Lisa Salisbury

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number NIHR132068, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1111/jan.15773 Aim: To understand the experience of critical care nurses during the COVID-19 pandemic, through the application of the Job-Demand-Resource model of occupational stress. Design: Qualitative interview study. Methods: Twenty-eight critical care nurses (CCN) working in ICU in the UK NHS during the COVID-19 pandemic took part in semi-structured interviews between May 2021 and May 2022. Interviews were guided by the constructs of the Job-Demand Resource model. Data were analysed using framework analysis. Results: The most difficult job demands were the pace and amount, complexity, physical and emotional effort of their work. Prolonged high demands led to CCN experiencing emotional and physical exhaustion, burnout, post-traumatic stress symptoms and impaired sleep. Support from colleagues and supervisors was a core job resource. Sustained demands and impaired physical and psychological well-being had negative organizational consequences with CCN expressing increased intention to leave their role. Conclusions: The combination of high demands and reduced resources had negative impacts on the psychological well-being of nurses which is translating into increased consideration of leaving their profession. Implications for the Profession and/or Patient Care: The full impacts of the pandemic on the mental health of CCN are unlikely to resolve without appropriate interventions. Impact: Managers of healthcare systems should use these findings to inform: (i) the structure and organization of critical care workplaces so that they support staff to be well, and (ii) supportive interventions for staff who are carrying significant psychological distress as a result of working during and after the pandemic. These changes are required to improve staff recruitment and retention. Reporting Method: We used the COREQ guidelines for reporting qualitative studies. Patient and Public Contribution: Six CCN provided input to survey content and interview schedule. Two authors and members of the study team (T.S. and S.C.) worked in critical care during the pandemic. Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number NIHR132068. This article reports on one component of the research award Work-related stress: the Impact of COVID-19 on critical care and redeployed nurses. For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/NIHR132068] DOI: https://doi.org/10.1111/jan.15773

Objective: To use the job demands−resources model of occupational stress to quantify and explain the impact of working in critical care during the COVID-19 pandemic on nurses and their employing organisation. Design: Two-phase mixed methods: a cross-sectional survey (January 2021–March 2022), with comparator baseline data from April to October 2018 (critical care nurses only), and semistructured interviews. Participants: Critical care nurses (n = 461) and nurses redeployed to critical care (n = 200) who worked in the United Kingdom National Health Service (primarily Scotland) between January 2021 and March 2022. The 2018 survey was completed by 557 critical care nurses (Scotland only). Survey response rate in Scotland was 32% but could not be determined outside Scotland. Forty-four nurses were interviewed (critical care = 28, redeployed = 16). Methods: A survey measured job demands, job resources, health impairment, work engagement and organisational outcomes. Data were compared to 2018 data. Regression analyses identified predictors of health impairment, work engagement and organisational outcomes. Semistructured interviews were conducted remotely, audio-recorded and transcribed. Data were analysed deductively using framework analysis. Findings: Three-quarters of nurses reached threshold for psychological distress, approximately 50% reached threshold for burnout emotional exhaustion and a third clinically concerning post-traumatic stress symptoms. Compared to 2018, critical care nurses were at elevated risk of probable psychological distress, odds ratio 6.03 (95% CI 4.75 to 7.95); burnout emotional exhaustion, odds ratio 4.02 (3.07 to 5.26); burnout depersonalisation, odds ratio 3.18 (1.99 to 5.07); burnout accomplishment, odds ratio 1.53 (1.18 to 1.97). There were no differences between critical care and redeployed nurses on health impairment outcomes, suggesting elevated risk would apply to redeployed nurses. Job demands increased and resources decreased during the pandemic. Higher job demands predicted greater psychological distress. Job resources reduced the negative impact of job demands on psychological distress, but this moderating effect was not observed at higher levels of demand. All organisational outcomes worsened. Lack of resources predicted worse organisational outcomes. In interviews, staff described the pace and amount, complexity, physical and emotional effort of their work as the most difficult job demands. The sustained high-demand environment impacted physical and psychological well-being, with most interviewees experiencing emotional and physical exhaustion, burnout, and symptoms of post-traumatic stress disorder. Camaraderie and support from colleagues and supervisors were core job resources. The combination of sustained demands and their impact on staff well-being incurred negative organisational consequences, with increasing numbers considering leaving their specialty or nursing altogether. Dissemination events with a range of stakeholders, including study participants, identified staffing issues and lack of learning and development opportunities as problematic. Critical care nurses are concerned about the future delivery of high-quality critical care services. Positive aspects were identified, for example, reduced bureaucratic systems, increased local autonomy and decision-making, recognition of the critical care nurse skill set. Conclusions: The National Health Service needs to recognise the impact of COVID-19 on this staff group, prioritise the welfare of critical care nurses, implement workplace change/planning, and support them to recover from the pandemic. The National Health Service is struggling to retain critical care nurses and, unless staff welfare is improved, quality of care and patient safety will likely decline. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132068.

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature. Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies. Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation. This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.

Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery. This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool. We anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery. PROSPERO CRD42015001068 .

Introduction: Mobilisation of patients in the intensive care unit (ICU) is an area of growing research. Currently, there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses. Methods: The objectives of the study were to (1) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs, (2) compare mobilisation practises between Australian and Scottish ICUs and (3) identify barriers to mobilisation in Australian and Scottish ICUs. We conducted a prospective, observational, cohort study with a 4-week inception period. Patients were censored for follow-up upon ICU discharge or after 28 days, whichever occurred first. Patients were included if they were >18 years of age, admitted to an ICU and received mechanical ventilation in the ICU. Results: Ten tertiary ICUs in Australia and nine in Scotland participated in the study. The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery (43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery. In total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay (p < 0.001). Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence interval 1.38–2.42). However, the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts. Physiological instability and the presence of an endotracheal tube were also frequently reported barriers. Conclusions: This is the first study to benchmark baseline practise of early mobilisation internationally, and it demonstrates variation in early mobilisation practises between Australia and Scotland.

Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established. To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid SP MEDLINE, Ovid SP EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host to 15 May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015 and will deal with the three studies of interest when we update the review. We included randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) that compared an exercise intervention initiated after ICU discharge versus any other intervention or a control or 'usual care' programme in adult (≥ 18 years) survivors of critical illness. We used standard methodological procedures as expected by the Cochrane Collaboration. We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both on the ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to length of hospital stay following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. For other domains, at least half of the studies were at low risk of bias. One study was at high risk of selection bias, attrition bias and other sources of bias. Risk of bias was unclear for the remaining studies across domains. We decided not to undertake a meta-analysis because of variation in study design, types of interventions and outcome measurements. We present a narrative description of individual studies for each outcome.All six studies assessed functional exercise capacity, although we noted wide variability in the nature of interventions, outcome measures and associated metrics and data reporting. Overall quality of the evidence was very low. Individually, three studies reported positive results in favour of the intervention. One study found a small short-term benefit in anaerobic threshold (mean difference (MD) 1.8 mL O2/kg/min, 95% confidence interval (CI) 0.4 to 3.2; P value = 0.02). In a second study, both incremental (MD 4.7, 95% CI 1.69 to 7.75 watts; P value = 0.003) and endurance (MD 4.12, 95% CI 0.68 to 7.56 minutes; P value = 0.021) exercise testing results were improved with intervention. Finally self reported physical function increased significantly following use of a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability was evident with regard to findings for the primary outcome of health-related quality of life. Only two studies evaluated this outcome. Individually, neither study reported differences between intervention and control groups for health-related quality of life due to the intervention. Overall quality of the evidence was very low.Four studies reported rates of withdrawal, which ranged from 0% to 26.5% in control groups, and from 8.2% to 27.6% in intervention groups. The quality of evidence for the effect of the intervention on withdrawal was low. Very low-quality evidence showed rates of adherence with the intervention. Mortality ranging from 0% to 18.8% was reported by all studies. The quality of evidence for the effect of the intervention on mortality was low. Loss to follow-up, as reported in all studies, ranged from 0% to 14% in control groups, and from 0% to 12.5% in intervention groups, with low quality of evidence. Only one non-mortality adverse event was reported across all participants in all studies (a minor musculoskeletal injury), and the quality of the evidence was low. At this time, we are unable to determine an overall effect on functional exercise capacity, or on health-related quality of life, of an exercise-based intervention initiated after ICU discharge for survivors of critical illness. Meta-analysis of findings was not appropriate because the number of studies and the quantity of data were insufficient. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others did not. No effect on health-related quality of life was reported. Methodological rigour was lacking across several domains, influencing the quality of the evidence. Wide...

Patients surviving critical illness frequently experience disabilities, poor health-related quality of life (HRQOL), and reduced ability to undertake activities of daily living.^1,2 Observational studies indicate high levels of fatigue, muscle weakness, and other symptoms that may contribute to delayed recovery.^1,3 Cognitive impairment, depression, anxiety, and posttraumatic stress are also prevalent.^4-6 Although patients are often older or have preexisting comorbidity,⁷ many were previously fit and of working age. The long-term costs of critical illness at individual, family, and societal levels are high.^8,9

Background: The present qualitative study aimed to explore the factors influencing nutritional recovery in patients after critical illness and to develop a model of care to improve current management of nutrition for this patient group.Methods: Patients were recruited into the study on discharge from a general intensive care unit (ICU) of a large teaching hospital in central Scotland. Semi‐structured interviews were carried out after discharge from the ICU, weekly for the duration of their ward stay, and at 3 months post ICU discharge. Observations of ward practice were undertaken thrice weekly for the duration of the ward stay.Results: Seventeen patients were recruited into the study and, using a grounded theory approach, ‘inter‐related system breakdowns during the nutritional recovery process’ emerged as the overarching core category that influenced patients’ experiences of eating after critical illness. This encompassed the categories, ‘experiencing a dysfunctional body’, ‘experiencing socio‐cultural changes in relation to eating’ and ‘encountering nutritional care delivery failures’.Conclusions: The findings from the present study provide a unique contribution to knowledge by offering important insights into patients’ experiences of eating after critical illness. The study has identified numerous nutritional problems and raises questions about the efficacy of current nutritional management in this patient group. Adopting a more individualised approach to nutritional care could ameliorate the nutritional issues experienced by post ICU patients. This will be evaluated in future work.