Contextual issues that influence preparedness of nurses for critical care nursing practice in Malawi

Developing effective In-Service Education for intensive care nurses: Exploring the views of clinical stakeholders in the Kingdom of Saudi Arabia

BACKGROUND

Evidence-based in-service education (ISE) in the intensive care unit (ICU) is essential to maintaining nurse skill and competence in this complex clinical area. However, there has been limited research that has focused on developing and optimising the specialised training required by ICU nurses working in trauma care.

OBJECTIVES

To explore the perspectives of ICU clinical stakeholders regarding their needs and preferences for ISE to inform the future development and implementation of effective educational interventions.

DESIGN

A qualitative, multiple-case study supported by the "Empowering Education" theoretical framework, which emphasises the importance of stakeholder involvement in education development.

SETTINGS

Adult ICUs in three major hospitals located in two geographical areas in Saudi Arabia.

PARTICIPANTS

Forty clinical nurses, twelve nurse managers, nine nurse leaders and seven clinical educators participated.

METHODS

Data were collected through semi-structured interviews followed by focus groups. Framework analysis was used for data analysis.

FINDINGS

Stakeholders wanted ISE and training by subject experts characterised by: (i): relevant educational content; (ii): a range of educational techniques and (iii) flexible delivery and format. Nurses also identified factors that encouraged them to participate in ISE including adequate resources and a supportive work environment, whilst heavy workloads, cost and scheduling issues hindered engagement.

CONCLUSION

This paper highlights the importance of considering staff needs and local context when developing in-service ICU education to support nurses' competence. Further recommendations and a proposed framework to develop future ISE in the ICU are provided.

TWEETABLE ABSTRACT

The key to effective in-service education for ICU nurses is understanding stakeholders' needs and motivational drivers, whilst addressing barriers to successful implementation.

Critical care capacity and care bundles on medical wards in Malawi: a cross-sectional study

INTRODUCTION

As low-income countries (LICs) shoulder a disproportionate share of the world's burden of critical illnesses, they must continue to build critical care capacity outside conventional intensive care units (ICUs) to address mortality and morbidity, including on general medical wards. A lack of data on the ability to treat critical illness, especially in non-ICU settings in LICs, hinders efforts to improve outcomes.

METHODS

This was a secondary analysis of the cross-sectional Malawi Emergency and Critical Care (MECC) survey, administered from January to February 2020, to a random sample of nine public sector district hospitals and all four central hospitals in Malawi. This analysis describes inputs, systems, and barriers to care in district hospitals compared to central hospital medical wards, including if any medical wards fit the World Federation of Intensive and Critical Care Medicine (WFSICCM) definition of a level 1 ICU. We grouped items into essential care bundles for service readiness compared using Fisher's exact test.

RESULTS

From the 13 hospitals, we analysed data from 39 medical ward staff members through staffing, infrastructure, equipment, and systems domains. No medical wards met the WFSICCM definition of level 1 ICU. The most common barriers in district hospital medical wards compared to central hospital wards were stock-outs (29%, Cl: 21% to 44% vs 6%, Cl: 0% to 13%) and personnel shortages (40%, Cl: 24% to 67% vs 29%, Cl: 16% to 52%) but central hospital wards reported a higher proportion of training barriers (68%, Cl: 52% to 73% vs 45%, Cl: 29% to 60%). No differences were statistically significant.

CONCLUSION

Despite current gaps in resources to consistently care for critically ill patients in medical wards, this study shows that with modest inputs, the provision of simple life-saving critical care is within reach. Required inputs for care provision can be informed from this study.

Family members' perception of their needs in critical care units at a tertiary hospital in Malawi: A qualitative study

BACKGROUND

Family members experience an emotional crisis when their loved one is critically ill and admitted to a critical care unit (CCU). An extensive literature has explored optimal ways to interact with families in the critical care setting, including intervention studies. What is less explored are perceptions of family members in low-income settings including Malawi. In such settings, perceptions may differ as a consequence of different cultural practices and resource limitations (personnel and technology). Therefore, this study explored family members' perceptions of their needs in CCUs at a tertiary hospital in Malawi.

STUDY DESIGNS AND METHODS

The study used a qualitative descriptive design. Data were gathered through interviews with 12 participants who were purposively selected from immediate family members of patients hospitalized for 48 h or more in adult intensive care unit (ICU) and high dependency unit (HDU). The interviews were audio recorded and transcribed verbatim. Data analysis followed the steps of content analysis.

FINDINGS

The following four themes were identified: perceived information, physical, and psychosocial needs, and coping mechanisms of the family members. The family members needed information about their patient's progress frequently and viewed this as a priority compared to other needs such as comfort and food.

CONCLUSION

This study suggests that there should be a collaborative relationship between the CCU team and family members in order to meet their needs. Findings affirm the need for health professionals to develop guidelines or standards that promote frequent discussions with CCU family members as a means to provide support and lessen anxiety.

A health systems approach to critical care delivery in low-resource settings: a narrative review

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Doctors' experiences of referring and admitting patients to the intensive care unit: a qualitative study of doctors' practices at two tertiary hospitals in Malawi

OBJECTIVE

To explore doctors' experiences of referring and admitting patients to the intensive care unit (ICU) at two tertiary hospitals in Malawi.

DESIGN

This was a qualitative study that used face-to-face interviews. The interviews were audiotaped and transcribed verbatim into English. The data were analysed manually through conventional content analysis.

SETTING

Two public tertiary hospitals in the central and southern regions of Malawi. Interviews were conducted from January to June 2021.

PARTICIPANTS

Sixteen doctors who were involved in the referral and admission of patients to the ICU.

RESULTS

Four themes were identified namely, lack of clear admission criteria, ICU admission requires a complex chain of consultations, shortage of ICU resources, and lack of an ethical and legal framework for discontinuing treatment of critically ill patients who were too sick to benefit from ICU.

CONCLUSION

Despite the acute disease burden and increased demand for ICU care, the two hospitals lack clear processes for referring and admitting patients to the ICU. Given the limited bed space in ICUs, hospitals in low-income countries, including Malawi, need to improve or develop admission criteria, severity scoring systems, ongoing professional development activities, and legislation for discontinuing intensive care treatments and end-of-life care.

Healthcare workers' experiences in caring for critically ill COVID-19 patients at a tertiary hospital in Malawi

Introduction

The coronavirus pandemic overwhelmed the healthcare landscape, placing a strain on healthcare workers worldwide. In addition to directly causing the deaths of people, the COVID-19 pandemic disrupted critical health services in developing countries. The study aimed to explore the experiences of healthcare workers who cared for critically ill COVID-19 patients at a tertiary hospital in Malawi.

Methods

A qualitative descriptive design was used. Data were gathered through in-depth interviews with doctors, clinical officers, nurses, and allied staff (n=25) who were involved in the care of critically ill COVID-19 patients at the hospital's COVID-19 treatment centres during the first and second waves of the pandemic in Malawi. The interviews were conducted in English, audiotaped, and later transcribed verbatim. Conventional content analysis was used to analyse the data following the steps proposed by Hsieh and Shannon1.

Results

The overall experience of the health workers was negative. However, delivering care to critically ill COVID-19 patients was associated with positive and negative experiences. The positive experience was a result of teamwork among staff and support from hospital authorities and the community. Negative experiences, on the other hand, were attributed to a lack of knowledge and skills in managing critically ill COVID-19 patients, a lack of resources, and abuse by some patients and members of the community. Furthermore, there was fear of contracting the virus from patients and fellow health workers while providing care.

Conclusion

The findings point to the need for adequate preparedness within the health sector to support and protect the healthcare workers and individuals they look after. There is a need for disease awareness strategies for health workers and the general public for future pandemics.

Critical care nursing role in low and lower middle-income settings: a scoping review

OBJECTIVES

A scoping review was conducted to answer the question: How is critical care nursing (CCN) performed in low-income countries and lower middle-income countries (LICs/LMICs)?

DESIGN

Scoping review guided by the JBI Manual for Evidence Synthesis.

DATA SOURCES

Six electronic databases and five web-based resources were systematically searched to identify relevant literature published between 2010 and April 2021.

REVIEW METHODS

The search results received two-stage screening: (1) title and abstract (2) full-text screening. For sources of evidence to progress, agreement needed to be reached by two reviewers. Data were extracted and cross-checked. Data were analysed, sorted by themes and mapped to region and country.

RESULTS

Literature was reported across five georegions. Nurses with a range formal and informal training were identified as providing critical care. Availability of staff was frequently reported as a problem. No reports provided a comprehensive description of CCN in LICs/LMICs. However, a variety of nursing practices and non-clinical responsibilities were highlighted. Availability of equipment to fulfil the nursing role was widely discussed. Perceptions of inadequate resourcing were common. Undergraduate and postgraduate-level preparation was poorly described but frequently reported. The delivery of short format critical care courses was more fully described. There were reports of educational evaluation, especially regarding internationally supported initiatives.

CONCLUSIONS

Despite commonalities, CCN is unique to regional and socioeconomic contexts. Nurses work within a complex team, yet the structure and skill levels of such teams will vary according to patient population, resources and treatments available. Therefore, a universal definition of the CCN role in LIC/LMIC health systems is likely unhelpful. Research to elucidate current assets, capacity and needs of nurses providing critical care in specific LIC/LMIC contexts is needed. Outputs from such research would be invaluable in supporting contextually appropriate capacity development programmes.

Improving competencies and skills across clinical contexts of care: a qualitative study on Malawian nurses' experiences in an institutional health and training programme

AIM

To explore what competencies and skills Malawian nurses gained after participating in an institutional health and training programme in Norway and how they viewed these competencies applicable upon return to Malawi. Furthermore, to examine facilitators and challenges experienced on the exchange programme and opportunities and obstacles to make the competencies usable in own local hospital context.

DESIGN

Qualitative study with an explorative design.

METHODS

Fourteen interviews and one focus group discussion were conducted at Queen Elizabeth Central Hospital, Blantyre, Malawi, from August to September 2018.

RESULTS

Competencies gained in Norway included clinical skills, teamwork, coordination and strengthened professionalism. The main finding was that the exchange programme was a transformative experience. Upon return to Malawi, the competencies gained on the exchange were helpful. However, the return was characterized by mixed emotions due to the considerable difference between the two clinical settings.

Improving nurses' knowledge of managing endotracheal tube cuff pressure in intensive care units: A quasi-experimental study

BACKGROUND

Previous studies conducted on nurses' knowledge regarding endotracheal tube cuff pressure revealed that there were differences in intensive care nurses' knowledge, leading to varying practices.

AIM

This study aimed to evaluate how an educational intervention based on the existing evidence-based guidelines, using both passive and active implementation strategies, could improve the knowledge of nurses regarding managing endotracheal tube cuff pressures in Malawian intensive care units.

SETTING

Six functional ICUs (four public and two private) in Malawi.

METHODS

The study followed a quasi-experimental, pre- and post-test design using an educational intervention. Intensive care nurses of six functional intensive care units in Malawi were randomly assigned to two intervention groups. Both groups received a half-day educational session, a printed version of the evidence-based guidelines, a printed and laminated summary of the guidelines and a related algorithm. Additionally, Intervention 2 group received four monitoring visits. Pre- and post-test questionnaires were conducted between February and August 2016. Descriptive and inferential data analyses (a chi-square test and t-test) were utilised.

RESULTS

An improvement in knowledge was observed on the nursing care practices for the management of endotracheal tube cuff pressure for both groups following the educational intervention, although only the results comparing Intervention 2 group participants indicate that the level of knowledge was significant (t[df = 48] = 2.08, p = 0.043, d = 0.59).

CONCLUSION

Implementation of a formal training and mentorship programme for Malawian intensive care nurses would be of great benefit to enhance the knowledge and skills managing endotracheal tube cuff pressure. Follow-up studies would also assist in understanding how guidelines could be implemented most effectively to achieve better knowledge outcomes.