They highlighted that support must be put in place for these nurses, who will have to demonstrate a new level of leadership during the coronavirus crisis but are at risk of being left traumatized as a result of their experiences.
Nicki Credland, chair of the British Association of Critical Care Nurses, and Suman Shrestha, professional lead for critical care at the Royal College of Nursing, spoke to Nursing Times as intensive care nurses were gearing up for what will likely be the biggest challenge of their careers.
Urgent preparations have been underway to boost intensive care capacity in the UK, ready for when cases of Covid-19 spike, including securing extra beds and equipment such as ventilators.
Plans have also been unveiled for a new temporary hospital in London – named after Florence Nightingale – to house 4,000 patients in need of critical care, with other “field hospitals” to follow in other places.
However, nursing leaders have been clear from the start that there are not enough intensive care nurses to meet demand.
As a result, the 1:1 nurse staffing ratio that is normally in place in critical care is being dropped in favor of a new “team-based” approach.
The nurse will be put in charge of a group of patients and will have support from a team of non-intensive care colleagues who may include a mix of recovery nurses, theater nurses, operating theatre practitioners and care assistants.
Ms Credland said the number of patients assigned to a team would depend on demand.
“We’ve worked up to quadruple occupancy and I think we will probably need to go beyond that but, until we know just how many patients we are going to need to put into intensive care, we are just going to have to dilute the skill mix accordingly, because that’s the only way we will be able to manage this.”
While she acknowledged that care quality could be affected, Ms Credland said there was no other choice given the fact “we simply do not have enough qualified intensive care nurses”.
“Nursing intensive care patients is not for everyone, it’s a real skilled profession. Bringing in staff into intensive care units that are unqualified in intensive care nursing, quite clearly is going to dilute the skill mix,” she said.
“Our ability to be able to provide the excellent care that we do normally is going to be made very, very difficult.”
Under these new ways of working, psychological support for intensive care nurses would be key, said Ms Credland.
“From a nurse’s point of view, that critical care nurse is going to have to look after a cohort of patients and also supervise a group of staff which don’t usually work in that environment, so for that intensive care nurse that’s a really stressful situation to be in,” she said.
She also noted how nurses were likely to be seeing “increased mortality” among the patients they were looking after during the coronavirus crisis, which would add to their distress.
“A lot of these patients, potentially, are going to die," said Ms Credland, senior lecturer and head of department for paramedical, peri-operative and advanced practice at the University of Hull.
“The nursing staff have obviously got to look after them and their families and there is a real risk that they are going to have some psychological trauma along this journey, without doubt."
“But we are working on some support mechanisms to try and put some help in place as fast as we possibly can.”
Meanwhile, Mr Shrestha said it was important for hospital leaders to take careful consideration over what they needed to do to make the new team approach work, because “that’s the only best solution we have at the moment”.
He said they should consider boosting the well-being and counselling available for these nurses, who were likely to “feel burdened” due to the extra pressures placed upon on.
Asked if critical care nurses may develop post-traumatic stress disorder in the aftermath of Covid-19, Mr Shrestha said: “It’s obviously early days, but from what we are seeing from the Italians, yes, this is why I think we need to invest and plan and put in place all this psychological help for our nurses so that we don’t have that.”
One lever that was being considered to help ensure the workload did not get too much for any nurse was to have “zone leaders” in place, to keep an oversight of how the unit was running, said Mr Shrestha.
In addition, the new army of volunteers that the government has assembled to support the coronavirus response could be used to help take pressure off intensive care nurses, for example, by getting them to do stock checks and visits to the hospital pharmacy, he added.
“All these little things will help so the ICU nurse doesn’t have to chase things up,” he said. “Those are the things that we can do because, let’s face it we are not going to have more critical care nurses, we just need to accept it and we just need to work out how we can make their life and the working conditions better by supporting them – that’s the key focus where everyone is concentrating.”
In terms of the nurses from other departments being brought into intensive care, Mr Shrestha said they were likely to be given training to “introduce them to the concepts of critical care”. But it would be made clear to them that they were not being trained to become a critical care nurse.
As Ms Credland stressed: “You can’t fast rack to be an intensive care nurse, it takes 18 months after you qualify to be able to get the skills and competence – it’s a really complicated, technical role.”
In the new teams, critical care nurses would focus on “all the technical aspects of the care delivery – like the ventilators, the dialysis, the complex drug infusions”, while colleagues would concentrate on tasks such as administering drugs, turning patients, and eye and mouth care, according to Mr Shrestha, a practicing consultant nurse in critical care.
“We need to change the concept of how we actually deliver care, we need to use a team-based approach,” he said. “It has to be a teamwork approach, and that’s the only way we can deliver good care to our patients.”
He encouraged hospitals to utilize staff who already had relevant skills that could be helpful in critical care. For example, recovery nurses who were able to administer medicine, give intravenous drugs and do dressings.
Mr Shrestha said he hoped to see the principle of greater multidisciplinary team-working in intensive care continue in future, highlighting that the way the different professional groups were banding together in preparation for Covid-19 “boosts our spirits a little bit”.
However, more than this, what both Mr Shrestha and Ms Credland were both hoping could be learnt from the pandemic was the consequences of depriving the NHS of enough of the nurses and other resources it needed.
“We are certainly doing everything we possibly can to put critical care nurses at the front and center of the stage,” said Ms Credland.
“We can only hope that, once this is all over, there will be some revisiting of funding of the NHS in general, and certainly funding around critical care bed provision and, therefore, nursing staffing. We have got some of the lowest critical care bed numbers in the entire European Union or world, for that matter.”
Both were clear that workforce, while it was one of the biggest challenges facing critical care, was not the only one. There remained ongoing concerns around the availability of key equipment to care for critically ill patients, and also personal protective kit to keep nurses safe.
Ms Credland praised critical care nurses for their “outstanding” leadership, so far, during this epidemic. “They will be looking after the sickest patients that we have in our hospitals, what they are facing is just horrific to be honest.
“And they are doing that really, really bravely, with their chin up, getting their hands dirty, getting in and sorting it out in the best way that they can possibly can, while supporting everybody else.”
Likewise, Mr Shrestha said even though critical care nurses were feeling anxious about what was to come, he had experienced “solidarity among the colleagues as well - team spirit”.
Ms Credland said she hoped those in positions of power would be able to gain a greater level of understanding of the role. While critical care nurses were “very well respected” by the public, Ms Credland said this did not appear to have reached those on the top tables.
“I don’t think the government actually understands what an intensive care nurse actually does,” she said. “Nurses are still seen as a Florence Nightingale, they pat people on the head and make cups of tea. I don’t think they understand that it is a safety critical profession.”