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

Abstract

AbstractAimsTo examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates.BackgroundPre-pandemic UK survey data show that up to 60% of intensive care units (ICUs) 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 ICUs 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.MethodsFocus groups with health care professionals working in ICUs (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.FindingsThree themes were identified: the constraining or enabling nature of ICU and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and ICU flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes.ConclusionsWhilst 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 wellbeing, ICU layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for ICU nurse staffing and highlights important factors to be accounted for in future research studies.Implications for Nursing ManagementThe potential opportunities for different staffing models are likely to be highly dependent on other professions. Hence, any change to staffing models needs to take into account how different professions work together.Factors such as ICU layout, reported to influence nurse staffing decisions, suggest that patient safety in ICU may not be best served by blanket ‘ratio’ approaches to nurse staffing, intended to apply uniformly across health services.The findings have the potential to feed into discussions about funding tariffs for critical care and quality metrics to be included in commissioning contracts.