants varied in the extent to which they were able to express their needs and negotiate recovery within professionally mediated boundaries.

CONCLUSION

These data provide new insights into the putative origins of the psychosocial distress that patients experience following ward transfer.

RELEVANCE TO CLINICAL PRACTICE

Meleis et al.'s work has resonance in terms of explicating intensive care patients' experiences of psychosocial distress throughout the transition to general ward-based care, such that the future role development of critical care outreach, follow-up and liaison services may be more theoretically informed.

Implementing clinical supervision for ICU Outreach Nurses: a case study of their journey

INTRODUCTION

Many health services with Intensive Care Units have developed ward liaison programs, managed by Outreach Nurses, to facilitate the transition for patients between the intensive care and general wards. This paper reports a case study of clinical supervision for two Outreach Nurses as they adapted to their new, largely autonomous role in an Australian tertiary hospital.

METHOD

Individual clinical supervision was provided fortnightly to two Outreach Nurses over 12 months by an experienced facilitator, and evaluated using a case study methodology. The Outreach Nurses completed a journal that captured their personal and professional growth and the supervisor also provided a reflective account. An interview was conducted with both Outreach Nurses to evaluate their experiences of clinical supervision.

FINDINGS

Key themes emerging from all the data sources included: respect for clinical supervision and the supervisor; role clarification; understanding and dealing with interpersonal issues; dedicated time for reflection; facing up to issues and letting them go.

CONCLUSION

The Outreach Nurses described the personal and professional benefits of clinical supervision and highlighted how it was successfully implemented for them in a busy clinical environment with limited available resources.

Supporting trail-blazing: A systematic review of the factors that facilitate or inhibit the implementation of new nursing roles: the experiences of UK consultant nurses

BACKGROUND

If emerging 'trail-blazers', such as the consultant nurse, are to be successful in developing and sustaining new ways of working then factors that support or inhibit new role developments need identification. There is a growing body of evaluative and anecdotal evidence about the experience of consultant nurses since the introduction of the role in the UK thirteen years ago.

OBJECTIVE

To synthesise the evidence on the experiences of UK consultant nurses in implementing a new role in order to identify inhibitors and facilitators of role development.

INCLUSION CRITERIA

This review sought qualitative and mixed methodology studies that yielded qualitative data about the phenomenon of interest, together with narrative opinion papers i.e. consultant nurses' experiences of role development.

SEARCH STRATEGY

The search in 14 databases considered studies and opinion papers published between January 1999 and April 2010 in English.

METHODOLOGICAL QUALITY

All retrieved studies and opinion papers were assessed by two independent reviewers using the standardised Joanna Briggs Institute critical appraisal tools.

DATA COLLECTION

Data were extracted from included papers using the standardised Joanna Briggs Institute data extraction tool.

DATA SYNTHESIS

Data synthesis used the Joanna Briggs Institute approach for meta-synthesis by meta-aggregation. Findings were synthesised into categories and categories were aggregated into synthesised findings.

RESULTS

On the basis of critical appraisal, no opinion papers were included in the review. A total of 11 qualitative studies were included, yielding a total of 313 findings. These were synthesised into 64 categories which were further synthesised into 11 synthesised findings about factors that facilitate and inhibit the role's implementation and development.

CONCLUSION

Drawing directly on consultant nurses' experiences, these findings add evidence to what is already known about what does and does not work in developing a consultant role. They indicate that an understanding about the role's core functions is needed, as is a supportive environment in which the consultant can fully operate.

IMPLICATIONS FOR PRACTICE

The implications for practice are derived from the results of the synthesised findings. An organisation, through its policies, practices, procedures and individuals, must support the consultant's leadership and collaborative goal directed approach to care delivery and service development. This can be achieved by allowing the consultant both autonomy and authority. The synthesised findings reinforce the need to optimise the facilitators and minimise the inhibitors of role development. They can also make a contribution to the conceptual understanding of the consultant role.

IMPLICATIONS FOR RESEARCH

Further research into the experiences of consultant nurses is necessary - in particular, how nurse consultants interpret their relationships with others, negotiate resources and demonstrate the impact of their role in each of the core functions, notably the leadership function.

ICU patient's transfer anxiety: a prospective cohort study

OBJECTIVE

The purpose of this study was to quantify the levels of anxiety experienced by Intensive Care Unit (ICU) patients just before transfer to the ward and then twice after transfer to the ward in order to test the hypothesis that anxiety levels would change over the three data collection periods.

DESIGN

A prospective, repeated measure cohort study.

SETTING

A Level 3 ICU in an Australian teaching hospital. The ICU had a liaison nurse service Monday to Friday but there was no medical emergency team service at the time of the study.

SUBJECTS

All adult ICU patients who remained in ICU for greater than 24h were eligible for the study.

MAIN OUTCOME MEASURES

Measurements of anxiety were undertaken using self report on the anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) on three occasions; after patients were told of their imminent transfer to the ward (Time 1), after 4h on the ward (Time 2) and after one night on the ward (Time 3).

RESULTS

In the 3 months of study 249 patients were admitted to the ICU. However, only 55 (22%) patients were eligible to participate and 44 (80% of the eligible patients) consented. Thirty-five patients (64% of eligible patients) completed all measurement points and represent the final sample. The mean anxiety levels remained low at all measurement points and did not change over time. Anxiety was present in six (17%) patients at Time 1, in three (6.8%) patients at Time 2, and in two (4.5%) patients at Time 3.

CONCLUSION

This small study provides a start to the prospective mapping of anxiety levels on time of transfer and shortly after transfer from an ICU to the wards. It also provides information to researchers who want to examine ICU transfer anxiety. By understanding the anxiety experienced by ICU patients, nurses are better able to provide psychological support and thus more holistic care to this group of patients.

Study protocol: home-based physical rehabilitation for survivors of a critical illness [ACTRN12605000166673]

INTRODUCTION

Numerous primary studies and several review papers have highlighted delayed physical and psychological recovery for survivors of critical illness, often beyond 6 months after discharge. This randomized controlled trial with blinded assessment aims to test the effects of an 8-week, home-based, individually tailored physical rehabilitation programme on physical and psychological recovery for survivors of a critical illness after discharge from hospital.

METHOD

Participants are survivors of a critical illness discharged from nine intensive care units (ICUs) in Australia, who are aged 18 years or older, in an ICU longer than 48 hours, discharged home to self-care or carer (non-institutional care), able to participate in physical rehabilitation, and within the hospitals' local geographical areas for home visits. The study is based in participants' home environments. Blinded assessments at weeks 1, 8 and 26 after hospital discharge examine physical functioning, exercise capacity, health-related quality of life and psychological well being. The intervention is graded, individualized endurance and strength training prescribed by a pulmonary rehabilitation physiotherapist over an 8-week period, with three home visits, five follow-up phone calls, and a printed exercise manual supporting the training. Initial focus is on lower limb exercises and walking, with warm-up stretches, and progresses to the addition of core stabilization and upper limb exercises.

RESULTS

The burden of a critical illness is well documented. This novel study will determine whether a home-based physical rehabilitation programme improves the recovery trajectory for survivors of critical illness. The projected sample size of 200 patients aims to detect a clinically important 10% improvement in physical functioning. The study will also examine whether other important physical and psychological measures are improved.

CONCLUSION

This multicentre, randomized controlled trial will examine outcomes that are meaningful to patients, their family and society, namely functional ability and well being. The study will also target a health problem that is likely to increase as the population ages. If the programme is effective, it will provide a model that can be easily adapted and adopted by existing primary care or community services to improve the recovery of individuals following critical illness.