The organisation of nurse staffing in intensive care units: A qualitative study

Abstract

Aims To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates. Background Pre‐pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence. Methods Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis. Findings Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes. Conclusions Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re‐allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well‐being, intensive care layout and the experience, and availability, of other members of the multi‐professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies. Implications for Nursing Management In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket ‘ratio’ approach to nurse staffing, intended to apply uniformly across health services.

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria, Australia

“…Of note, other countries have reported chronic ICU nurse under-staffing prior to the pandemic, which the pandemic has exacerbated. 4 , 28 , 29 The ICU nurse vacancy rate across Australia prior to the pandemic was over 6% [ 27 ] so likewise, the Australian ICU nursing workforce was already depleted. Detailed information about the ICU nursing workforce has not been regularly captured before and continued collection of such data has the potential to provide valuable information regarding the ICU nursing workforce during regular operations and during other extraordinary events e.g.…”

Nurses' perceptions of point of care testing in critical care: A cross‐sectional survey

“…19 As noted by Endacott et al, however, evidence supporting changes to workforce models is currently lacking. 20 Many nurses and the organizations that represent them have also publicly declared their concerns. 21,22 Furthermore, whilst emergency approaches to critical care workforce management were necessary to manage an unprecedented situation, task-orientated nursing practice was rejected many years ago in favour of a more holistic approach to patient care, with the nurse at the centre, coordinating the needs of the patient and their family.…”

Intensive Care Strain Indicators: Recommendations for Critical Care Processes and Research Objectives

“…Combined census, admission timing, and unit acuity dashboard This includes optimal staffing and published literature clearly demonstrates higher intensity nursing, physician, and pharmacy staffing decreases ICU and hospital length of stay LOS and mortality [27][28][29][30][31] .…”

“…ICU nurse staffing requires optimizing both sufficient numbers of nurses and appropriate workload, both of which contribute to decreasing mortality risk, and with lapses in either causing significant degradation of care 27,28,32,33 . In addition, experienced nursing teams have greater resilience for reallocating nursing resources, co-locating nursing assignments, and functioning with higher autonomy 27,29,32 .…”

“…ICU nurse staffing requires optimizing both sufficient numbers of nurses and appropriate workload, both of which contribute to decreasing mortality risk, and with lapses in either causing significant degradation of care 27,28,32,33 . In addition, experienced nursing teams have greater resilience for reallocating nursing resources, co-locating nursing assignments, and functioning with higher autonomy 27,29,32 . Finally, nursing leadership strongly advocates for having dedicated personnel to fill shift based responsibilities, such as critical resource and float nurses to optimize quality, safety, and cost 34 .…”