A workforce survey of critical care nurses in the National Health Service.

AIM: To measure key aspects of the critical care nursing workforce across the National Health Service (NHS) and compare these with recommended standards where they exist. BACKGROUND: The provision of high-quality and safe critical care services is dependent on adequate numbers of highly skilled nurses. Understanding the issues and challenges within critical care services across the NHS is key to future planning and policy in this area. DESIGN: A stakeholder-driven consensus development approach was adopted to design a workforce survey by members of the Critical Care National Network Nurse Leads (CC3N) Forum. METHODS: The survey was conducted across all the critical care units in England, Northern Ireland, Wales, and Scotland. Data were collated to enable presentation of descriptive statistics. RESULTS: Data returns were received from 240 of the 272 units in England and Northern Ireland. Scotland and Wales data were excluded from analysis and reporting. Differences in the sample and data returns limited comparison with the previous survey in some aspects. Stability was seen in vacancy and sickness rates. Improvements were seen in safe nurse: patient ratios, supernumerary "nurse in charge," critical care outreach service cover, use of national competency framework, and agency use. Dependency on overseas nurses in some units remains high. Specialist critical care training levels in many units do not meet current required standards. CONCLUSION: Clear improvements have been made. There is significant stability. Some challenges remain. Continued review of resource allocation is important in the coming years, as is policy and strategy to ensure recruitment, appropriate training, and support for staff well-being. RELEVANCE TO CLINICAL PRACTICE: The reader will gain insight into the critical care nursing workforce in the NHS in England and Northern Ireland. The results are useful for nurses, nurse managers, and policymakers.

Reducing ventilator associated pneumonia in adult patients through high standards of oral care: a historical control study.

OBJECTIVES: Implement and evaluate the impact of oral hygiene measures (teeth brushing, 1% oral chlorhexidine and oropharyngeal suction) on the incidence of ventilator-associated pneumonia (VAP) and the costs of prevention and treatment. DESIGN: A historical control study of all 1087 patients, mechanically ventilated for at least 48hours in a general adult critical care unit, between July 2009 and December 2011. The incidence of VAP in 528 patients before a practice change was compared with the incidence in 559 patients after a practice change. The clinical audit cycle was used to review compliance with existing standards and implement a regime of enhanced oral hygiene. The costs of changing the oral care regime and the treatment of VAP with antibiotics was calculated. SETTING: 22 bed combined intensive care and high dependency unit in England. MAIN OUTCOME MEASURES: (1) Compliance with standards for oral care. (2) The incidence of VAP before and after the change. RESULTS: 91% (95% CI 90-93%) compliance with the standards for oral care was achieved throughout the 30 months of the study with very little difference before (90%, 95% CI 88-93%) and after (92%, 95% CI 90-95%) the changes in oral care standards were introduced. Of 528 patients mechanically ventilated for at least 48 hours before the change, 47 developed VAP. The mean incidence of VAP was 0.09 (8.9%) (95% CI 0.07-0.12). The mean VAP per 1000 ventilator days was 13.6 (95% CI 13.1-14.0). After the change 24 of 559 patients developed VAP. The mean incidence of VAP after the change was 0.04 (4.1%) (95% CI 0.03-0.06). The mean VAP per 1000 ventilator days was 6.9 (95% CI 6.5-7.1). There was a £6319 ($10,112, €7518) cost saving on preventing and treating VAP following the practice change. A statistically significant difference (p<0.01) was seen between the incidence of VAP expected and that observed after the change in oral care. This represents a relative risk reduction of 0.53 (95% CI 0.25-0.71) and number needed to treat (NNT) of 21. CONCLUSION: An enhanced oral care bundle, incorporating 1% Chlorhexidine Gluconate, was associated with a significant reduction in VAP and the costs of treating VAP. Limitations of the study relate to analysis of other variables, in particular severity of illness, between the two groups and the lack of agreement in the literature on VAP criteria, which limits generalisation of these findings.

A critical review and synthesis of qualitative research on patient experiences of critical illness.

AIMS: To critically review the literature in order to describe the themes associated with the experience of critical illness and consider how these inform the patients understanding. BACKGROUND: Critical illness requires life-saving intervention and application of high technology medicine and intensive nursing within a specialist critical care unit. Whilst an extensive and rapidly advancing knowledge of the physiological basis for treating critical illness exists, understanding how critical illness is experienced by the patient is less well understood. DATA SOURCES: Literature was retrieved through systematic searching of electronic databases, hand searches of journals and incremental searching. REVIEW METHODS: 26 qualitative studies of firsthand experiences of adult patients who had been in a critical care unit were reviewed. Key, common, explicit themes between the studies were identified as well as implicit themes that emerged through preliminary synthesis. RESULTS: Eight common explicit themes were identified. These included: Transformations of perception: Unreal experiences and dreams; Proximity to death; Transformation and perception of the body in illness; Transformation and perception of time; The critical care environment: technology and dependence; Care, communication and relationships with healthcare professionals; The support of family and friends and desire for contact; Transfer from critical care and recovery from critical illness. A further two implicit themes related to the primacy of the critical care unit within the studies; and the focus of recall or personal meaning which divided the literature. CONCLUSION: The explicit themes highlight the steps taken by researchers to understand what is salient about the critical care experience for those who have been critically ill. Future research exploring the whole illness-recovery trajectory and the way personal meaning contributes to understanding life experiences is justified.

Developing and evaluating critical care follow-up.

The effects of critical illness not only affect the patient and relative during the intensive care stay but often affect for a considerable time afterwards. A growing body of opinion and evidence suggests that many of the needs of those who have been critically ill can be met through critical care follow-up services. A growing number of follow-up services now exist. Their establishment, development and evaluation pose significant challenges for those involved. This paper describes Bassetlaw hospital's critical care follow-up service, how it was established and what an elementary service evaluation project has shown. The findings and experiences are compared with others in published literature, and the paper may be of interest to those who are currently involved in follow-up or who plan to develop such services in the future.

From ward-based critical care to educational curriculum 2: a focussed ethnographic case study.

The earlier published literature review (Part 1) identified the limits of our current understanding of the context of ward-based critical care nursing. Critical care curriculum for acute ward nurses, which will have to develop as part of meeting the mandates for 'training' outlined in Comprehensive Critical Care [Comprehensive Critical Care: a Review of Adult Critical Care Services (2000) Department of Health], will benefit from greater understanding of the culture and context of ward-based critical care nursing. In this, Part 2, the methods and findings of a focussed ethnographic case study are presented. The study explored, in depth, the culture and context of ward-based critical care in one acute surgical ward. Seven nurses were interviewed about their experiences of caring for critically ill ward patients. The data were analysed with a view to exploring what knowledge and skills were 'compatible' with the nurses' perceived role and the 'practical applicability' and 'relative advantage' of such knowledge for these practitioners. The context of ward care was found to be busy and contradictory for the nurses. The concepts central to this study; 'compatibility', 'practical applicability' and 'relative advantage' [Communication of Innovations (1971) The Free Press] were found to be complex concepts when studied in relation to real life clinical practice.

From ward-based critical care to educational curriculum 1: a literature review.

There has been recent recognition in the literature, and a longer standing awareness amongst clinicians, that critically ill patients are to be found outside of intensive care units. These patients are not always well managed and some have concluded that their care is 'suboptimal' [Br. Med. J. 316 (1998) 1853] and that they die of preventable clinical problems [Extremes of Age: the 1999 Report of the National Confidential Enquiry into Perioperative Deaths (1999) NCEPOD]. Whilst the cause of this situation in the NHS probably involves a complex interplay of factors including failures in management, policy and the evidence/information base for practice, education failures have also been blamed. In response the government has mandated formal critical care education for ward nurses [Comprehensive Critical Care: a Review of Adult Critical Care Services (2000) Department of Health]. In this two-part paper, the literature around education for ward-based critical care is examined (Part 1) prior to a report of the findings (Part 2) of a case study exploring the everyday practices, context and culture of an acute surgical ward where seriously ill patients were cared for prior to the introduction of a critical care outreach service (Part 2). Implications for practice, education and future research are discussed.