Detecting Sepsis in 2016 – CRICU Sepsis Nursing Workshop

This post is a collation of references and resource material from my first presentation in the inaugural Caboolture Redcliffe ICU Sepsis Workshop for nurses.

The objective of this talk was to provide an update on triage and screening for sepsis, the current International standards and how this filters into ongoing refinement of diagnosis and treatment in our ICU.


JAMA Network Consensus Definitions for Sepsis and Septic Shock


Primary Literature:

Secondary Sources:

Extra Reading:

Social Learning for Educators


This blog post was created for and during the Social Learning for Simulation Educators workshop at the Laerdal SUN Meeting Sydney 2016. Here are the fabulous editorial team.

IMG_3304


Some great simulation education blogs:

Extensive collection of simulation content resources from Injectable Orange

Simulating Healthcare – blog by Paul Phrampus

The Simulated Man – blog by Pete Dickens, Swedish sim technician

EM SIM Cases – Peer-reviewed clinical simulation scenarios


References

ICENET – Personal Learning Networks: A hack to maintain competence 

Teaching Course Podcast – Personalised Learning Networks

ICENET – Building effective communication networks: Part 1

Injectable Orange – Lose the egg: take off on Twitter

smaccRUN Dublin

smaccRUN-1

Important: please complete run disclaimer and expression of interest form here


Day: Sunday


Date: 12th June 2016


Time: 14:00


Distance: 5.2K


Meeting Point: Convention Centre Dublin


Route Map:

SMACCRun Route

Route Details:

(adapted from this site) NOTE: different start/finish points!

 

Just in front of Dublin Convention Centre is the sleek new car bridge, the Samuel Beckett Bridge. Cross it to get to the south side of the Liffey, and continue running eastwards from there.

 Beckett Bridge
Samuel Beckett Bridge to Grand Canal Quay

Pass the Ferryman pub and hotel and run along Sir John Rogerson’s Quay till the road ends, where you turn right on Benson Street.

 Rogerson's Quay
Rowers along Sir John Rogerson’s Quay

In 2 blocks you’ll hit the Grand Canal Quay basin, where you turn right. Don’t forget to heed the warning sign!

 Signpost
Don’t forget to turn right at the water!

Now you run towards that huge new glass building with the red sticks growing out front: the Bord Gáis Energy Theatre in Grand Canal Square.

 Energy Theatre
The Bord Gáis Energy Theatre

Continue past the theatre, along its right side, till the street ends at Cardiff Lane, where you turn right and run the two blocks to the river. Here, near the Ferryman again, turn left on Sir John Rogerson’s Quay and run the whole way back along the riverside to the Ha’penny Bridge.

 Street
 Ha'Penny bridge
The Ha’penny Bridge

You’re going to need to cross the spiritual heart of Dublin, at the old Ha’penny footbridge at Temple Bar. Standing on the bridge, with Temple Bar to your right, you can look over the whole route.

 Boardwalk
The new boardwalk along the Liffey

So, cross the bridge and turn right to run along the new wooden boardwalk over the river. The boardwalk goes all the way to the Custom House.

 Custom House
The Custom House

At the imposing, classical Custom House, the boardwalk ends, so cross the street to continue along the pavement. In just a block past the Custom House, you’ll run over an old iron draw-bridge. Immediately after the bridge, turn left to run north into the big open square surrounding the Custom House Quay.

 Custom house quay
Custom House Quay

You’ll run right through a stone archway. On the other side of the quay, cross Mayor Street with its modern tram line (Luas Red Line). You’ll see the Harbour House restaurant on the left, with the glass-room on the waterside. Continue running north past the restaurant along the other side of the canal leading to the next basin in just a hundred meters.

 Custom House Harbour
In Custom House Harbour

Turn right here, between new Custom House Harbour apartment buildings, and run along the basins until the path ends. You take the steps going down to the right, on Commons street. Run right back to the riverside, where you turn left to continue running along the water.

 Jeannie
The Jeannie Johnston

A tall ship, the Jeannie Johnston, is anchored here, serving as a museum for the great emigration wave that resulted from the potato famine in 1845. Just behind you is the sleek new pedestrian bridge, the Sean O’Casey Bridge. Continue with the Jeannie Johnston on your right and you’ll soon see the Convention Centre Dublin up ahead on your left – hurrah!

 

We look forward to joining you all for a hot lap of the Dublin Quays. Make sure to follow @smaccRUN for updates and use #smaccRUN to organise runs during the week with your fellow SMACCDUB attendees.

Remember, IT’S NOT A RACE.

Important: please complete run disclaimer and expression of interest form here

Cheers, Jesse and Natalie

Managing Exposure: Resilience in ICU

Authored by Jennifer

Editor’s note (Jesse Spurr): This summary explains Jennifer’s research study for her Master’s thesis, where she set out to learn how  critical care nurses become resilient. You can read the entire thesis here, watch a short YouTube video here, or a detailed YouTube video summary here. I see the effects of burnout and, conversely, the protective shroud that resilience on a daily basis in the ICU. I believe this is an important line of inquiry for anyone who works in critical care.

 

Managing Exposure: A Grounded Theory of Burnout and Resilience in Critical Care Nurses

Burnout was identified in nursing in 1978[1], and continues to be problematic in the profession[2]. There are many factors that make critical care settings challenging places to work, and burnout among critical care nurses remains high[3]. However, we also know that resilience is an important factor for critical care nurses. Resilience can be defined as “the ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner.”[4] Essentially, resilience is the ability to address something difficult in one’s life in a healthy, positive way. Resilience is important for a lot of professionals, including teachers[5] and soldiers[6], and it was suspected that resilience would be important for nurses as well.

Resilience has been widely studied, in a variety of contexts. However, many of these studies have focused on personality traits associated with resilience, or prevalence rates of resilience or burnout. In this study, I explored how resilience actually happens; that is, how nurses go from experiencing adversity to becoming burnt out or resilient. By explaining how nurses become resilient, we can support nurses by making the process of resilience more visible and easier to manifest. This research is important because we know that resilient nurses call in sick less frequently[7], and can provide safer care to patients and their families. There are nursing and economic benefits to having a resilient nursing workforce.

I spoke with 11 nurses in critical care settings, for up to 90 minutes. We discussed a variety of topics about their experiences at work, their efforts to cope with challenges, and their beliefs about the nursing profession. I combined all of this information to create a framework showing how nurses become resilient. I hoped that if I could illustrate how nurses become resilient, we could make it easier for nurses to follow this process.

So how do nurses become resilient? By Managing Exposure. This model explains how nurses become burnt out or resilient, which opens the door to strategic interventions.

Managing-exposure-website-optimized

It is important to note that this model is presented as being linear and one directional for ease of explanation. In reality, these processes are dynamic and fluid.

 

WA-bar-for-website-1024x104

 

Resilience begins when nurses face adversity. There are many forms that adversity can take; for the purposes of this study, the focus was on adversity that is found in the workplace. Nurses reported several levels of adversity that they encounter every day at work. These included broad, societal influences, such as a lack of respect for nursing. Nurses reported that many people (including patients, families, and nurses’ family members) did not understand or appreciate the role of nurses in critical care. This lack of understanding translated to disrespectful treatment and a lack of support.

Adversity was also found in the culture of the unit, practical concerns, the nature of critical care nursing, and interpersonal conflicts. Nurses described difficulty caring for patients when they plan of care was not what a nurse thought would be best for the patient. Nurses also reported that an inability to access vacation time from work made it difficult for them to address burnout.

There are lots of factors that constituted workplace adversity for nurses. Rather than see these as a list of problems, it is important to recognize that each point is a place where intervention can make a difference. There are concrete opportunities in the workplace to decrease the amount of adversity faced by nurses. While it is impossible to have an adversity-free workplace, there are many ways to decrease adversity and make nursing more manageable.

 

Aware-for-website-1024x104

The factor that moves this model forward is awareness. When nurses had awareness about how they were being affected by workplace adversity, they could make choices to manage their exposure to this adversity. Awareness created the opportunity for nurses to take action.

In order to have awareness, nurses required a disclosure of information that was relevant to their work. They could perceive and understand this information, reflect on it, and consider the outcomes of different courses of action. Based on these potential outcomes, a nurse would choose how to respond.

Awareness is important because it is how nurses understand their experiences and make decisions. If nurses did not have awareness, they would become burnt out.

 

ME-for-website-1024x104

The most important part of this model is Managing Exposure. This is the actions that nurses take to address workplace adversity.

When nurses work in infectious environments, they put on protective equipment, limit their time in sensitive areas, remove the equipment when they leave the area, and clean their hands as they move away. Nurses can use these same strategies psychologically as well, in order to manage their exposure to workplace adversity.

These actions fell broadly into 4 categories:

Protecting: Strategies that nurses used to emotionally protect themselves from adversity, and offload when they were overwhelmed. This included developing a protective shell against emotional concerns, and delegating tasks to colleagues.

Processing: How nurses made meaning from their experiences in critical care. The most common form of processing was talking about challenges at work, especially during change-of-shift report. This time was preferred because it was private, normal, and nurses could talk to someone who shared their experiences.

Decontaminating: Restorative processes that nurses can use to be rejuvenated after difficult experiences. These included developing supportive relationships at work, and outside of work. Nurses also managed exposure by engaging in meaningful activities that were either physical, such as yoga, or creative, such as knitting.

Distancing: The need for nurses to be physically away from the patient bedside. This included short periods of time, such as breaks or a few minutes to recover after a crisis. Nurses also periodically needed longer breaks, such as granted vacation. Ultimately, many nurses recognized that it was difficult for them to manage their exposure to adversity in critical care, and would begin planning to leave the unit years in advance, in anticipation of their own burnout.

 

Nurses told me that they were the most resilient when they could easily use these strategies, with the support of their colleagues, families and organizations. Nurses who used a variety of these strategies told me that they felt more resilient than nurses who only used one or two strategies.

 

indicators-for-website-1024x104

There are a variety of ways that nurses experienced the process of Managing Exposure. Nurses reported they were thriving when they loved their work, and felt passionate, energized, and fully engaged. Nurses achieved resilience when they were able to face difficulties in the workplace, and feel good about the nursing care they could provide. Nurses described themselves at a survival level when they said they struggled at work, but they were trying to retain their compassionate approach to patient care. Finally, nurses reported burnout when they saw patient care as a series of tasks rather than a caring act. They felt anxious before or after work, had difficulty separating their professional and personal lives, and felt like they did not have adequate time to recover between shifts.

It is likely that burnout can lead to post traumatic stress disorder (PTSD), but as PTSD is a psychiatric diagnosis, it was beyond the scope of this study to investigate it directly.

 

So what is the bottom line?

The major finding of this study is that nurses who are burnt out and nurses who are resilient are coming from the same pathway. Just as dating can lead to breakups or marriages, the exposure to adversity can lead to burnout or resilience. Nurses who are burnt out are not bad people, or lacking in personal coping skills. They are having difficulty managing their exposure, which can occur because of personal challenges or systemic barriers. For example, previous studies have identified burnout as a source of increase sick calls7. My research adds another dimension to this: nurses are experiencing burnout and they are trying to manage (potentially by requesting vacation, or trying to seek out interpersonal support). If nurses are not able to manage, such as not being able to get vacation hours granted, or being overwhelmed at home and unable to spend time with support people, they resort to calling in sick because they see no other options. The findings of this study clearly demonstrate that resilience and burnout are not entirely determined by individual nurses. There are systemic factors that can overwhelm a nurse, in spite of good personal coping skills. Workplace adversity can have a toxic impact on nurses, and needs to be taken seriously.

 

The findings of this research study also demonstrate the power of intervention to foster nursing resilience. Nurses shared stories of managers, educators, and colleagues, who had supported them through teaching and advocacy. It is clear that nurses learn how to promote their own resilience, and can be positively impacted by the people and systems around them.

 

Nurses who are resilient give better care to patients. It is important that nurse leaders consider how to support nurses to manage their exposure, to promote safe, dignified health care delivery.

 

To learn more about this research, and see how it may apply to your settings, please see:

A short YouTube summary of the project is here: https://www.youtube.com/watch?v=Z4F-x0dx0mo

A longer YouTube video that describes the details of the project is here: https://www.youtube.com/watch?v=cUHpyqq0M8U

And the full thesis document is available here: http://hdl.handle.net/10791/183 Chapter 4 of the thesis explains the findings of the study in the participants’ own words.

 

References

[1] Shubin, S., & Milnazic, K. (1978). Burnout: The professional hazard you face in nursing. Nursing8, 22-27. Retrieved from: http://journals.lww.com/

[2] Epp, K. (2012). Burnout in critical care nurses: A literature review. Dynamics, 23, 25-31. Retrieved from: http://www.caccn.ca/en/publications/dynamics/

[3] Khamisa, N., Peltzer, K., & Oldenburg, B. (2013). Burnout in relation to specific contributing factors and health outcomes among nurses: A systematic review. International Journal of Environmental Research and Public Health10, 2214-2240. doi: 10.3390/ijerph10062214

[4] Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity. Journal of Advanced Nursing, 60, 1-9. doi: 10.1111/j.1365-2648.2007.04412.x

[5] Taylor, J. L. (2013). The power of resilience: A theoretical model to empower, encourage and retain teachers. Qualitative Report18, 1-25. Retrieved from: http://web.b.ebscohost.com/

[6] Simmons, A., & Yoder, L. (2013). Military resilience: A concept analysis. Nursing Forum48, 17-25. doi:10.1111/nuf.12007

[7] Schaufeli, W. B., Bakker, A. B., & Van Rhenen, W. (2009). How changes in job demands and resources predict burnout, work engagement, and sickness absenteeism. Journal of Organizational Behaviour, 30, 893–917. doi: 10.1002/job.595

 

Managing Exposure: Resilience in ICU

Authored by Jennifer

Editor’s note (Jesse Spurr): This summary explains Jennifer’s research study for her Master’s thesis, where she set out to learn how  critical care nurses become resilient. You can read the entire thesis here, watch a short YouTube video here, or a detailed YouTube video summary here. I see the effects of burnout and, conversely, the protective shroud that resilience on a daily basis in the ICU. I believe this is an important line of inquiry for anyone who works in critical care.

 

Managing Exposure: A Grounded Theory of Burnout and Resilience in Critical Care Nurses

Burnout was identified in nursing in 1978[1], and continues to be problematic in the profession[2]. There are many factors that make critical care settings challenging places to work, and burnout among critical care nurses remains high[3]. However, we also know that resilience is an important factor for critical care nurses. Resilience can be defined as “the ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner.”[4] Essentially, resilience is the ability to address something difficult in one’s life in a healthy, positive way. Resilience is important for a lot of professionals, including teachers[5] and soldiers[6], and it was suspected that resilience would be important for nurses as well.

Resilience has been widely studied, in a variety of contexts. However, many of these studies have focused on personality traits associated with resilience, or prevalence rates of resilience or burnout. In this study, I explored how resilience actually happens; that is, how nurses go from experiencing adversity to becoming burnt out or resilient. By explaining how nurses become resilient, we can support nurses by making the process of resilience more visible and easier to manifest. This research is important because we know that resilient nurses call in sick less frequently[7], and can provide safer care to patients and their families. There are nursing and economic benefits to having a resilient nursing workforce.

I spoke with 11 nurses in critical care settings, for up to 90 minutes. We discussed a variety of topics about their experiences at work, their efforts to cope with challenges, and their beliefs about the nursing profession. I combined all of this information to create a framework showing how nurses become resilient. I hoped that if I could illustrate how nurses become resilient, we could make it easier for nurses to follow this process.

So how do nurses become resilient? By Managing Exposure. This model explains how nurses become burnt out or resilient, which opens the door to strategic interventions.

Managing-exposure-website-optimized

It is important to note that this model is presented as being linear and one directional for ease of explanation. In reality, these processes are dynamic and fluid.

 

WA-bar-for-website-1024x104

 

Resilience begins when nurses face adversity. There are many forms that adversity can take; for the purposes of this study, the focus was on adversity that is found in the workplace. Nurses reported several levels of adversity that they encounter every day at work. These included broad, societal influences, such as a lack of respect for nursing. Nurses reported that many people (including patients, families, and nurses’ family members) did not understand or appreciate the role of nurses in critical care. This lack of understanding translated to disrespectful treatment and a lack of support.

Adversity was also found in the culture of the unit, practical concerns, the nature of critical care nursing, and interpersonal conflicts. Nurses described difficulty caring for patients when they plan of care was not what a nurse thought would be best for the patient. Nurses also reported that an inability to access vacation time from work made it difficult for them to address burnout.

There are lots of factors that constituted workplace adversity for nurses. Rather than see these as a list of problems, it is important to recognize that each point is a place where intervention can make a difference. There are concrete opportunities in the workplace to decrease the amount of adversity faced by nurses. While it is impossible to have an adversity-free workplace, there are many ways to decrease adversity and make nursing more manageable.

 

Aware-for-website-1024x104

The factor that moves this model forward is awareness. When nurses had awareness about how they were being affected by workplace adversity, they could make choices to manage their exposure to this adversity. Awareness created the opportunity for nurses to take action.

In order to have awareness, nurses required a disclosure of information that was relevant to their work. They could perceive and understand this information, reflect on it, and consider the outcomes of different courses of action. Based on these potential outcomes, a nurse would choose how to respond.

Awareness is important because it is how nurses understand their experiences and make decisions. If nurses did not have awareness, they would become burnt out.

 

ME-for-website-1024x104

The most important part of this model is Managing Exposure. This is the actions that nurses take to address workplace adversity.

When nurses work in infectious environments, they put on protective equipment, limit their time in sensitive areas, remove the equipment when they leave the area, and clean their hands as they move away. Nurses can use these same strategies psychologically as well, in order to manage their exposure to workplace adversity.

These actions fell broadly into 4 categories:

Protecting: Strategies that nurses used to emotionally protect themselves from adversity, and offload when they were overwhelmed. This included developing a protective shell against emotional concerns, and delegating tasks to colleagues.

Processing: How nurses made meaning from their experiences in critical care. The most common form of processing was talking about challenges at work, especially during change-of-shift report. This time was preferred because it was private, normal, and nurses could talk to someone who shared their experiences.

Decontaminating: Restorative processes that nurses can use to be rejuvenated after difficult experiences. These included developing supportive relationships at work, and outside of work. Nurses also managed exposure by engaging in meaningful activities that were either physical, such as yoga, or creative, such as knitting.

Distancing: The need for nurses to be physically away from the patient bedside. This included short periods of time, such as breaks or a few minutes to recover after a crisis. Nurses also periodically needed longer breaks, such as granted vacation. Ultimately, many nurses recognized that it was difficult for them to manage their exposure to adversity in critical care, and would begin planning to leave the unit years in advance, in anticipation of their own burnout.

 

Nurses told me that they were the most resilient when they could easily use these strategies, with the support of their colleagues, families and organizations. Nurses who used a variety of these strategies told me that they felt more resilient than nurses who only used one or two strategies.

 

indicators-for-website-1024x104

There are a variety of ways that nurses experienced the process of Managing Exposure. Nurses reported they were thriving when they loved their work, and felt passionate, energized, and fully engaged. Nurses achieved resilience when they were able to face difficulties in the workplace, and feel good about the nursing care they could provide. Nurses described themselves at a survival level when they said they struggled at work, but they were trying to retain their compassionate approach to patient care. Finally, nurses reported burnout when they saw patient care as a series of tasks rather than a caring act. They felt anxious before or after work, had difficulty separating their professional and personal lives, and felt like they did not have adequate time to recover between shifts.

It is likely that burnout can lead to post traumatic stress disorder (PTSD), but as PTSD is a psychiatric diagnosis, it was beyond the scope of this study to investigate it directly.

 

So what is the bottom line?

The major finding of this study is that nurses who are burnt out and nurses who are resilient are coming from the same pathway. Just as dating can lead to breakups or marriages, the exposure to adversity can lead to burnout or resilience. Nurses who are burnt out are not bad people, or lacking in personal coping skills. They are having difficulty managing their exposure, which can occur because of personal challenges or systemic barriers. For example, previous studies have identified burnout as a source of increase sick calls7. My research adds another dimension to this: nurses are experiencing burnout and they are trying to manage (potentially by requesting vacation, or trying to seek out interpersonal support). If nurses are not able to manage, such as not being able to get vacation hours granted, or being overwhelmed at home and unable to spend time with support people, they resort to calling in sick because they see no other options. The findings of this study clearly demonstrate that resilience and burnout are not entirely determined by individual nurses. There are systemic factors that can overwhelm a nurse, in spite of good personal coping skills. Workplace adversity can have a toxic impact on nurses, and needs to be taken seriously.

 

The findings of this research study also demonstrate the power of intervention to foster nursing resilience. Nurses shared stories of managers, educators, and colleagues, who had supported them through teaching and advocacy. It is clear that nurses learn how to promote their own resilience, and can be positively impacted by the people and systems around them.

 

Nurses who are resilient give better care to patients. It is important that nurse leaders consider how to support nurses to manage their exposure, to promote safe, dignified health care delivery.

 

To learn more about this research, and see how it may apply to your settings, please see:

A short YouTube summary of the project is here: https://www.youtube.com/watch?v=Z4F-x0dx0mo

A longer YouTube video that describes the details of the project is here: https://www.youtube.com/watch?v=cUHpyqq0M8U

And the full thesis document is available here: http://hdl.handle.net/10791/183 Chapter 4 of the thesis explains the findings of the study in the participants’ own words.

 

References

[1] Shubin, S., & Milnazic, K. (1978). Burnout: The professional hazard you face in nursing. Nursing8, 22-27. Retrieved from: http://journals.lww.com/

[2] Epp, K. (2012). Burnout in critical care nurses: A literature review. Dynamics, 23, 25-31. Retrieved from: http://www.caccn.ca/en/publications/dynamics/

[3] Khamisa, N., Peltzer, K., & Oldenburg, B. (2013). Burnout in relation to specific contributing factors and health outcomes among nurses: A systematic review. International Journal of Environmental Research and Public Health10, 2214-2240. doi: 10.3390/ijerph10062214

[4] Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity. Journal of Advanced Nursing, 60, 1-9. doi: 10.1111/j.1365-2648.2007.04412.x

[5] Taylor, J. L. (2013). The power of resilience: A theoretical model to empower, encourage and retain teachers. Qualitative Report18, 1-25. Retrieved from: http://web.b.ebscohost.com/

[6] Simmons, A., & Yoder, L. (2013). Military resilience: A concept analysis. Nursing Forum48, 17-25. doi:10.1111/nuf.12007

[7] Schaufeli, W. B., Bakker, A. B., & Van Rhenen, W. (2009). How changes in job demands and resources predict burnout, work engagement, and sickness absenteeism. Journal of Organizational Behaviour, 30, 893–917. doi: 10.1002/job.595