Critical care workforce challenges

An experienced ICU workforce is a valuable resource. Staffing capacity, particularly for registered nurses, is the factor most likely to constrain the potential for an ICU to surge in capacity in response to demand.4 More recently, the COVID-19 pandemic illuminated the skills, knowledge and resources required to successfully treat critically ill patients in ICUs, resulting in an increased focus and media interest on the workforce, particularly the nursing workforce.4 The demand for appropriately trained and experienced ICU nurses continues to outstrip supply and the recognised shortage of a qualified workforce both in the UK and internationally remains a significant patient safety issue.4 Globally, the ICU workforce is currently experiencing unprecedented demand driven by burnout, sickness and the fallout from COVID-19,5 which further depleted an already understaffed healthcare service alongside years of underfunding have all created a perfect storm relative to ICU supply and demand.6

Anticipating and controlling demand, managing workload and resources

In this issue of BMJ Quality and Safety, the qualitative study undertaken by Page and colleagues7 explores and describes the types of everyday pressures that confront HCPs and the strategies they use to respond to such challenges in clinical practice in ICU. Semistructured interviews were undertaken with a purposive sample of senior HCP from four acute care hospitals across England working in roles with line management responsibilities for a multidisciplinary team and/or running an ICU service. The final sample of 20 participants included 5 medical consultants, 9 nursing leads, 4 senior nurses and 2 senior physiotherapists.

The authors used a thematic template approach to analyse the interview data based on a previously developed taxonomy of pressures and strategies.8 Textual data from the interviews were analysed using a staged approach that included familiarisation and initial coding, developing a framework for organising the data based on a previously developed classification of pressures and strategies. Study findings indicated that a major source of pressure related to a lack of skilled and experienced staff to manage an increasing number of highly complex patients being admitted to ICU. This situation often led to concomitant increases in staff workloads and reduced patient flow.7

The study by Page and colleagues7 is methodologically robust, with a clear audit trail detailed throughout. The use of an a priori framework8 based on the key strategies and pressures as described by participants enhances the credibility and validity of the findings, and allows a more comprehensive understanding of the strategies used by clinician participants. Other strengths include the use of multiple hospital sites that were diverse in size and location, the representation of different HCPs and the breadth of participant experiences and perspectives. Limitations include the inability to describe the impact of unintended consequences of the various strategies identified by participants.

Lessons learned

So, what can we learn from participants’ experiences in delivering vital ICU services? Page and colleagues illustrate the adaptative strategies used by ICU clinicians at times of pressure to minimise risk and promote patient safety.7 Although their work focused on the ICU setting, their findings have relevance to other healthcare environments. All healthcare workers regardless of the country, role or discipline are experiencing significant pressures because the very nature of healthcare delivery carries a heavy emotional burden.5 Thus, developing an adaptive healthcare workforce is an important feature of a robust patient safety culture. Others have also acknowledged that HCPs demonstrate significant adaptative capacity when faced with ongoing clinical challenges like staff and bed shortages,3 9 and similar to Page and colleagues’ work, these adaptative strategies included organisational adaptions.7 For instance, reorganising the environment, or changing the model of care to improve care processes or personal adaptative strategies. Changing roles and responsibilities or undertaking additional education to provide safe care has also been described in the context of developing adaptive capacity.10 11 Yet, despite the ability to adapt to the daily pressures of high-stress clinical environments, ICU staff may still experience psychological strain, which can diminish their personal resilience.

Unintended consequences of using adaptive strategies

However, activating these adaptative strategies may lead to unintended consequences that threaten patient and staff safety. These adaptations have the potential to cause harm by leading to the abandonment of established policies and procedures. Adjustments to usual practice require clinicians to make calculated trade-offs, but these temporary adjustments can develop to become long-term normalised deviations from best practice.12 This shift creates tension for staff as they navigate care environments that might be unsafe or not focused on patient care. For instance, situations such as discharging a patient directly from an ICU or assigning an inexperienced nurse to a critically ill, ventilated patient can arise, increasing the risk for both staff and patients. These adaptative strategies can increase staff stress, burnout and the risk of moral injury.13 In the ICU environment, this may also culminate in compassion fatigue,14 resulting in a workforce that is disconnected from their work and, most importantly, from patients. When this happens, care becomes task-focused and ritualistic, and patient safety is compromised.

Page and colleagues identified a myriad of adaptative strategies used by critical care clinicians in response to managing the everyday pressures of an ICU environment.7 Yet, it remains unclear what the long-term impacts such strategies have on patient safety and the wider healthcare workforce. There is increasing awareness that healthcare requires a physiologically well workforce to deliver positive patient experiences and outcomes.15 We know the long-term impact of chronic exposure to stress and pressure can also whittle away HCPs’ personal resilience. Therefore, further research is needed to assess the benefits, risks and potential trade-offs of different combinations of adaptive strategies as described in Page and colleagues’ study.7

Clearly, an adaptive workforce is a key protective factor in responding to the ongoing pressures of working in the ICU environment, but it is not enough. Adaptive strategies may incur costs, and if used for extended periods, could potentially harm the healthcare service and most importantly cause patient harm. However, healthcare leaders are ideally positioned to enable adaptive capacity in healthcare teams. Many adaptive strategies involve structures such as technology and communication tools, as well as processes like changes in prioritisation and policies, which healthcare leaders can impact or shape.16 Importantly, not all adaptive strategies necessarily result in harm. Knowledge and understanding of the different adaptive strategies used by ICU staff to manage increasing demands may inform the implementation of targeted interventions that promote a workforce, which can rise above the strain of challenging complex, and dynamic ICU environments. Ultimately, this will deliver safe competent care to the hospital’s most vulnerable patients.