'You can't walk through water without getting wet' UK nurses' distress and psychological health needs during the Covid-19 pandemic: A longitudinal interview study.

BACKGROUND: Pre-COVID-19 research highlighted the nursing profession worldwide as being at high risk from symptoms of burnout, post-traumatic stress disorder (PTSD) and suicide. The World Health Organization declared a pandemic on 11th March 2020 due to the sustained risk of further global spread of COVID-19. The high healthcare burden associated with COVID-19 has increased nurses' trauma and workload, thereby exacerbating pressure on an already strained workforce and causing additional psychological distress for staff. OBJECTIVES: The Impact of COVID-19 on Nurses (ICON) interview study examined the impacts of the pandemic on frontline nursing staff's psychosocial and emotional wellbeing. DESIGN: Longitudinal qualitative interview study. SETTINGS: Nurses who had completed time 1 and 2 of the ICON survey were sampled to include a range of UK work settings including acute, primary and community care and care homes. Interviewees were purposively sampled for maximum variation to cover a broad range of personal and professional factors, and experiences during the COVID-19 pandemic, including redeployment. METHODS: Nurses participated in qualitative in-depth narrative interviews after the first wave of COVID-19 in July 2020 (n = 27) and again at the beginning of the second wave in December 2020 (n = 25) via video and audio platform software. Rigorous qualitative narrative analysis was undertaken both cross-sectionally (within wave) and longitudinally (cross wave) to explore issues of consistency and change. RESULTS: The terms moral distress, compassion fatigue, burnout and PTSD describe the emotional states reported by the majority of interviewees leading many to consider leaving the profession. Causes of this identified included care delivery challenges; insufficient staff and training; PPE challenges and frustrations. Four themes were identified: (1) 'Deathscapes' and impoverished care (2) Systemic challenges and self-preservation (3) Emotional exhaustion and (4) (Un)helpful support. CONCLUSIONS: Nurses have been deeply affected by what they have experienced and report being forever altered with the impacts of COVID-19 persisting and deeply felt. There is an urgent need to tackle stigma to create a psychologically safe working environment and for a national COVID-19 nursing workforce recovery strategy to help restore nurse's well-being and demonstrate a valuing of the nursing workforce and therefore support retention.

Realist evaluation of Schwartz rounds® for enhancing the delivery of compassionate healthcare: understanding how they work, for whom, and in what contexts.

BACKGROUND: Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds 'work' to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. METHODS: Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings. RESULTS: Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a 'slow intervention' the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change. CONCLUSIONS: Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.

Nursing work and sensory experiences of hospital design: A before and after qualitative study following a move to all-single room inpatient accommodation.

The embodied experience of nursing practice is rarely studied. Drawing on data from an internationally relevant larger study conducted in 2013-14, here we explore the sensory dimension of the embodied experiences of nursing staff working on two acute NHS hospital wards before and after a move to all-single room inpatient accommodation. We undertook a secondary analysis of 25 interviews with nursing staff (12 before and 13 after the move with half [13/25] using photographs taken by participants) from a mixed-method before-and-after study. This analysis focused on the sensory dimensions of nursing staff's experiences of their working practices and the effect of the built environment upon these. Drawing on Pallasmaa's theoretocal insights, we report how the all-single room ward design prioritises 'focused vision' and hinders peripheral perception, whilst the open ward environment is rich in contextual and preconscious information. We suggest all-single room accommodation may offer staff an impoverished experience of caring for patients and of working with each other.

Health promotion: perceptions of Project 2000 educated nurses.

The new approach to pre-registration nursing education in the UK (Project 2000) has an overt health focus as well as a specific remit to prepare nurses for a role as promoters of health. Data reported in this paper illuminate Project 2000 students' understanding of the concepts of health promotion and health education, and indicate the extent to which qualified nurses who have completed this new Project 2000 programme perceive themselves to be prepared for a health promotion role. Findings indicate that students are confused about the terms health education and health promotion, although most feel there is a distinction between the two. Students' descriptions emphasize individualistic approaches, and lifestyle and behaviour changes. Many recognize that health promotion should have a broader application and demonstrate a sophisticated grasp of the philosophy underpinning the promotion of health through their general perceptions of nursing. This understanding is not labelled health education or health promotion, but is embedded in their articulation of concepts such as holism, patient-centred care and enhancing independence. Paradoxically, both students and Project 2000 qualified nurses (diplomates) illustrate a clear grasp of the more complex issues surrounding the concept of health promotion while remaining confused by the terminology and its relationship to practice.

Project 2000 diplomates' perceptions of their experiences of transition from student to staff nurse.

This paper presents findings from an exploratory study of the transition experiences of newly qualified Project 2000 diplomates. A qualitative approach was utilized involving in-depth interactive interviews with a sample of 10 staff nurses. The data indicate that some aspects of transition were initially difficult, but that all those interviewed were enjoying nursing. Similarities to the experiences of 'traditionally prepared' colleagues are highlighted by the use of phrases such as 'in at the deep end' and 'cast adrift', reflecting the practice environment once qualified. Paradoxically initial transition for Project 2000 diplomates is characterized by a lack of confidence, while their questioning approach to practice and a willingness to ask others when unsure ('no bluffing') suggests a high degree of confidence. Preceptorship in the context of a supportive environment is suggested as a model for easing the transition process. A re-evaluation of what an initial preparation course can and should achieve, and a re-assessment of the skills and knowledge expected of newly qualified nurses, are also indicated.

Project 2000. Perception of the philosophy and practice of nursing: preparation for practice.

As part of a comprehensive study of perceptions of the philosophy and practice of nursing Project 2000 students and newly qualified diplomates were asked to reflect on their Project 2000 course as a preparation for professional practice. Data were collected from both students and diplomates through self-completion questionnaires and a small number of interviews with diplomates in two study centres, one in the north and the other in the south of England. Nurse managers and G grade practitioners were invited in focus group interviews to discuss the Project 2000 preparation and assess the diplomates 'fitness for purpose'. Findings suggest that the majority of students and diplomates acknowledged that the course had prepared them well. They acknowledged the importance of the inter-personal skills component of the course, together with the life sciences input. The diplomates particularly valued the theoretical aspect of the course, being well versed in research and keen to continue their learning. Perceived limitations of the course were the management preparation and course organization. Practical skill deficits were perceived as initial skills deficits only. Managers and practitioners were keen to employ the diplomates, whilst acknowledging their need for support and preceptorship. Three important issues for nursing and nurse education are discussed, including the balance of the Project 2000 course, preceptorship and support, and preparation for a role in the community.

The impact of Project 2000.

The research study described here was commissioned by the English National Board to examine nursing in the context of Project 2000 implementation. The research team explored the impact of Project 2000 on students, managers and practitioners. Students and diplomates were perceived to be patient-oriented and holistic in approach; basic nursing care was identified as a central role of qualified nurses. Perceptions of nursing shifted as the course progressed to include health promotion, and research and theory as a basis for practice. Aspects of the course valued by students included the broader academic input, interpersonal skills, life sciences, supernumerary status and the challenging approach advocated by the course. Students were concerned about the timing of the biological science modules, which often did not coincide with their practice experiences. Students identified poor course organisation and poor teaching skills of some lecturers as areas for concern. Managers and practitioners identified students as potential agents of change who challenged traditional expectations of newly qualified nurses.

Project 2000: perceptions of the philosophy and practice of nursing: shifting perceptions--a new practitioner?

This is the first of two papers which address aspects of the findings of a large scale study commissioned by the English National Board which set out to examine the impact of Project 2000 on perceptions of the philosophy and practice of nursing. The findings presented here suggest that there have been fundamental shifts in perceptions of the nature and discipline of nursing. Students and diplomates of the course perceive themselves as knowledgeable doers, with their practice well grounded in theory and research. They value the interpersonal skills teaching and place the patient firmly at the centre of care delivery, viewing the patient holistically and being prepared to be fierce patient advocates where necessary. It is difficult to determine the extent to which these shifts can be attributed to the Project 2000 course, although the Project 2000 approach to education appears to be an important factor.

Preceptorship and support for staff: the good and the bad.

In this article the support received by 10 diplomates when starting their staff nurse posts is examined. In particular the potential role of preceptorship in facilitating a smooth transition is highlighted. This is the second of two articles, the first of which appeared in Nursing Times on October 30.

Making the transition from student to staff nurse.

Project 2000 was designed to provide a nursing workforce equipped with the flexibility and skills to adapt to changes in health care. This qualitative study explored how 10 diplomates fared after qualification. The findings, as part of a larger study, question what should be expected of newly qualified staff and the support they receive. Like traditionally trained nurses, they experienced the shock of increased responsibility, but they also faced negative attitudes because of their preparation. Despite a self-perceived lack of confidence, their willingness to question themselves and others suggests self-confident practitioners. A second paper, exploring the professional support of newly qualified staff, will appear later.

Health promotion: a concept analysis.

Health promotion is a concept which is frequently used, but is often ill defined. Current health care trends, and the emphasis on the nurse of the future as a promoter of health suggest that it would be useful to attempt to clarify the concept. This paper develops a conceptual analysis of health promotion using the process developed by Rodgers (1989). Attributes, antecedents, consequences and references are described following an examination of the ongoing debate in the literature surrounding the meaning of the concept. Empirical work is also reviewed which suggests that nurses' understandings of the concept are firmly embedded in the more traditional approach rather than the more modern or new paradigm approach to health promotion. A model case is described, and the analysis results in a proposed definition of health promotion which it is hoped will stimulate further discussion.

Perceptions and practice of health education and heath promotion in acute ward settings.

This paper reports on an overview of the findings from a two-year Department of Health-funded research project. The study had two overall aims: to describe the extent to which health education and health promotion had become integrated into nurses' practice in acute-care settings and to identify the facilitative and inhibitory factors involved. The study comprised separate sequential stages of data collection and utilised a multi-method approach. Findings from a survey of ward sisters and from ward-based case studies are presented and discussed. These suggest that nurses have yet to fulfill their potential as educators and promoters of health and that a number of influences interact at ward level to encourage or impede the development of this role.

Health education in nursing: perceptions of practice in acute settings.

A postal questionnaire survey design was utilized to establish a national overview of perceptions of health education practice in general acute ward settings. Questionnaires were sent to individuals identified as the most senior nurse within each district health authority in England (n = 195). Respondents were asked to specify--with the help of their nursing teams--the progress made on wards within their respective district health authorities in relation to a range of health education activities. A response rate of 73% (n = 142) was achieved. The majority of responses reflected the perceptions of senior nurse managers or their deputies. The data showed that respondents felt health education activities generally are a feature of nursing practice on acute wards. However, on the majority of wards, they were seen as only partially included into some areas of nursing practice. On only a small proportion (4%) of wards was health education of any type reported not to be a feature of practice. Of the five specific health education areas explored in the questionnaire, 'patient education' and 'information-giving' were felt to be occurring on a significantly greater number of wards and significantly more frequently than 'encouraging patients and their families to participate in care'. Data analysis also showed that all the activities specified--that is, patient education, information-giving, healthy lifestyle advice and encouraging patient and family participation in care--were positively correlated.