Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done.

BACKGROUND: Appropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process. METHODS: Thirty Applied Cognitive Task Analysis interviews were conducted with clinical experts (>4 years' experience) including Ward Nurses (n = 7), Outreach or Sepsis Nurses (n = 8), Nurse Manager or Consultant (n = 6), Physiotherapists (n = 4), Advanced Practitioners (n = 4), and Doctor (n = 1) from two National Health Service hospitals and analysed using Framework Analysis. Task-related elements of care escalation were identified and represented in a Functional Resonance Analysis Model. FINDINGS: The NEWS2's clinical escalation response constitutes eight unique tasks and illustrates work-as-prescribed, but our interview data uncovered an additional 24 tasks (n = 32) pertaining to clinical judgement, decisions or processes reflecting work-as-done. Over a quarter of these tasks (9/32, 28 %) were identified by experts as cognitively challenging with a high likelihood of performance variability. Three out of the nine variable tasks were closely coupled and interdependent within the Functional Resonance Analysis Model ('synthesising data points', 'making critical decision to escalate' and 'identifying interim actions') so representing points of potential escalation failure. Data assimilation from different clinical information systems with poor usability was identified as a key cognitive challenge. CONCLUSION: Our data support the emphasis on the need to retain clinical judgement and suggest that future escalation protocols and audit guidance require in-built flexibility, supporting staff to incorporate their expertise of the patient condition and the clinical environment. Improved information systems to synthesise the required data surrounding an unwell patient to reduce staff cognitive load, facilitate decision-making, support the referral process and identify actions are required. Fundamentally, reducing the cognitive load when assimilating core escalation data allows staff to provide better and more creative care. Study registration (ISRCTN 38850) and ethical approval (REC Ref 20/HRA/3828; CAG-20CAG0106).

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review.

PURPOSE: Patient safety has developed as a strong marker for healthcare quality. Safety matters are important in the intensive care unit (ICU) where complex clinical decisions are made, intensive technology is used, and families hold a unique role. The aim of this review was to identify and describe factors that influence family member's perceptions of safety in the adult ICU. DATA SOURCES: Searches were conducted between September and November 2018 and repeated in July 2020 using CINAHL, MEDLINE (EBSCO), PubMed and PsycINFO databases. STUDY SELECTION: Published primary studies undertaken in adult ICUs and involving adult family member participants exploring safety or feeling safe. No date restrictions were applied. DATA EXTRACTION: A data extraction form collected information about sample, study design, data collection methods and results from each paper. Methodological quality was assessed using the QualSyst tools for qualitative and quantitative studies. Narrative synthesis was undertaken. RESULTS OF DATA SYNTHESIS: Twenty papers were included with 11 papers published since 2010. The majority of papers reported on qualitative studies (n = 16). Four factors were identified that influenced whether family members felt that the patient was safe in ICU: family visiting, information and communication, caring and professional competence. CONCLUSION: In detailing specific practices that make families feel safe and unsafe in ICU, these review findings provide a structure for clinicians, educators and researchers to inform future work and gives opportunity for the family role in patient safety to be reconsidered.

Physiotherapy interventions for people with dementia and a hip fracture-a scoping review of the literature.

BACKGROUND: People with dementia are 2.7 times more likely to suffer a hip fracture than those without and their management is estimated to cost £0.92 billion per year. Yet there has been little focus on the effectiveness of interventions for this population. OBJECTIVE: The aim of this scoping review was to summarise the current available evidence for physiotherapy interventions for people with dementia who fracture their hip as well as to identify gaps in the literature that may require further research. DATA SOURCES: A systematic search of the following databases was undertaken-TRIP, CINAHL, Amed, Embase, PEDro, PsycINFO, Cochrane Library, Open Grey, Ethos, ISRCTN, Proquest, PROSPERO and UK Clinical Trials Gateway. STUDY SELECTION: Articles were included if they described an intervention which is considered within the scope of a physiotherapist and targeted those with both a hip fracture and dementia. SYNTHESIS METHODS: A narrative summary was then undertaken to describe the current state of the literature. RESULTS: Twenty six studies were included, of which thirteen were observational, six RCTs, two qualitative, two surveys and three systematic reviews. Only nine studies focused explicitly on physiotherapy interventions. CONCLUSION: The findings of this scoping review suggest there is limited evidence to guide physiotherapists in the management of people with dementia who fracture their hip. No evidence was found about perceptions or experiences of patients in this group or of the physiotherapists involved in their care. Further research is needed to develop and evaluate physiotherapy interventions for people with dementia who fracture their hip.

The experiences of physiotherapists treating people with dementia who fracture their hip.

BACKGROUND: It is estimated that people with dementia are approximately three times more likely to fracture their hip than sex and age matched controls. A report by the Chartered Society of Physiotherapy found that this population have poor access to rehabilitation as inpatients and in the community. A recent scoping review found a paucity of research in this area, indeed there has been no qualitative research undertaken with physiotherapists. In order to address this evidence gap, the aim of this current study was to explore the experiences of physiotherapists treating this population. METHODS: Semi-structured interviews with physiotherapists were undertaken in order to gain an in-depth understanding of how they manage this population. Physiotherapists were recruited from all over the UK and a purposive sampling strategy was employed. Thematic analysis was utilised. RESULTS: A total of 12 physiotherapists were interviewed, at which stage data saturation was reached as no new themes were emerging. The participants had a broad range of experience both in physical and mental health settings. Analysis identified three separate themes: challenges, "thinking outside the box" and realising potential. Physiotherapists felt significant pressures and challenges regarding many aspects of the management of this population. Mainly this was the result of pressures placed on them by guidelines and targets that may not be achievable or appropriate for those with dementia. The challenges and importance of risk taking was also highlighted for this population with an appreciation that standard treatment techniques may need adapting. "Rehabilitation potential" was highlighted as an important consideration, but challenging to determine. CONCLUSION: Interventions for the management of people with dementia and hip fracture need to consider that a traditional biomedical physiotherapy approach may not be the most appropriate approach to use with this population. However physiotherapists reported feeling pressurised to conform to a biomedical approach.

Perceptions of a good death: A qualitative study in intensive care units in England and Israel.

OBJECTIVES: To explore factors perceived to contribute to 'a good death' and the quality of end of life care in two countries with differing legal and cultural contexts. DESIGN AND METHODS: Multi-centre study consisting of focus group and individual interviews with intensive care nurses. Data were analysed using qualitative thematic analysis; emotional content was analysed using specialist linguistic software. SETTINGS/PARTICIPANTS: Fifty five Registered Nurses in intensive care units in Israel (n=4) and England (n=3), purposively sampled across age, ICU experience and seniority. FINDINGS: Four themes and eleven sub-themes were identified that were similar in both countries. Participants identified themes of: (i) timing of communication, (ii) accommodating individual behaviours, (iii) appropriate care environment and (iv) achieving closure, which they perceive prevent, and contribute to, a good death and good quality of end of life care. Emotional content showed significant amount of 'sadness talk' and 'discrepancy talk', using words such as 'could and 'should' when participants were talking about the actions of clinicians. CONCLUSIONS: The qualities of a good death were more similar than different across cultures and legal systems. Themes identified by participants may provide a framework for guiding end of life discussions in the intensive care unit.

Workplace abuse narratives from dentistry, nursing, pharmacy and physiotherapy students: a multi-school qualitative study.

INTRODUCTION: Previous healthcare student abuse research typically employs quantitative surveys that fail to explore contributory factors for abuse and students' action in the face of abuse. Following a recent qualitative study of medical students' abuse narratives, the current study explores dental, nursing, pharmacy and physiotherapy students' abuse narratives to better understand healthcare workplace abuse. METHODS: We conducted three individual and 11 group interviews with 69 healthcare students in three Universities to elicit professionalism dilemma narratives. Of 226 professionalism dilemmas elicited, 79 were coded as student abuse. Secondary-level thematic analysis of the abuse narratives addressed the following questions: What types of abuse experiences do healthcare students narrate? What factors do they cite as contributing to abuse and their responses to abuse? RESULTS: Healthcare students reported mostly covert abuse in their narratives. Although narrators described individual, relational, work and organisational factors contributing to abuse, they mostly cited factors relating to perpetrators. Most participants stated that they acted in the face of their abuse, and they mostly cited factors relating to themselves for acting. Students who did nothing in the face of abuse typically cited the perpetrator-recipient relationship as the main contributory factor. DISCUSSION: There are many similarities across the narratives of the five healthcare student groups, suggesting that complex interactional/organisational factors are all-important when considering how abuse is perpetuated within the healthcare workplace. Although some organisational factors may be difficult to change, we recommend that educational initiatives are a key starting point to tackle healthcare workplace abuse.

Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM).

OBJECTIVES: To define a set of indicators that could be used to improve quality in intensive care medicine. METHODOLOGY: An European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes. RESULTS: A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes. CONCLUSION: This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

Doing the right thing at the right time.

OBJECTIVE: To identify factors that clinicians consider when a patient is dying, enabling implementation of the Liverpool Care Pathway. BACKGROUND: In order to improve the care of the dying patient and their families it is helpful to implement the Liverpool Care Pathway for the dying. It therefore is necessary to identify the dying patient in a timely fashion. METHOD: A phenomenological study using semi-structured interviews (n=five nurses and five doctors) conducted on a hospice inpatient unit. FINDINGS: There was a prominent theme of anxiety about getting the timing of diagnosing dying right, with an emphasis how the dying patient and their families would cope if this were wrong. The main factors identified were: support for decision making, understanding the patient's journey and concern that the care given is appropriate. CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE: All clinicians interviewed for this study had concerns about increasing the patient's/carers' distress if the Liverpool Care Pathway implementation was mistimed. There is a risk that clinicians are avoiding difficult conversations with families and there may be a lack of understanding around the reasons for use of the Liverpool Care Pathway. Specific communications training may help clinicians in this role.

Qualitative research: specific designs for qualitative research in emergency care?

This article follows our description of generic qualitative approaches, focusing on the specific designs of ethnography, grounded theory and phenomenology. Distinguishing features are described, including methodological approaches and methods for enhancing rigour. The use of these designs in emergency care is unusual but informative, and important work has been produced. Whether used in a pure or applied manner, it is likely that such approaches will add to our understanding of the emergency world.

Stability in shifting sands: contemporary leadership roles in critical care.

BACKGROUND: Contemporary nursing leadership roles in critical care are a reflection of the changing environment in which critical care is provided. KEY ISSUES: In the UK, critical care nursing faces challenges in the form of: reduced number and seniority of medical staff cover for acute wards; mandated responsibility for management of patients outside of critical care units, without corresponding responsibility for managing staff; increased public and political awareness of deficits in critical care; increased use of Assistant Practitioners; and emphasis on longer-term outcomes from intensive care. EVALUATION: New leadership roles have met these challenges head on with two main foci: patient management across the acute/critical care interface and hospital wide policies and practice. CONCLUSIONS: The leadership roles examined in this paper highlight three underpinning goals: improved quality and safety of patient care; improved communication between professionals; and empowerment of junior nurses and doctors. IMPLICATIONS FOR NURSING MANAGEMENT: There has been considerable investment in strategic leadership roles for critical care nursing; evidence is developing of the return on this investment for patient and service outcomes. Consideration must now be given to the preparation, mentorship and development of leadership roles for the next generation of nurse leaders.

Generic qualitative research: a design for qualitative research in emergency care?

The frequency of qualitative studies in the Emergency Medicine Journal, while still low, has increased over the last few years. All take a generic approach and rarely conform to established qualitative approaches such as phenomenology, ethnography and grounded theory. This generic approach is no doubt selected for pragmatic reasons but can be weakened by a lack of rigor and understanding of qualitative research. This paper explores qualitative approaches and then focuses on "best practice" for generic qualitative research.

The impact of bispectral index monitoring on sedation administration in mechanically ventilated patients.

The aim of this prospective randomised controlled trial was to assess the effectiveness of the Bispectral Index (BIS) monitor in supporting clinical sedation management decisions in mechanically ventilated intensive care unit patients. Fifty adult mechanically ventilated surgical and general intensive care unit patients receiving sedative infusions of morphine and midazolam were randomly allocated to receive BIS monitoring (n=25) or standard sedation management (n=25). In the BIS group, sedation was titrated to maintain a BIS value of greater than 70. In the standard management group, sedative needs were titrated based on subjective assessment and clinical signs. There was no statistically significant difference in the amount of sedation administered (morphine P = 0.67 and midazolam P = 0.85). However, there was a statistically significant difference in sedation administration over time. Patients in the BIS group received increasing amounts of sedation over time whilst those in the control group received decreasing amounts of sedation over time. The same inverse relationship existed for both sedative agents (morphine P = 0.005, midazolam P = 0.03). Duration of mechanical ventilation was comparable in the two groups. We conclude that the use of BIS monitoring did not reduce the amount of sedation used, the length of mechanical ventilation time or the length of ICU stay.

Clinical research 1: Research questions and design.

This research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

Clinical research 2: Legal and ethical issues in research.

This research series is aimed at clinicians who wish to develop research skills, or who have a particular clinical problem that they think could be addressed through research. The series aims to provide insight into the decisions that researchers make in the course of their work, and to also provide a foundation for decisions that nurses may make in applying the findings of a study to practice in their own Unit or Department. The series emphasises the practical issues encountered when undertaking research in critical care settings; readers are encouraged to source research methodology textbooks for more detailed guidance on specific aspects of the research process.

The impact of an ICU liaison nurse on discharge delay in patients after prolonged ICU stay.

The mismatch between intensive care unit (ICU) bed availability and demand may be improved with timely patient discharges, however little is known about the nature and contributing factors of discharge delays. This study investigated the impact of a specific intervention--the ICU liaison nurse role--in reducing ICU discharge delay using a prospective block intervention study. One hundred and eighty-six ICUpatients (101 control and 85 liaison nurse intervention) with an ICU length of stay of three days or longer and who survived to ICU discharge were examined. The liaison nurse was involved in assessment of patients for transfer to the ward, with a major focus on coordinating patient transfer including liaison with ward staff prior to and following ICU discharge. Logistic regression was used to quantify the risk of discharge delay associated with the liaison nurse intervention with adjustment for potential confounding variables. While no demographic or clinical variables were significant predictors of ICU discharge delay, those in the liaison nurse group were almost three times less likely to experience a discharge delay of at least two hours and about 2.5 times less likely to experience a delay of four or more hours. The positive effect of the liaison nurse role in reducing the discharge delay remained after adjustingforpotential confounders. We conclude that the liaison nurse role is effective in reducing the discharge delay in ICU transfer

Balancing stakeholder needs: a review of ENB 100 and 415 courses. English National Board for Nursing, Midwifery and Health Visiting.

This paper reports the findings of a documentary analysis and literature review of general and paediatric intensive care unit (ICU) courses (ENB 100 and ENB 415). The findings are part of a larger review of critical care courses commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB), also incorporating operating department, coronary care and accident and emergency courses. It was important to set the curriculum review in the context of intensive care practice and education, hence the study also comprised interviews with lecturers and ICU managers. The study findings reveal diversity in major aspects of the critical care courses, including the academic level of the programmes and credits they attracted; the assessment strategies for theory and practice, the extent of shared learning and the amount of student effort. Many factors influenced this diversity including contrary opinion among stakeholders about the purpose of the course: to prime the students for working in the specialty; or to consolidate previous experience (in some cases up to 15 years). Course structure and content have changed in response to local university requirements and directives from the statutory bodies, as well as in response to the higher level of academic credit awarded for pre-registration programmes (qualification inflation). The perceived shift in course content as well as the diversity across programmes had led a group of ICU managers to define their own list of competencies (Crunden 1998). However, the majority of the managers interviewed for this study (63% of General ICU managers (n = 19) and 83% (n = 6) of Paediatric ICU managers) were generally satisfied with the competencies and skills of the nurses who had undertaken the ENB course. The authors conclude from the diverse nature of the courses that there is little national comparability in the courses although this finding might be an artefact of documentary analysis. The extent to which this (apparent) diversity results in different levels of competence in practice requires further exploration.

A formula for diversity: a review of critical care curricula.

This paper is based on a documentary analysis and literature review of critical care nursing commissioned by the English National Board for Nursing, Midwifery and Health Visiting. Five critical care programmes were included in the analysis: ENB 100, 124, 199, 176/183, and 415. In total, 105 curricula were reviewed from 30 institutions. Data were extracted and analysed using an adapted grounded theory approach. The documentary analysis was supplemented by two telephone surveys with lecturers (n = 84) and clinical managers (n = 81). There was great diversity in the programmes in terms of the academic level at which the courses were set, module configuration, approaches to practice assessment and the amount of student effort for the same professional award. Diversity arose because of different university module formulae, different methods to differentiate level 2 and level 3 practice, different views about the purpose of the course, and an attempt to make the programmes increasingly flexible to accommodate a heterogeneous student population. Documentary analysis has its limitations, and although the research team were able to check out issues with lecturers throughout the analysis, they were unable to capture the lived experience of the curriculum. A second study has been commissioned by the ENB to explore how these issues influence practice.