The nurse staffing deficit in critical care is an age-old problem, with the issue seeming to worsen over time. In light of an international shortage of nurses,1 COVID-19 and the global surge in critical care capacity,2 which resulted in a rapid expansion of critical care capacity, there has been widespread implementation of alternative staffing models, with non-critical care qualified nurses, such as support staff, allied health professionals (AHPs) and other professionals providing bedside care to critically ill patients, reaching 70% at the peak surge of hospitalizations in the United Kingdom.3
In the United Kingdom, the prevailing model for critical care staffing has long been determined by National Health Service (NHS) service specification, with 50% of registered nurses (RNs) required to have ICU qualification and specified patient to registered nurse (RN) ratios linked to patient acuity and dependency levels.4, 5 Yet, high vacancy rates of around 10% to 15% nationwide before the COVID19 pandemic6 prompted increased interest in more flexible alternatives to the status quo. The United Kingdom has one of the lowest nurse numbers per capita in Europe, according to recent OECD data,7 and one of the lowest critical care bed numbers per 100 000 population,8 with deficits in overall capacity dependent almost entirely on critical care nurse numbers.9 Optimizing the deployment of this scarce critical care nursing workforce is paramount for patient safety, but also for staff well-being.10 This was emphasized by Bae et al's systematic review,11 reported in this issue, highlighting the consistent link between nurse staffing and burnout. Repeated surges in critical care admissions associated with the pandemic globally, and the potential for COVID-19 to become endemic, coupled with an increased need for agile staffing in response to the demand placed by COVID-19,12 compels examination of critical care nurse staffing with a critical lens.
Clear associations exist between nurse staffing and patient outcomes including mortality, nosocomial infection, hospital costs and family satisfaction,13-15 alongside nurse outcomes16 and nurse-sensitive indicators.17 This link has also been demonstrated in critical care units18, 19 from a small number of epidemiological studies.20, 21 However, casual mechanisms between critical care staffing and outcomes are not established.13 It remains unclear how to describe what “nurse staffing” comprises as an entity. This is the crux of the problem. As a profession, it is arguable that we are struggling to define this: determining what constitutes nurse staffing in critical care has become increasingly blurred, particularly with the advent of new roles in the United Kingdom such as advanced critical care practitioners, nurse associates and nurse apprentices, none of which require the post-holder to be a RN with a critical care qualification. While recognizing that these roles and plans for an effective career framework in critical care are increasingly pivotal in addressing critical care staffing crises, there still needs to be more unpacking of what critical care nursing involves and how to nurture future workforces.
Critical care nurse staffing remains a complex phenomenon determined by a range of factors, including nurse: patient ratios, environment, workforce availability and skill mix. The numbers of RNs, with critical care qualification, and skill mix variation are undefined in much of the existing evidence, and subsequent inconsistency in measuring of staffing leads to vague conclusions in practice. There are no intervention studies to guide the deployment of staffing in critical care, and no evidence to support one staffing model over another.10 Most studies focus on reporting observed variation within otherwise stable systems.10 As is widely known, more RNs are positively associated with a range of patient outcomes22 and decreased omissions in care.23
Whether the simplistic ratio approach to staffing, predicated on organ system failure rather than patient acuity and dependency, and advocated in national guidance24 sufficiently addresses the nuances and complexity of critical care requirements is questionable. This further compels the need for closer examination of model configuration.25 Moreover, a lack of scrutiny of critical care nurses' roles in those models also warrants examination,26 given variations in practices and roles, leading to the question: what is it that defines the unique role of a critical care nurse, and why is this important to examine?
With COVID-19, we have seen the advent of task-teams often focusing on fundamentals of care, such as moving and handling (proning), mouth care, hygiene care, which have created anxiety for many critical care nurses around the reduction of nursing to tasks, and the erosion of what it is to be a critical care nurse. A national staffing framework in the United Kingdom was developed to meet exceptional ICU demand during COVID1927, 28 that involved critical care nurses moving to supervisory roles, overseeing support workers (non-RNs), AHPs, physician colleagues and RNs, with delegation of many clinical tasks. Similar models, described as pod models, were implemented globally.29 Hospitals also created internal solutions to extreme staffing issues associated with an influx from COVID-19 related admissions. Critical care nurses, by necessity, moved to supervise non-critical care staff to provide bedside patient care. This has presented a threat to the concept of what it is to be a critical care nurse. The World Federation of Critical Care Nursing outlined the highly skilled nature of the critical care nursing workforce and suggested that critical care nurses should focus on the tasks that require advanced expert skills, expertise and knowledge of best practice in patient care.30 Moreover, various staffing models should be considered, including the use of support staff to prioritize critical care nurses for delivery of high-quality expert care.30 The notion of a critical care nurse was challenged in recent research, the SEISMIC study (Study to Evaluate the Introduction of a Staffing Model in Intensive Care, National Institute for Health Research ref: 200100),31 where senior leaders who were interviewed suggested that bedside care did not always need a qualified critical care nurse. This finding potentially compounds the fear of not being able to clearly identify the attributes of a critical care nurse and, in turn, what that means for planning nurse staffing in critical care.
Several large hospital Trusts in the United Kingdom are using different establishments of non-RNs in critical care, with those with no health care background at all (who are supported through internal training programmes), comprising as much as 30% of their “nursing” workforce. We do not yet know the implications of these changes in practice, and what the downstream effect will be on patient outcomes, attrition, job satisfaction and nurse-sensitive outcomes. Indeed, a question arises on how critical care nurse-sensitive outcomes (eg, hospital-acquired infections, satisfaction, weaning, falls, pressure injuries, staffing) are measured if registered critical care nurses are not delivering the bedside and fundamental care?
The Royal College of Nursing in the United Kingdom has historically defined a critical care nurse as:
a registered nurse who has the right knowledge, skills, and competencies to meet the needs of a critically ill patient without direct supervision. The knowledge, skills and competencies they require to nurse critically ill patients should reflect the level of patient need, rather than being determined by the patient care environment (eg, a high dependency or intensive care unit).32
The key difference between critical care nurses and support workers or other RNs working in critical care centres on the planning and supervision of care and delivery of expert care requiring advanced skills; while non-nurses may be able to deliver elements of fundamental nursing, the care must be overseen and planned by a registered critical care nurse who can independently care for a critically ill person. A critical care nurse is much more than a technologically competent practitioner, but a professional who is able to interpret complex information, provide therapeutic benefit through presence and comfort measures and plan a dynamic programme of care for critically ill patients in a critical care unit, as well as supporting other staff to provide critical care.
Allen's seminal contributions through ethnographic research on the invisible work of nursing outline how nurses undertake “organising of work,”33 which is viewed as “dirty” or “invisible” work, as not involving direct patient care. Considerable energy is spent on creating working knowledge, through information location, interpretation, sense-making and checking to translate into narratives for contributing to individuals care trajectories.33 This could include a senior critical care nurse in charge of a shift organizing staffing and contributing to patient flow in the hospital through discharge discussions. There can be a tension between a managerial nursing focus on maintaining patient flow, supporting the efficiency of the organization and wider population needs, and the professional impetus to care for individuals (such as the bedside nurse caring for a sick individual who does not want to discharge someone to the ward too early). The complexity of patients and the organizing of work supersede the notion of staffing numbers. All too frequently, it is easy to become distracted by the notion of numbers and ratios rather than understanding what nursing resource is required to safely meet individual and population needs in a health care organization, mitigating risk and ensuring delivery of high-quality care. Lydahl34 outlines the invisibility of nursing work in delivering person-centred care through articulation of care, linking tasks together to maintain a patient narrative, ensuring partnership and documenting care, moving away from routinization of care. This can present a challenge in that classifying tasks render care more visible, and more likely to be subject to determining costs of services, discretionary judgement, autonomy and developing contingencies. Nurses have to find a way to coordinate contradictory and information and tasks.34 For critical care nurses at the bedside, this invisible work is often manifested in the need to balance technology and caring; coordinating these to achieve person-centred care. Locsin's revisiting of her original dialectic on technology and caring,35 where critical care nurses were viewed as connoisseurs of technology, achieving knowing of the person through delicately managing complex responses to meet human needs, emphasized how tasks need to be skilfully managed through nurses and that technology and caring can co-exist in critical care.36
Tensions in the balance between the art and science of nursing, where critical care nurses wanting to be technologically competent but remain caring and focused on the needs of an individual and their family, have been heightened in recent months with COVID-19 and nurse-patient ratios as high as one critical care nurse overseeing six patients (with support from non-critical care nurses and non-RN support workers) in some parts of the world.37-39 The organizing of work, and supervision, has had to take primacy over direct care for many critical care nurses who have found themselves in a supervisory capacity during the pandemic.
So, while numbers are important for understanding overall establishments at a unit level in critical care, or daily requirements, the past year has presented an unprecedented challenge to both bedside nurses and those planning care. The pressure to meet safe levels of critical care nursing care has at times felt unbearable since the pandemic-induced staffing surges. Chronic shortages in critical care nurses,40 with high intention to leave41 and poor nurse well-being,42, 43 have been compounded with the pandemic and warrant examination of not only the role of nursing in critical care but also how different workforce models affect critical care nursing. The human costs of recent staffing pressures are all too clear, with a predicted exodus of critical care nurses,42 risking further dilution of qualified critical care nursing workforce and the available skill mix to staff critical care.
The pandemic has shone a light on how contextual and situational factors are highly important26 in relation to staffing models, and tools to support staffing deployment decisions lack a robust evidence base.10, 13, 44 A consistent message from these systematic reviews has been that there is a lack of evidence to support one model of critical care nurse staffing over another, and that a higher level of staffing was associated with improved outcomes (patients/services/nursing); however, there is ongoing dispute over the 1:1 nursing model (where one critical care nurse cares for the highest acuity critically ill patient).
In spite of all this work, there is a huge amount still to address; for instance, a high degree of heterogeneity exists in defining skill mix more broadly (eg, percentage of nurses who are RN; proportion of care provided by RN), suggesting a need for clarity,22, 25 and this is likely to be even more complex in critical care, especially with the advent of the aforementioned new roles. While skill mix is a known factor within staffing models, it does not account for context and how care is organized (eg, shift patterns/patient flow) and the associated nursing work in organizing this care. We need to understand how alternative models addressed unprecedented staffing challenges in COVID, and their legacy, such as patient outcomes (eg, mortality, adverse events, rehabilitation), service outcomes (eg, staff costs/shift patterns) and nurse outcomes (eg, retention).
Some Trusts have retained flexible models,31 using these outwith pandemic surge scenarios, but as yet we have little evidence on the effectiveness of these approaches from both nursing and patient outcome perspectives. The United Kingdom has one of the lowest numbers of ICU beds per population across Europe, and there are moves to address this nationally; however, with that comes new anxieties on how to meet the increased staffing demand, and what will that mean for the future of critical care nursing? We have to recruit and train more critical care nurses,9 not just in the United Kingdom but globally, by making it an attractive area in which to work, emphasizing the varied career trajectories, camaraderie, autonomy and opportunities available, as well as value the highly skilled workforce that defines critical care nursing. Through being our own advocates, and defending the unique contribution of critical care nursing to critical care as a specialty, we hold on to hope for the future of critical care nursing and developing a workforce fit to meet the population demands.
重症监护中的护士人员短缺是一个古老的问题，随着时间的推移，这个问题似乎越来越严重。鉴于国际护士短缺1 COVID-19 和全球重症监护能力激增2导致重症监护能力迅速扩张，替代人员配备模式得到广泛实施，非重症监护合格护士，例如支持人员、专职医疗人员 (AHP) 和其他为危重病人提供床边护理的专业人员，在英国住院高峰期达到 70%3。
在英国，重症监护人员配备的流行模式早已由国民健康服务 (NHS) 服务规范决定，50% 的注册护士 (RN) 需要具有 ICU 资格和指定的患者与注册护士 (RN) 的比例与患者的敏锐度和依赖性水平有关。4 , 5然而，在 COVID19 大流行6之前，全国范围内大约 10% 到 15% 的高空置率促使人们对更灵活的现状替代方案的兴趣增加。根据最近的经合组织数据，英国是欧洲人均护士人数最少的国家之一，7也是每 10 万人口中重症监护床位数量最少的国家之一，8整体能力的不足几乎完全取决于重症监护护士的数量。9优化这一稀缺的重症监护护理人员的部署对于患者安全和员工福祉至关重要。10 Bae 等人的系统评价强调了这一点，11在本期报告中强调了护士人员配备和职业倦怠之间的一致联系。与全球大流行相关的重症监护入院人数反复激增，以及 COVID-19 成为地方病的可能性，再加上为响应 COVID-19 的需求而对敏捷人员配置的需求增加，12迫使对重症监护护士人员配置进行检查带着批判的镜头。
护士人员配备与患者结果之间存在明显关联，包括死亡率、医院感染、住院费用和家庭满意度13 - 15以及护士结果16和护士敏感指标。17这种联系也已在重症监护病房18、19少数流行病学研究中得到证实。20 , 21然而，重症监护人员配备和结果之间的临时机制尚未建立。13目前尚不清楚如何将“护士人员配备”作为一个实体来描述。这是问题的关键。作为一个职业，我们正在努力定义这一点是有争议的：确定什么构成重症监护护士人员配置已经变得越来越模糊，特别是随着英国高级重症监护从业人员、护士助理和护士等新角色的出现。学徒，其中没有一个要求职位持有人是具有重症监护资格的注册护士。虽然认识到这些角色和计划在重症监护中建立有效的职业框架在解决重症监护人员配备危机方面越来越重要，但仍然需要更多地了解重症监护护理涉及的内容以及如何培养未来的劳动力。
重症监护护士人员配备仍然是一个复杂的现象，由一系列因素决定，包括护士：患者比例、环境、劳动力可用性和技能组合。在现有的许多证据中，具有重症监护资格和技能组合变化的 RN 的数量是不确定的，随后在衡量人员配备方面的不一致导致实践中得出模糊的结论。没有干预研究来指导重症监护人员配置，也没有证据支持一种人员配置模式优于另一种人员配置模式。10大多数研究侧重于报告在其他稳定系统内观察到的变化。10众所周知，更多的 RN 与一系列患者结果呈正相关22并减少护理遗漏。23
在 COVID-19 中，我们看到了任务团队的出现，通常专注于护理的基础知识，例如移动和处理（俯卧）、口腔护理、卫生护理，这让许多重症监护护士对减少护理工作感到焦虑任务，以及成为重症监护护士的侵蚀。在英国一个国家工作人员框架是COVID19期间，以满足特殊的ICU需求27，28于包括重症监护护士转移到监督的角色，监督支持工人（非RNS），AHPS，内科医师和注册护士，拥有众多的代表团临床任务。类似的模型，称为 pod 模型，已在全球实施。29医院还针对与 COVID-19 相关入院患者大量涌入相关的极端人员配备问题制定了内部解决方案。必要时，重症监护护士开始监督非重症监护人员提供床边病人护理。这对成为重症监护护士的概念构成了威胁。世界重症监护联合会概述了重症监护护理人员的高技能性质，并建议重症监护护士应专注于需要高级专家技能、专业知识和患者护理最佳实践知识的任务。30此外，应考虑各种人员配备模式，包括使用支持人员优先安排重症监护护士，以提供高质量的专家护理。30重症监护护士的概念在最近的研究中受到挑战，即 SEISMIC 研究（重症监护中人员配备模型的评估研究，美国国立卫生研究院 ref: 200100），31接受采访的高级领导建议床边护理并不总是需要合格的重症监护护士。这一发现可能会加剧人们对无法清楚地确定重症监护护士的属性的恐惧，反过来，这对规划重症监护护士人员配置意味着什么。
艾伦通过对护理隐形工作的人种学研究做出的开创性贡献概述了护士如何进行“工作组织”，33这被视为“肮脏”或“隐形”工作，不涉及直接的患者护理。相当多的精力花在创造工作知识上，通过信息定位、解释、意义构建和检查转化为有助于个人护理轨迹的叙述。33这可能包括一名高级重症监护护士，负责轮班组织人员配备并通过出院讨论促进医院的患者流动。在专注于维持患者流动、支持组织效率和更广泛人群需求的管理护理与护理个人的专业动力（例如床边护士照顾不想过早将某人出院到病房）。患者的复杂性和工作组织取代了人员配备数量的概念。很多时候，很容易被数字和比率的概念分心，而不是了解需要哪些护理资源才能安全地满足医疗保健组织中的个人和人群需求，降低风险并确保提供高质量的护理。莱达尔34概述了护理工作在提供以人为本的护理方面的隐形性，通过护理的衔接，将任务联系在一起以保持患者的叙述，确保伙伴关系和记录护理，远离常规护理。这可能会带来挑战，因为分类任务使护理更加明显，并且更有可能受制于确定服务成本、酌情判断、自主权和发展中的突发事件。护士必须找到一种方法来协调矛盾的信息和任务。34对于床边的重症监护护士来说，这种无形的工作往往表现在需要兼顾技术和关怀；协调这些以实现以人为本的护理。Locsin 重新审视她对技术和关怀的原始辩证法， 35在那里，重症监护护士被视为技术鉴赏家，通过巧妙地管理复杂的反应来满足人类需求来了解人，强调如何通过护士巧妙地管理任务，以及技术和护理可以在重症监护中共存。36
最近几个月，随着 COVID-19 和护士-病人的出现，护理艺术与科学之间的平衡紧张，重症护理护士想要在技术上胜任，但仍然关心并专注于个人及其家人的需求。在世界某些地区，这一比例高达一名重症监护护士负责监督 6 名患者（在非重症监护护士和非 RN 支持人员的支持下）。37 - 39对于在大流行期间发现自己处于监督地位的许多重症监护护士来说，工作的组织和监督必须优先于直接护理。
因此，虽然数字对于了解重症监护病房或日常需求的整体机构很重要，但过去一年对床边护士和护理计划人员都提出了前所未有的挑战。自从大流行引起的人员配备激增以来，满足安全水平的重症监护护理的压力有时令人难以忍受。重症监护护士的长期短缺，40 名有很高的离职意愿41 名护士福利不佳，42 名、43 名大流行使情况更加复杂，不仅需要检查护理在重症监护中的作用，而且还需要检查不同的劳动力模式如何影响重症监护。最近人员配备压力的人力成本非常明显，预计重症监护护士将外流，42 有可能进一步稀释合格的重症监护护理人员和重症监护人员的可用技能组合。
大流行揭示了背景和情境因素对于人员配备模型的重要性26，而支持人员配备部署决策的工具缺乏可靠的证据基础。10 , 13 , 44这些系统评价的一致信息是，缺乏证据支持一种重症护理护士人员配备模式优于另一种模式，并且人员配备水平较高与改善结果（患者/服务/护理）；然而，1:1 护理模式（一名重症监护护士照顾最严重的危重病人）一直存在争议。
尽管进行了所有这些工作，但仍有大量工作需要解决；例如，在更广泛地定义技能组合时存在高度的异质性（例如，注册护士的百分比；注册护士提供的护理比例），这表明需要明确，22 , 25这在重症监护中可能会更加复杂，尤其是随着上述新角色的出现。虽然技能组合是人员配备模型中的一个已知因素，但它没有考虑上下文和护理的组织方式（例如，轮班模式/患者流动）以及组织这种护理的相关护理工作。我们需要了解替代模型如何解决 COVID 中前所未有的人员配备挑战及其遗留问题，例如患者结果（例如，死亡率、不良事件、康复）、服务结果（例如，员工成本/轮班模式）和护士结果（例如，保留）。
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