Management and leadership of intensive care units for the future.

Abstract

This special issue of Nursing in Critical Care highlights the commitment of nurses and nursing to the ongoing contribution of developing nursing management and leadership in intensive care units (ICUs) now and for the future. The articles featured in this special issue provide valuable insight into the landscape of intensive care for the future and highlight areas that need further attention and greater understanding in the field. Deepening our understanding of the complexities that exist within ICU settings across a broad range of areas, including workforce issues and retention, and the psychological impacts of the work, is essential, particularly at a time when the nursing profession is experiencing shortages worldwide, causing a major public health issue for health care systems.1 As such, the prominent themes and findings, which emerged in this issue represent an opportunity for anticipating and advancing responsive organizational management and leadership. It can be discerned that contemporary research relating to ICU and critical care settings cannot be discussed without acknowledging the COVID-19 pandemic. As such, the impacts of COVID-19, particularly on nurses' mental health and wellbeing, are an important theme, which permeates the papers in this issue. Nursing turnover has a significant impact on health systems, nurses, patients and their families.2 It is expensive economically and costly in terms of the potential negative consequences it can have on nurses' morale, confidence and satisfaction as well as on patient outcomes and effective health system responses in critical care settings. Turnover intention precedes a nurse's final decision to leave the job and therefore serves as a crucial point for managers to intervene.3 Xu et al.'s3 meta-analysis identified a pooled prevalence of 27% turnover intention amongst ICU nurses globally, although, importantly, it recognized the substantial variation across different studies and contexts. However, despite varying levels of intentions to leave, there is agreement on the contributing factors that lead to intentions to leave, which include job stress, workplace environment, workplace violence, moral distress, exhaustion and burnout.2-6 Further to this, we must recognize the importance of understanding specific relationships between turnover intention and variables, such as demographics, job-related factors, depressive symptoms and organizational commitments. Jiang et al.'s4 study examined these relationships and concluded that the intention to leave amongst Chinese Emergency Department nurses was strongly influenced by experiences of workplace violence, symptoms of depression, poor self-rated health and the number of night shifts per month. These findings point to a number of priority areas for leadership and management to address as a way of averting or forestalling turnover intentions and enabling deeper insights into and understanding of the individual factors that intensify or ameliorate job (dis)satisfaction and intentions to leave. Positive workplace environments are fundamental in reducing intention to leave and also in preventing adverse emotional and physical consequences amongst nurses. Despite this, links between ICU working environments and high levels of burnout amongst health professionals such as nurses continue to be found.5 Aspects contributing to unhealthy workplace environments include experiences of workplace bullying, which is recognized by the World Health Organization as a major public health issue.7 As such, this area of study is essential in critical care nursing settings where reported rates of bullying are high.8 Examining this area, Amini et al.'s9 study from Iran showed a positive relationship between workplace bullying and occupational burnout syndrome and highlighted concerning levels of both experiences (respectively 75.5% and >70%) amongst participants. Flexibility, understanding and involving nurses in their work assignments were recognized as important in reducing the potential for burnout. In some studies, for example, when nurses worked in their preferred units, they experienced greater job satisfaction, reduced burnout, and lower stress levels.5, 10 Understanding the individual characteristics that support positive coping strategies and wellbeing in high pressure ICU environments is important. Contributing to this area of research is Cichoń et al.'s11 study, which found that high emotional intelligence was associated with positive coping strategies. While we recognize the importance of understanding the intrinsic features within an individual that serve as protective factors, it is imperative to also focus on organizational factors, which have the potential to address unhealthy working environments. Leadership styles have been found to influence ICU nurses' quality of professional life and, indeed, represent an opportunity for nurse management to systematically implement training to support leadership styles, which offer the most positive outcomes for staff. Cosentino et al.12 found that leaders who showed concern towards their staff had a significant positive impact on nurses' compassion and satisfaction. Knowing and understanding positive leadership dimensions provides an informed foundation for management to adopt leadership strategies that promote such characteristics. Conversely, negative workplace environments and unsustainable workloads can have deleterious impacts that compromise patient safety.13 The challenge of heavy workloads and staff shortages is an important issue, which commonly arises in ICU settings and reflects a disquieting dichotomy between workload requirements versus expectations and workforce availability versus capability. Further to this it represents a very challenging situation when essential care is required, but the potential for further harm because of scarce human resources exists. As conveyed by Falk,14 it is essential that nursing managers understand the specific competencies and skills required to meet the needs of patients with diverse characteristics in ICUs. Staffing competency is also important when considering the delivery of interventions that require compliance with international standards. As Rashid et al.'s15 study of ICUs in Peshawar reflects, staffing non-compliance with international guidelines can be as concerning as staff shortages. Moral distress is recognized internationally as a major factor in nurses' intentions to leave, job dissatisfaction and turnover. In a survey cited by Işık & Yıldırım,16 43% of ICU nurses in Treviso, Italy reported considering leaving their jobs because of moral distress.17 Further, Witton et al.6 found that nurses with higher moral distress were more likely to leave their current job. The American Association of Critical-Care Nurses notes that “moral distress occurs when you know the ethically correct action to take but you are constrained from taking it.”18 Işık and Yıldırım's16 study reflected this definition, finding the greatest levels of moral distress reported were caused by experiences where nurses felt a violation of the patient's autonomy and the no-harm principle of medical ethics. Ethical decision-making is a core feature of nursing; however, the turbulent conditions created by the pandemic have meant nurses face complex situations requiring moral and ethical decision-making more often.10 Expanding on this area is a study from Turkey conducted during the COVID-19 pandemic that evaluated moral sensitivity and moral courage in ICU nurses.10 In the study, moral courage is understood as making decisions based on what is morally right, and moral sensitivity is related to a nurse's capacity to make ethical decisions. The study found that the pandemic created ethical dilemmas for nurses as a result of overcrowding, resource scarcity, extended working hours and an increased workload. Further to the aforementioned discourse on morality, Sumner19 discusses the emerging concept of moral injury in the field of critical care nursing. Moral injury occurs when actions that violate an individual's deeply held moral beliefs are witnessed or experienced. For nurses working in ICUs amidst the COVID-19 pandemic, moral injury was reported to have developed as a frequent experience because of the conflict of upholding COVID-19 restrictive visitor policies versus their own moral beliefs. In these contexts, nurses were often subjected to witnessing patients dying without having loved ones by their side and were required to make unprecedented and urgent decisions about which patient amongst many in need of urgent critical care should be treated first.19 A study from the UK captured these experiences and their impact in responses from an e-survey completed by critical care nurses.20 Many respondents expressed concern because they felt they were delivering substandard nursing care, with one nurse stating, “Not being able to provide adequate care to patients and not allowing visitors. This was awful and conflicted with my morals and personal values” (Respondent 56, p. 6). Prior to the pandemic, ICU nurses' experiences of burnout, emotional exhaustion, compassion fatigue and moral distress were well understood, and their relationship with turnover and intent to leave critical care settings was well established.21 This has since been further compounded by COVID-19, and the critical care workforce has been “profoundly affected and destabilized”.6 Jim Campbell, WHO Director of Health Workforce states, “the levels of anxiety, stress and depression among health and care workers has become a “pandemic within a pandemic.”1 Most importantly, this statement acknowledges that although COVID-19 was first considered a physical health crisis, the reality is that it has become a major mental health crisis.22 The international literature, including Baraka et al.'s23 study from Egypt, highlights the adverse psychological impacts COVID-19 has had on critical care nurses, including increased anxiety, stress and depression.23-25 Experiences of clinically concerning psychiatric distress (85.4%) amongst nurses working with COVID patients and non-COVID patients in Nepal were identified,26 and nurses from the UK have reported significant psychological trauma as a result of working amidst the pandemic. One respondent in Stayt et al.'s20 study, for example, explained the trauma as like being in a war zone. In line with this statement, novel research from Segev27 explores critical care nurses' wartime experiences and adeptly correlates themes with contexts like COVID-19. An important theme identified by Segev's study was nurses' need for recognition. In the context of COVID-19, where initial outpourings of support and recognition for frontline staff were observed, a form of COVID-19 compassion fatigue amongst the global community can be witnessed, and as a result, frontline recognition and support can be seen to waver, despite a persistent demand for frontline workers to work in high-risk, high-pressure environments. When considering the management and leadership of ICUs for the future, the articles and empirical evidence included in this special issue demonstrate the urgent need for “creative and deliberate interventions”19 to not only support but protect the mental health of ICU staff. As the World Innovation Summit for Health Chief Executive Officer, Sultana Afdhal states, “COVID-19 has brought into sharp focus the need for better care for those who care for us.”1 As such, nurses' wellbeing is high on the international political agenda. However, at the same time, greater conceptual clarity is required regarding our understanding of wellbeing and its link to job satisfaction, demands and stress. Understanding the influences on nurses' wellbeing needs to encompass organizational and management features. The utilization of a demand/control/support model28, 29 provides for an understanding that the clinical environment is naturally challenging and demanding, and that offsetting this, and improving the wellbeing of nurses, requires more than just supporting wellbeing, but rather extends to role autonomy and managerial and collegial support. Having control over one's job is key, as is the social aspect of the workplace and effective leadership, all of which are highlighted in this issue. Research ought to be developed and encouraged that begins to explore the impact of specific interventions for nurses and specific relationships between nurses' wellbeing and patient outcomes, longitudinally to build on the bulk of descriptive cross-sectional data that exists. Large multisite international studies would also be useful. Studies to improve nurses' wellbeing ought to focus on increasing nurses' autonomy within their roles, improving managers' leadership skills and fostering a nurturing environment. Overall, there is a need to develop and disseminate research that examines the links between nurse wellbeing and patient outcomes to contribute to the body of knowledge in international nursing management and leadership worldwide. The authors declare no conflicts of interest.