Managing Exposure: Resilience in ICU

Authored by Jennifer

Editor’s note (Jesse Spurr): This summary explains Jennifer’s research study for her Master’s thesis, where she set out to learn how  critical care nurses become resilient. You can read the entire thesis here, watch a short YouTube video here, or a detailed YouTube video summary here. I see the effects of burnout and, conversely, the protective shroud that resilience on a daily basis in the ICU. I believe this is an important line of inquiry for anyone who works in critical care.

 

Managing Exposure: A Grounded Theory of Burnout and Resilience in Critical Care Nurses

Burnout was identified in nursing in 1978[1], and continues to be problematic in the profession[2]. There are many factors that make critical care settings challenging places to work, and burnout among critical care nurses remains high[3]. However, we also know that resilience is an important factor for critical care nurses. Resilience can be defined as “the ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner.”[4] Essentially, resilience is the ability to address something difficult in one’s life in a healthy, positive way. Resilience is important for a lot of professionals, including teachers[5] and soldiers[6], and it was suspected that resilience would be important for nurses as well.

Resilience has been widely studied, in a variety of contexts. However, many of these studies have focused on personality traits associated with resilience, or prevalence rates of resilience or burnout. In this study, I explored how resilience actually happens; that is, how nurses go from experiencing adversity to becoming burnt out or resilient. By explaining how nurses become resilient, we can support nurses by making the process of resilience more visible and easier to manifest. This research is important because we know that resilient nurses call in sick less frequently[7], and can provide safer care to patients and their families. There are nursing and economic benefits to having a resilient nursing workforce.

I spoke with 11 nurses in critical care settings, for up to 90 minutes. We discussed a variety of topics about their experiences at work, their efforts to cope with challenges, and their beliefs about the nursing profession. I combined all of this information to create a framework showing how nurses become resilient. I hoped that if I could illustrate how nurses become resilient, we could make it easier for nurses to follow this process.

So how do nurses become resilient? By Managing Exposure. This model explains how nurses become burnt out or resilient, which opens the door to strategic interventions.

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It is important to note that this model is presented as being linear and one directional for ease of explanation. In reality, these processes are dynamic and fluid.

 

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Resilience begins when nurses face adversity. There are many forms that adversity can take; for the purposes of this study, the focus was on adversity that is found in the workplace. Nurses reported several levels of adversity that they encounter every day at work. These included broad, societal influences, such as a lack of respect for nursing. Nurses reported that many people (including patients, families, and nurses’ family members) did not understand or appreciate the role of nurses in critical care. This lack of understanding translated to disrespectful treatment and a lack of support.

Adversity was also found in the culture of the unit, practical concerns, the nature of critical care nursing, and interpersonal conflicts. Nurses described difficulty caring for patients when they plan of care was not what a nurse thought would be best for the patient. Nurses also reported that an inability to access vacation time from work made it difficult for them to address burnout.

There are lots of factors that constituted workplace adversity for nurses. Rather than see these as a list of problems, it is important to recognize that each point is a place where intervention can make a difference. There are concrete opportunities in the workplace to decrease the amount of adversity faced by nurses. While it is impossible to have an adversity-free workplace, there are many ways to decrease adversity and make nursing more manageable.

 

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The factor that moves this model forward is awareness. When nurses had awareness about how they were being affected by workplace adversity, they could make choices to manage their exposure to this adversity. Awareness created the opportunity for nurses to take action.

In order to have awareness, nurses required a disclosure of information that was relevant to their work. They could perceive and understand this information, reflect on it, and consider the outcomes of different courses of action. Based on these potential outcomes, a nurse would choose how to respond.

Awareness is important because it is how nurses understand their experiences and make decisions. If nurses did not have awareness, they would become burnt out.

 

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The most important part of this model is Managing Exposure. This is the actions that nurses take to address workplace adversity.

When nurses work in infectious environments, they put on protective equipment, limit their time in sensitive areas, remove the equipment when they leave the area, and clean their hands as they move away. Nurses can use these same strategies psychologically as well, in order to manage their exposure to workplace adversity.

These actions fell broadly into 4 categories:

Protecting: Strategies that nurses used to emotionally protect themselves from adversity, and offload when they were overwhelmed. This included developing a protective shell against emotional concerns, and delegating tasks to colleagues.

Processing: How nurses made meaning from their experiences in critical care. The most common form of processing was talking about challenges at work, especially during change-of-shift report. This time was preferred because it was private, normal, and nurses could talk to someone who shared their experiences.

Decontaminating: Restorative processes that nurses can use to be rejuvenated after difficult experiences. These included developing supportive relationships at work, and outside of work. Nurses also managed exposure by engaging in meaningful activities that were either physical, such as yoga, or creative, such as knitting.

Distancing: The need for nurses to be physically away from the patient bedside. This included short periods of time, such as breaks or a few minutes to recover after a crisis. Nurses also periodically needed longer breaks, such as granted vacation. Ultimately, many nurses recognized that it was difficult for them to manage their exposure to adversity in critical care, and would begin planning to leave the unit years in advance, in anticipation of their own burnout.

 

Nurses told me that they were the most resilient when they could easily use these strategies, with the support of their colleagues, families and organizations. Nurses who used a variety of these strategies told me that they felt more resilient than nurses who only used one or two strategies.

 

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There are a variety of ways that nurses experienced the process of Managing Exposure. Nurses reported they were thriving when they loved their work, and felt passionate, energized, and fully engaged. Nurses achieved resilience when they were able to face difficulties in the workplace, and feel good about the nursing care they could provide. Nurses described themselves at a survival level when they said they struggled at work, but they were trying to retain their compassionate approach to patient care. Finally, nurses reported burnout when they saw patient care as a series of tasks rather than a caring act. They felt anxious before or after work, had difficulty separating their professional and personal lives, and felt like they did not have adequate time to recover between shifts.

It is likely that burnout can lead to post traumatic stress disorder (PTSD), but as PTSD is a psychiatric diagnosis, it was beyond the scope of this study to investigate it directly.

 

So what is the bottom line?

The major finding of this study is that nurses who are burnt out and nurses who are resilient are coming from the same pathway. Just as dating can lead to breakups or marriages, the exposure to adversity can lead to burnout or resilience. Nurses who are burnt out are not bad people, or lacking in personal coping skills. They are having difficulty managing their exposure, which can occur because of personal challenges or systemic barriers. For example, previous studies have identified burnout as a source of increase sick calls7. My research adds another dimension to this: nurses are experiencing burnout and they are trying to manage (potentially by requesting vacation, or trying to seek out interpersonal support). If nurses are not able to manage, such as not being able to get vacation hours granted, or being overwhelmed at home and unable to spend time with support people, they resort to calling in sick because they see no other options. The findings of this study clearly demonstrate that resilience and burnout are not entirely determined by individual nurses. There are systemic factors that can overwhelm a nurse, in spite of good personal coping skills. Workplace adversity can have a toxic impact on nurses, and needs to be taken seriously.

 

The findings of this research study also demonstrate the power of intervention to foster nursing resilience. Nurses shared stories of managers, educators, and colleagues, who had supported them through teaching and advocacy. It is clear that nurses learn how to promote their own resilience, and can be positively impacted by the people and systems around them.

 

Nurses who are resilient give better care to patients. It is important that nurse leaders consider how to support nurses to manage their exposure, to promote safe, dignified health care delivery.

 

To learn more about this research, and see how it may apply to your settings, please see:

A short YouTube summary of the project is here: https://www.youtube.com/watch?v=Z4F-x0dx0mo

A longer YouTube video that describes the details of the project is here: https://www.youtube.com/watch?v=cUHpyqq0M8U

And the full thesis document is available here: http://hdl.handle.net/10791/183 Chapter 4 of the thesis explains the findings of the study in the participants’ own words.

 

References

[1] Shubin, S., & Milnazic, K. (1978). Burnout: The professional hazard you face in nursing. Nursing8, 22-27. Retrieved from: http://journals.lww.com/

[2] Epp, K. (2012). Burnout in critical care nurses: A literature review. Dynamics, 23, 25-31. Retrieved from: http://www.caccn.ca/en/publications/dynamics/

[3] Khamisa, N., Peltzer, K., & Oldenburg, B. (2013). Burnout in relation to specific contributing factors and health outcomes among nurses: A systematic review. International Journal of Environmental Research and Public Health10, 2214-2240. doi: 10.3390/ijerph10062214

[4] Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity. Journal of Advanced Nursing, 60, 1-9. doi: 10.1111/j.1365-2648.2007.04412.x

[5] Taylor, J. L. (2013). The power of resilience: A theoretical model to empower, encourage and retain teachers. Qualitative Report18, 1-25. Retrieved from: http://web.b.ebscohost.com/

[6] Simmons, A., & Yoder, L. (2013). Military resilience: A concept analysis. Nursing Forum48, 17-25. doi:10.1111/nuf.12007

[7] Schaufeli, W. B., Bakker, A. B., & Van Rhenen, W. (2009). How changes in job demands and resources predict burnout, work engagement, and sickness absenteeism. Journal of Organizational Behaviour, 30, 893–917. doi: 10.1002/job.595

 

Is there a Critical Care (Nurse) Practitioner in the House?

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Editor (Jesse): It is with very humble pleasure that injectableorange.com plays host to a great insight into the strategic, organisational and personal history of critical care nurse practitioner role in the UK. @ccpractitioner himself shares an insight into his world. I have long been a fan of Jonathan’s website. Jonathan is a living example of the ethos of critical care, tirelessly working to better himself and in the process raising the bar and sharing resources for others. Without further ado, over to Jonathan.

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The NHS Plan (2000) identified the need to undertake some experiments regarding skill mix in the National Health Service. This was followed by the Modernisation Agency establishing a New Ways of Working team in 2001. The Changing Workforce Programme subsequently developed into the National Practitioner Programme and consequently a number of new ways of working, streams were established. These covered surgery, medical care, anaesthesia, critical care, endoscopy and assistant roles in theatre.

It is widely accepted that the reduction in junior doctors’ hours (Council Directive, 2000), coupled with career development, namely Modernizing Medical Careers (SEHD, 2005), could result in a reduction in the number of hours junior doctors are available for service provision. These changes may have specific implications for the provision of medical care for critically ill patients.

A major component of this strategy was the development and introduction of the Advanced Practitioner roles. It had been recognised already that there were many healthcare professionals who wanted to use their extended skills in new ways of working. There were consequently four main ways in which roles were redesigned to offer practitioners more potential for development.

The International Council of Nursing defines an advanced nurse practitioner as;

“A registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which she/he is credentialed to practice”

There were several goals for the development of the new roles, which included ensuring the necessary skills and competencies required by care pathways or interventions are present in the workforce, encouraging working across professional boundaries, matching skill mix to service delivery models, reducing workforce cost and attracting a new workforce where shortages exist.

The advanced practitioner role often requires management of own caseloads with high levels of decision-making and diagnostic reasoning. The development of these roles has required substantial investment and as a consequence evidence of added value has been essential when considering developing these roles.

Both the Royal College of Nursing (RCN) and the Department of Health (DoH) have reiterated the need for advanced practitioners to be educated to Masters level and in order to achieve this I first undertook a post graduate diploma in Anaesthetic practice which I then went on to convert to a Masters degree by completing a research dissertation over another year.

The current critical care practitioners within my trust study towards their Masters degree by undertaking several modules. These include Clinical History Taking and Examination, Clinical Diagnostics, Clinical Investigations, Non-Medical Prescribing (which entitles them to prescribe anything a doctor can) and a research module teaching them how to critically analyse and formulate a research plan. These modules are also backed up by achieving a series of clinical competencies related to the intensive care unit, supervised by their consultant mentor.

They are also required to keep a logbook of the procedures they have undertaken, which initially they have to be supervised for. It is only when they are assessed as competent by their consultant mentor in that particular skill that they are able to undertake it independently. These skills include Arterial line placement, central venous catheter insertion, dialysis line placement and intubations. All the practitioners are also Advanced Life Support providers and most are also Advanced Life Support instructors.

Once considered qualified the practitioner works alongside the junior doctors on their rota on both the day and the night shift, providing valuable support to the team.

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It would not be true to say that the advance practitioner role has been taken up across the entire health service. Decisions to develop the advance practitioner role have often been taken at a local level within the health service and often depends upon the championing of extended or advance practitioner roles by one or more key individuals, commonly heads of department or chief executives. It is probably fair to say that the development of the role requires a lot of support because without it there can be resentment among staff and the feeling that the advance practice role has been introduced simply to increase volume rather than the scope of practice.

The path has not always been a smooth one during my experience as a practitioner. Initially I found it very difficult to adjust to my change in role. With my many years experience in the intensive care environment, I initially felt myself going from expert to non-expert quite quickly. Whilst I felt that I already had a lot of relevant knowledge, I very quickly became aware of the steep learning curve. Occasionally some of the junior doctors also seem to have been a little confused about the new role. I think it was hard for them to understand where nursing input stops and our practitioner role began. I do believe, however, that the practitioner now offers more teaching opportunities and learning situations for the junior doctor, rather than less. Certainly, for some of the procedures there is more likely to be support to offer them when they are trying to learn.

I think the greatest benefit to having the critical care practitioner is the continuity that they offer to the medical team. Many of the junior doctors rotate through the intensive care unit fairly quickly. This results in a team of doctors with reduced levels of experience in intensive care every few months. The critical care practitioner is able to bridge this gap and ensure that the care in the intensive care unit is led by current practice and research and carried out in a safe and consistent manner.

One of the issues mentioned with the advance practitioner role is that there are few further routes for career advancement. In the current climate I find this a slightly pointless argument. I was at band seven in my nursing role in critical care and without going into either education or management I was unlikely to achieve a higher grade without a major change. That major change came about when I was offered the opportunity to take up the advance practice training. Once qualified I was then able to achieve a higher band, 8a, which I otherwise was not going to get. In my trust there are now some senior advance practitioners at even higher grades, so I feel that this change in my career pathway has only raised the ceiling for me.

It is difficult to foresee where the advance practice roles will go, but I can only say that it is been a huge developmental step for me personally.

 

Reading List

 

Advanced nursing roles in critical care- a natural or forced evolution? Coombs et al. Journal of Professional Nursing Vol 23, No 2 2007: pp 83- 90.

 

Practitioner role in a hospital setting. Dalton, M. British Journal of Nursing Vol 22, No 1 2013 : pp 48- 53

 

Advanced level nursing- a position statement. Department of Health 2010

 

Exploring advanced nursing practice: past, present and future. Duke, N. British Journal of Nursing Vol 21 No 17 2012 : pp 1026-1031

 

Steering a course to advanced nursing practice. Nursing in Critical Care Vol 16 No 2 2011 : pp67-76

 

Evaluation of advanced practitioner roles. Institute for Employment studies. 2009

 

Advanced nurse practitioners. Royal College of Nursing. 2012.

Uppers, Downers & Squeezers – Presentation

Another from the vault of old presentations. Again, a very text heavy ppt (not something I am overly proud of), but intended for other nurse educators to be able to pick up and use and also, the perioperative and ICU staff I delivered this to, requested to keep it as a resource. All references available on request (can’t remember why didn’t upload them)?

Talking SMACC – A nurse eye view.

In what felt like being part of a spectacular experiment, the SMACC 2013 program launched in style with an opening plenary to end all others, imploring us all to consider what make critical care so different? For the uninitiated, SMACC 2013 was the inaugural Social Media and Critical Care Conference, held at the Sydney Convention and Exhibition Centre 11-13th March. It was a gathering of passionate healthcare providers who engage largely in social media and whose day jobs are mostly in critical care. The build up was the most amazing multi-pronged social media campaign I have seen and the conference exceeded all expectations.

First of all, I need to declare something. I am a male nurse. I am well accustomed to being in the minority. Even in critical care, my gender predisposes me to being the lower number in a ratio of 5:1. From a very superficial analysis of attendance at SMACC 2013, I would estimate about 20-30 maximum representation of nurses at a conference of approximately 600 delegates. This is ok. I heard whispered (tweeted) laments of imbalance in the program. Who cares? Am I a self loathing nurse? No. Am I a frustrated wannabe doctor? Also no. The jobs are different. I know, who’d have thought? Does it make me a SNAG? Well, my wife thinks so.

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My view of critical care, is that we are meeting patients and, more often, their families at the lowest moment in their life, isolated, scared, confused and disempowered. Hospitals swallow people and turn them into bed numbers. I see the role of the critical nurse as something different all together. If in any way I can make the darkest time of someone’s life more bearable, I am up for the challenge. I have had more rewarding moments from facilitating a good passing than resuscitating a patient. One of the most fulfilling moments I have experienced was when caring for an elderly man, whose prognosis was awful and cessation of treatment was imminent. His family, who I had come to know as jovial and upbeat people even at the worst moments, where all in huddled around the bed in awkward silence (I know, breaking the rules, be damned the 2 visitors only epithet – I’ve had to sit in an ICU waiting room, it is rubbish). Taking a chance and trying to read my audience I asked “what sort of a bloke is Bob? (pseudonym obviously). I haven’t really had a chance to meet him properly, he’s not been real chatty (he was invasively ventilated and unconscious). The sons and wife burst out laughing and I breathed a sigh of relief at what could have made me come off as an insensitive moron. “He is the sort of bloke who would love that you just said that.” “It’s not a church”, I replied, “you don’t have to be silent and there is no right or wrong way to deal with the fact that Bob is in this predicament.” That was enough to start the ball rolling with funny anecdotes about Bob’s life, tales from his profession, laughter and tears for the rest of my evening shift. Yes @emcrit “We are critical care”.

We don’t just instil fluids (not too much or the wrong ones thanks John Myburgh). We don’t just give propofol (the devil’s semen, thanks Cliff Reid), it’s not all about Ketamine and airway (Sorry Minh) and we don’t just use complex gadgets like transpulmonary thermodilution catheters (Roger Harris had everyone squirming in their seats for different reasons with this talk). I love to learn the physics, chemistry and biology behind the interventions I deliver. Not because I wish I was a doctor, but because it makes me a better nurse. It makes me a better data gatherer and analyst. It reduces the cognitive load and turns things from complex tasks I didn’t understand into planned executions of a bigger overall strategy. It makes more able me help save lives. It makes me quicker and more efficient, which means I get to sit on my butt and do nothing? No, it means I can talk to my patient and family. It means I can use that extra time to check and recheck for things that could go wrong and it means I can fill that time with more learning.

I love to learn from other nurses. This is one of the best things I have been given by the world of social media and it’s application for things other than posting selflies and pictures of food. This is why I got so much from SMACC and this is why I am happy to be in the minority. Meeting the likes of Ian (@impactednurse) and Kane Guthrie (like me has no fancy Twitter handle) among others at SMACC, my passion for being a critical care nurse found a bit of a counterpoint.

A common theme from SMACC 2013 was questioning dogma and being a subversive campaigner for change. For these two reasons, I don’t think much needs to change in the world of #FOAMed (other than maybe offsetting the cost of free – donations anyone?). How can you regulate change? How can you formalise subversion? My humble thoughts… why would you want to? On this theme of subversive ideas, my applause go to super nurse Sarah Webb, Resuscitation Coordinator at Royal North Shore. Getting up in front of a room full of emergency and intensive care physicians and pointing out that nurses too can make excellent leaders in resuscitation. The data on comparing ICU and ED Nurses and other disciplines certified as ALS providers at RNS was a moment that caused embarrassed gasps from the heavily under represented medical fraternity.  To confront this topic with style and grace (and a calm exterior) was pretty damn impressive. So to those who were concerned that nurses were under-represented at SMACC 2013, you probably weren’t looking in the right rooms. How about we do something about it and shout it from the rooftops for SMACC 2014. Lets drag our colleagues kicking and screaming into the world of Life In the Fast Lane, ICN, Impacted Nurse and the other plethora of great resources that can help broaden our often specialised focus and provide some insight into areas that are different from our own environment.

The measure of a successful conference is a feeling of reinvigoration for your work/cause and even with snot and sore throat, I returned with passion to teach today. I feel motivated, if not obligated to add to the bank of resource, thought and comment as we move to a new world of true evidence based practice rather than journal/eminence based. In all disciplines this is vital.

My only regret from SMACC 2013 was that, as a simulation educator, I missed Sim Wars (SONOWARS was a spectacle to behold), but lo and behold I can watch it for free http://prehospitalmed.com/2013/03/15/simwars-smacc-2013-download-280mb/. To finish up, I can genuinely say I understand the concept of FOAM now. To quote Scott Weingart, “don’t just dip your toes in, jump in the river and try and drink it!” I am thirsty for more, bring on the videos of all the awesome sessions I couldn’t see and bring on SMACC 2014.