Dr Louise Stayt

Aim: This systematic integrative literature review explores how clinicians make decisions for patient management plans in telehealth.

Background: Telehealth is a modality of care that has gained popularity due to digital technology development and the COVID-19 pandemic. It is recognised that telehealth, compared to traditional clinical settings, carries a higher risk to patients due to its virtual characteristics. Even though the landscape of healthcare service is increasingly moving towards virtual systems, the decision-making process in telehealth remains not fully understood.

Design: A systematic integrative review.

Data Sources: Databases include CINAHL, APA PsycInfo, Academic Search Complete, Pubmed, Web of Science, and Google Scholar.

Review Methods: This systematic integrative review method was informed by Whittemore and Knafl (2005).  The databases were searched with keywords initially in November 2022 and then repeated in October 2023. Thematic synthesis was conducted to analyse and synthesise the data.

Results: The search identified 382 articles. After screening, only 10 articles met the eligibility criteria and were included.  5 studies were qualitative, 1 quantitative and 4 were mixed method.  Five main themes that are relevant to decision-making processes in telehealth were identified: characteristics of decision-making in telehealth, patient factor, clinician factor, CDSS factor, and external influencing factor.

Conclusions:  The decision-making process in telehealth is a complicated cognitive process that is influenced by multi-faceted components, including patient factors, clinician factors, external influencing factors and technological factors.

Impact: Telehealth carries higher risk and uncertainty than face-to-face encounters. CDSS, rather than bringing unification and clarity, seems to bring more divergence and ambiguity. Some of the clinical reasoning processes in telehealth remain unknown and need to be verbalised and made transparent, to prepare junior clinicians with skills to minimise risks associated with telehealth. 

Patient or Public Contribution: Not Applicable

Keywords: Decision-making, patient management plan, telehealth

Purpose: Fatigue is a common and debilitating problem in patients recovering from critical illness. To address a lack of evidence-based interventions for people with fatigue after critical illness, we co-produced a self-management intervention based on self-regulation theory. This article reports the development and initial user testing of the co-produced intervention.

Methods: We conducted three workshops with people experiencing fatigue after critical illness, family members, and healthcare professionals to develop a first draft of the FACT intervention, designed in web and electronic document formats. User testing and interviews were conducted with four people with fatigue after critical illness. Modifications were made based on the findings.

Results: Participants found FACT acceptable and easy to use, and the content provided useful strategies to manage fatigue. The final draft intervention includes four key topics: (1) about fatigue which discusses the common characteristics of fatigue after critical illness; (2) managing your energy with the 5 Ps (priorities, pacing, planning, permission, position); (3) strategies for everyday life (covering physical activity; home life; leisure and relationships; work, study, and finances; thoughts and feelings; sleep and eating); and (4) goal setting and making plans. All material is presented as written text, videos, and supplementary infographics. FACT includes calls with a facilitator but can also be used independently.

Conclusions: FACT is a theory driven intervention co-produced by patient, carer and clinical stakeholders and is based on contemporary available evidence. Its development illustrates the benefits of stakeholder involvement to ensure interventions are informed by user needs. Further testing is needed to establish the feasibility and acceptability of FACT.

Implications for clinical practice: The FACT intervention shows promise as a self-management tool for people with fatigue after critical illness. It has the potential to provide education and strategies to patients at the point of discharge and follow-up.

Keywords

Critical illness; fatigue; self-management; self-regulation 

Background: The importance of good oral hygiene for patients in Intensive Care Units (ICUs) is well recognised, however, the most effective way to achieve good oral care in the ICU is unclear.

Aim: The aim of this study was to provide a national picture of oral care practices in adult ICUs in the United Kingdom (UK) to identify areas for improvement.

Study Design: A national one-day point prevalence study was undertaken in adult ICUs in the UK in the period from 30th September to 14th October 2021. Data were collected on all patients in the ICU on the date of data collection. Using a validated electronic data collection form, anonymised data were collected on methods and frequency of oral care provided, and the use of oral care protocols within the ICU. Data were analysed using descriptive analysis.

Results: Data from 195 patients in 15 ICUs in England, Wales and Northern Ireland were collected. Written oral care protocols were available for use in the care of 65% (n=127) of patients. 73% (n=142) of patients received oral care within the 24-hour period. Oral care methods included toothbrushing 41% (n=79), foam sticks 3% (n=5), moisturising the oral cavity 10% (n=19) and mouth rinse with chlorhexidine 3% (n=5) and other oral care methods not specified 12% (n=23).   44% (n=85) of patients had an oral assessment within the 24-hour period and variable assessment methods were used.

Conclusion: There is large variability in oral care provision and methods for intubated ICU patients and a lack of consensus was revealed in the study. Oral assessment is conducted less frequently using multiple tools.  Optimal oral care standards and further research into oral care provision is pivotal to address this important patient-relevant practice.

Relevance to Clinical Practice: Oral care is a fundamental part of care for ICU patients, however, there is a large degree of variability, and oral care is often not based upon oral assessment. The use of an oral care protocol and oral assessments would help to improve patient care, ease of use for staff and provide a tailored oral care plan for patients, improving efficiency and preventing wasted resources.

Purpose: Fatigue is a common symptom after critical illness. However, evidence-based interventions for fatigue after critical illness are lacking. We aimed to identify interventions to support self-management of fatigue caused by physical conditions and assess their effectiveness and suitability for adaptation for those with fatigue after critical illness.

Materials and methods: We conducted an umbrella review of systematic reviews. Databases included CINAHL, PubMed, Medline, PsycINFO, British Nursing Index (BNI), Web of Science, Cochrane Database of Systematic Reviews (CDSR), JBI Evidence Synthesis Database, and PROSPERO register. Included reviews were appraised using the JBI Checklist for Systematic Reviews and Research Syntheses. Results were summarised narratively.

Results: Of the 672 abstracts identified, 10 met the inclusion criteria. Reviews focused on cancer (n=8), post-viral fatigue (n=1), and Systemic Lupus Erythematosus (SLE) (n=1). Primary studies often did not address core elements of self-management. Positive outcomes were reported across all reviews, and interventions involving facilitator support appeared to be most effective.

Conclusions: Self-management can be effective at reducing fatigue symptoms and improving quality of life for physical conditions and has clear potential for supporting people with fatigue after critical illness, but more conclusive data on effectiveness and clearer definitions of self-management are required.

Aim 

Blood pressure guidelines have undergone multiple revisions in accordance with updated science. Understanding patients’ hypertension symptoms can assist healthcare professionals’ awareness of individual, cultural, and behavioural responses and improve diagnostic accuracy to optimize treatment. Therefore, the purpose of this review was to evaluate and synthesize current literature exploring symptoms experienced by patients with hypertension. 

Methods 

Databases searched included MEDLINE® (PubMed®), CINAHL® (EBSCO), Scopus, and Web of Science™ from January 2010 to January 2022 for studies with reported hypertension symptoms.  The search followed the PRISMA guidelines.  The McMaster critical review forms were used to determine quality of both qualitative and quantitative articles. Synthesis of the data was guided by the Joanna Briggs Institute Convergent Integrated Approach to Mixed Study Systematic Reviews. 

Results 

Forty-one articles were included in the review, including nine qualitative studies and thirty-two quantitative.  Quality of the articles varied. Symptoms included commonly reported symptoms and some less prevalent, including some reporting absence of symptoms. Factors that affected symptoms included culture, beliefs, psychosocial factors and knowledge. We also found that there may be a bidirectional relationship with symptoms and behaviours that may lead to self-management. 

Conclusion 

Hypertension is common and symptoms are frequently reported. Hypertension management is related to multiple factors. Symptoms continue in a number of individuals after initial diagnosis. Evaluating symptoms after initial diagnosis may help to optimally manage and meet BP guidelines.  

Keywords: hypertension, symptoms, mixed methods review, systematic review 

Background: Since the start of the global COVID-19 pandemic in 2019, critical care nurses across the world have been working under extreme levels of pressure.

Aim: To understand critical care nurses’ experiences of and satisfaction with their role in the pandemic response across the United Kingdom (UK).

Study design: A cross sectional electronic survey of critical care nurses (n=339) registered as members of the British Association of Critical Care Nurses. Anonymous quantitative and open-ended question data were collected in March and April 2021 during the height of the second surge of COVID-19 in the UK via an online questionnaire. Quantitative data were analysed using descriptive statistics and free text responses were collated and analysed thematically.

Results: There was a response rate of 17.5%. Critical care nurses derived great satisfaction from making a difference during this global crisis and greatly valued teamwork and support from senior nurses. However, nurses consistently expressed concern over the quality of safe patient care, which they perceived to be suboptimal due to staff shortages and a dilution of the specialist skill mix. Together with the high volume of patient deaths, critical care nurses reported that these stressors influenced their personal wellbeing.

Conclusions: This study provides insights into the key lessons health care leaders must consider when managing the response to the demands and challenges of the ongoing COVID-19 pandemic. COVID-19 is unpredictable in its course, and what future variants might mean in terms of transmissibility, severity, and resultant pressures to critical care remains unknown.

Relevance to clinical practice: Future responses to the challenges that critical care faces must consider nurses’ experiences and create an environment that engenders supportive teamwork, facilitates excellent nursing practice and effective safe patient care where critical care nursing may thrive.

Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19.Design: A qualitative interview study informed by constructivism.

Method: Semi-    structured interviews were conducted and audio- recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework.

Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short-  and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer 

Support.

Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an under-standing of the holistic and long-term impacts on patient safety and recovery from critical illness.

Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing work-force modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals.

Aims: To explore adult experiences of fatigue after discharge from an intensive care unit and to identify potential management strategies.

Design: An exploratory qualitative study

Methods: One to one audio-recorded semi-structured interviews with 17 adult survivors of critical illness in the United Kingdom, lasting up to one hour, between September 2019 and January 2020. Anonymised and verbatim-transcribed interview data underwent a standard process of inductive thematic analysis as described by Braun and Clarke.

Findings: Three themes were identified: fatigue is different for everyone; complex interrelating interactions; and personalised fatigue strategies. Fatigue was described as a distressing symptom, unique to the individual that causes an array of complex, often long-term interrelating impacts on the survivor and their wider family, made worse by a lack of understanding, empathy, and support resources. Support from others, alongside interventions such as exercise, good nutrition, information, and alternative therapies are used by survivors with variable degrees of success.

Conclusions: This qualitative study reports peoples’ experiences of fatigue after critical illness. Findings highlight the significant impact it has on people’s lives and those of their family and friends.

Impact: aim; findings and recommendations  

• This study explored the problem of fatigue in survivors of critical illness.

• Fatigue causes an array of complex, often long-term interrelating impacts on the survivor and their wider family, made worse by a lack of understanding, empathy, and support resources. Interventions such as exercise, good nutrition, information and alternative therapies are used by survivors with variable degrees of success.
• Acknowledgement of fatigue by health and social care staff and the provision of personalised information to patients and their family on fatigue and how it can be managed could improve patients’ experience and their overall quality of life.

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an intensive care unit and split the data we extracted into three datasets: vitality scores from the Short Form Health Survey-36 (n = 54); other quantitative data (n = 19); and qualitative data (n = 9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; and assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. Short Form Health Survey-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately 1 month following ICU discharge (mean (SD) 56.44 (32.30); 95%CI 52.92–59.97). They improved over time, but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors’ quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific to critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness, and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed.

Aim: To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients.  
Design:  A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion.

Methods:  The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration.  The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable.
 
Results: The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use. 
 
Conclusion: Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort.

Aims. To identify factors that influence recognition and response to adult patient deterioration in acute hospitals. Design. A Mixed-Studies Systematic Review. Data sources. CINAHL, Medline and Web of Science were searched for relevant literature published between; 2007-2018. Review Methods. Studies were critically appraised, data extracted and thematically analyzed. Results. Thirteen papers met the inclusion criteria. Three main themes were identified: (1) Knowledge and understanding of clinical deterioration; (2) Organizational factors; managing deterioration and staffing levels; and (3) Communication; inter-professional relationships and professional-patient communication. Conclusion. Despite national guidelines, the review findings suggest that the recognition and response to adult patient deterioration in acute hospital settings is sub-optimal. A multitude of factors influencing the recognition and response to adult patient deterioration emerged from the findings. Impact. Patients are receiving sub-optimal care due to failure in recognizing and responding to patient deterioration in an appropriate and timely manner. Nurses lack knowledge and understanding of deterioration. Organizational factors contribute to inadequate care and communication among professionals was highlighted as challenging. The factors that influence the recognizing and responding to patient deterioration in acute hospitals are multi-faceted, however this review highlights immediate recommendations for professionals in the acute care setting. 

Background. Patients discharged from intensive care may experience psychological and physical deficits resulting in a long and complex rehabilitation upon discharge. Relatives are also vulnerable to psychological pathologies and diminished health‐related quality of life following the patients' critical illness. Relatives often provide care during the patients' rehabilitation, which may influence their health. Aim. To report the outcomes and experiences of relatives of patients discharged home after critical illness. Design. Systematic integrative review. Methods. Electronic databases Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase®, and PsychINFO® were searched using keywords, synonyms, and medical subject headings. Reference lists of articles and critical care journals were manually searched. Studies eligible for inclusion reported primary research and were published in English between 2007 and 2017. Studies were appraised using the Critical Appraisal Skills Programme checklists. Data were extracted and then analysed according to framework. Findings. Twenty‐five studies were included: 19 quantitative, 4 qualitative, and 1 mixed method study. Three themes were identified: health and well‐being, employment and lifestyle, and caregiving role. Health and well‐being reports the incidence and significance of psychological morbidity such as post‐traumatic stress disorder, anxiety, and depression. Employment and lifestyle describes the impact of caregiving on the relative's ability to work and engage in usual social activities. The final theme describes and discusses the caregiving role in terms of activities of daily living, knowledge and skills, and adaption to the role. Conclusions. There is a significant and meaningful impact on outcomes and experiences of relatives of patients discharged home after critical illness. Relatives' caregiving is embedded within the context of their psychological morbidity and social adjustment. Relevance to practice. If informal care giving is to be sustainable, there is a need to design effective strategies of supporting families through all stages of the critical illness trajectory.

Background

Patients entering intensive care encounter physical and psychological stress which may lead to psychological morbidity such as depression, anxiety and post-traumatic stress. It has been suggested that constructing a story may assist psychological recovery however this has been minimally investigated in the intensive care patient.

Aim

The aim of this paper is to examine the process of story construction in patients’ phenomenological accounts of being a patient in the technological environment of intensive care.

Study design

The study design was informed by Heideggerian phenomenology.

Methods

Semi-structured interviews were conducted in nineteen patients who had been in intensive care for at least four days. Interviews were digitally recorded, transcribed and analysed utilising Van Manen’s framework for thematic analysis.

Findings

Making sense of their experiences in ICU appeared to be fundamental to story construction. Themes that arose were: “Why am I here?”, “Filling in the gaps”, “Sorting the real from the unreal” and “Searching for familiarity”. These themes describe how participants sought temporal and causal coherence in order to construct their integrated and understandable story. Families appeared to play a critical role in assisting participants in filling in the gaps, sorting the real from the unreal and their subsequent psychological recovery.

Conclusions and relevance to clinical practice

The importance of early support from health care professionals to facilitate patients’ story construction is highlighted. The study also emphasizes the role of families in supporting patients in making sense of their experiences and the associated psychological recovery process. Further research to evaluate methods of facilitating story construction such as nurse-led de-briefing, patient diaries, is recommended. In addition investigation of families’ perceptions of their role in assisting patients to construct their story may facilitate health care professionals in developing strategies to effectively support families in their role. 

Aims

To investigate patients’ experiences of technology in an adult intensive care unit

Background

Technology is fundamental to support physical recovery from critical illness in Intensive Care Units. As well as physical corollaries, psychological disturbances are reported in critically ill patients at all stages of their illness and recovery. Nurses play a key role in the physical and psychological care of patients, however there is a suggestion in the literature that the presence of technology may dehumanise patient care and distract the nurse from attending to patients psychosocial needs. Little attention has been paid to patients’ perceptions of receiving care in a technological environment.

Design

This study was informed by Heideggerian phenomenology.

Methods

The research took place in 2009-2011 in a university hospital in England. Nineteen participants who had been patients in ICU were interviewed guided by an interview topic prompt list. Interviews were transcribed verbatim and analysed using Van Manen’s framework.

Findings

Participants described technology and care as inseparable and presented their experiences as a unified encounter. The theme ‘Getting on with it’ described how participants endured technology by ‘Being Good’ and ‘Being Invisible’. ‘Getting over it’ described why participants endured technology by ‘Bowing to Authority’ and viewing invasive technologies as a ‘Necessary Evil’.

Conclusion

Patients experienced technology and care as a series of paradoxical relationships: alienating yet reassuring, uncomfortable yet comforting, impersonal yet personal. By maintaining a close and supportive presence and providing personal comfort and care nurses may minimise the invasive and isolating potential of technology.

Aims

To report the results of a randomised controlled trial which explored the effectiveness of clinical simulation in improving the clinical performance of recognising and managing an adult deteriorating patient in hospital.

Background

There is evidence that final year undergraduate nurses may lack the knowledge, clinical skills and situation awareness required to competently manage a deteriorating patient in hospital. The effectiveness of clinical simulation as an educational strategy to teach the skills required to recognise and effectively manage the early signs of clinical deterioration needs to be evaluated.

Method

This was a two centre, randomised, controlled trial with single blinded assessments. Data were collected in July 2013. Ninety- eight first year nursing students were randomised either into a control group where they received a traditional classroom lecture, or an intervention group where they received simulation training. Participants completed a pre and post- intervention objective structured clinical examination. General Perceived Self Efficacy and Self-Reported Competency scores were measured before and after the intervention. Student satisfaction with teaching was surveyed after the teaching intervention.

Results

The intervention group performed significantly better in the objective structured clinical examination after their simulation training. General Perceived Self Efficacy and Self-Reported Competency were not correlated with performance. There was no significant difference in the post intervention General Perceived Self Efficacy and Self-Reported Competency scores between the control and intervention group. The intervention group were significantly more satisfied with their teaching method.

Conclusion

Simulation based education may be an effective educational strategy to teach nurses the necessary skills to effectively recognise and manage a deteriorating patient.

BACKGROUND: Clinical skill development is essential to nurse education. Clinical skills are frequently taught in higher education institutions using clinical simulation. It is unclear if clinical skills are subsequently consolidated and developed in clinical placements.

OBJECTIVES: The aim of this survey was to evaluate pre-registration student nurses perceptions of the frequency of opportunities to practise, the level of supervision and assessment of, clinical skills in their clinical placements.

DESIGN: This was a cross-sectional survey design using an online, self-report questionnaire including a Likert-type scale and open ended comments.

PARTICIPANTS: Four hundred and twenty one students, from all year groups, from a university in the south of England on a wide variety of clinical placements participated.

METHODS:

Participants evaluated the frequency of opportunity to practise, level of supervision and assessment of and feedback on performance of specific clinical skills. Clinical skills evaluated were measurement of vital signs, aseptic non-touch technique, assisting with eating and drinking, and assisting with comfort and hygiene. Data were analysed utilising Statistical Package for the Social Sciences Version 19.

RESULTS:

The frequency of opportunities to practise skills in clinical placement was variable with some participants reporting that they never had opportunity to practise essential skills. Similarly the level of supervision and assessment was also inconsistent suggesting that participants frequently practised clinical skills unsupervised without being assessed as competent.

CONCLUSIONS: Inconsistencies in clinical skill development may lead to graduates who are not work ready and as a result, insufficient clinical competence potentially leads to unsafe practice and poor patient care. This calls for stronger partnerships between educators and clinical areas and the prioritisation of mentor preparation and education as well as organisational support in terms of mentor workload planning.