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Critical care workforce in crisis: A path forward

      Healthcare professionals are carers at their core. They are highly educated, trained, and skilled professionals that provide a breadth of care to the sickest in our communities. This is most evident in critical care, where each patient is cared for by one nurse and a team of physicians, physiotherapists, and other allied health professionals who closely monitor patients and conduct invasive procedures to maintain life. Without a healthy and functioning clinical workforce, health care cannot be delivered, and our communities and the people within suffer.

      1. The supply of critical care clinicians is at risk

      The World Health Organization (WHO) has predicted the health workforce to have a shortfall of 10 million by 2030, with low- and middle-income countries bearing the brunt.
      World Health Organization
      State of the world's nursing 2020: investing in education, jobs and leadership.
      ,

      World Health Organization: Health Workforce. Available from: (https://www.who.int/health-topics/health-workforce#tab=tab_1).

      Nursing is the largest professional group, accounting for approximately 59% of the total health workforce. In 2020, the first State of the World's Nursing report, published by the WHO, reported that in 2018 the global nursing workforce was 27.9 million with an estimated global shortfall of 5.9 million nurses; 89% of that shortage was concentrated in low- and middle-income countries.
      World Health Organization
      State of the world's nursing 2020: investing in education, jobs and leadership.
      While the COVID-19 pandemic has upended intensive care unit (ICU) human resources and human capital, such workforce concerns are not new. Having enough critical care healthcare professionals has been an ongoing concern for at least the last 20 years; predictions from the early 2000s suggested that there would not be enough physicians and nurses to care for the aging population.
      • Angus D.C.
      • Kelley M.A.
      • Schmitz R.J.
      • White A.
      • Popovich Jr., J.
      Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?.
      ,
      • Reuben D.B.
      • Zwanziger J.
      • Bradley T.B.
      • et al.
      How many physicians will Be needed to provide medical care for older persons? Physician manpower needs for the twenty-first century.
      International immigration patterns and ‘brain drain’ has, at times, crippled the healthcare workforce in developing countries, all the while supplying developed nations with a steady stream of experienced clinicians.
      • Bradby H.
      International medical migration: a critical conceptual review of the global movements of doctors and nurses.
      These circumstances were only exacerbated and further complicated by COVID-19, which also highlighted not only the lack of medical and nursing workforce but also that there are limited workforce data on specialised critical care allied health professionals who are an essential part of the critical care team.
      • Grenvik A.
      Role of allied health professionals in critical care medicine.
      ,
      • Ridley E.J.
      • Freeman-Sanderson A.
      • Haines K.J.
      Surge capacity for critical care specialised allied health professionals in Australia during COVID-19.

      2. The health of the workforce is at risk

      Burnout, dissatisfaction, and psychological distress in our ICU workforce are staggering.
      • Wahlster S.
      • Hartog C.
      Coronavirus disease 2019 aftermath: psychological trauma in ICU healthcare workers.
      Estimates from ICU healthcare workers suggest that rates of post-traumatic stress disorder are upwards of 47%, burnout at 45–85%, depression at 16–65%, and moderate to extreme anxiety and stress reported at around 28%.
      • Wahlster S.
      • Hartog C.
      Coronavirus disease 2019 aftermath: psychological trauma in ICU healthcare workers.
      ,
      • Hammond N.E.
      • Crowe L.
      • Abbenbroek B.
      • et al.
      Impact of the coronavirus disease 2019 pandemic on critical care healthcare workers' depression, anxiety, and stress levels.
      These negative impacts on the critical care workforce have been magnified by the pandemic with increased personal safety risk to health professionals which have included unacceptably high rates of infections
      • Barranco R.
      • Ventura F.
      COVID-19 and infection in health-care workers: an emerging problem.
      ,

      World Health Organisation: Health and Care Worker Deaths during COVID-19. (https://www.who.int/news/item/20-10-2021-health-and-care-worker-deaths-during-covid-19).

      and increased reports of physical violence and psychological stigma during the COVID-19 pandemic.
      • Saragih I.D.
      • Tarihoran D.E.T.A.U.
      • Rasool A.
      • Saragih I.S.
      • Tzeng H.-M.
      • Lin C.-J.
      Global prevalence of stigmatization and violence against healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis.
      ,
      • Bagcchi S.
      Stigma during the COVID-19 pandemic.
      Not surprisingly, then, reports of ICU nursing turnover and intention to leave are the highest reported ever; in a survey by the International Council of Nurses in December 2020, 90% of the National Nurses Association respondents were somewhat or extremely concerned that heavy workloads, insufficient resources, stress, and burnout were the drivers for nurses leaving the profession. In another survey conducted in 2021 by the American Association of Critical-Care Nurses, 67% of surveyed nurses reported they intend to leave their job in the next 3 years.
      • Ulrich B.
      • Cassidy L.
      • Barden C.
      • Varn-Davis N.
      • Delgado S.A.
      National nurse work environments - october 2021: a status report.
      Understanding how to support, sustain, and maintain the human resources and human capital of the ICU healthcare workforce is integral to the ability of the globe to address the health concerns plaguing our countries. In this special issue of Australian Critical Care, which is focused on a wide range of workforce issues, papers can be broadly categorised into articles that focus on sustaining the workforce (i.e., examining surge capacity, studying specialty nursing roles) as well as a number of articles that focus on supporting the workforce, as it relates to team dynamics, mental health, aggression, discrimination, and harassment in the workforce and the workplace.
      The special issue begins with a qualitative study exploring the potential negative impacts that the angel and hero narrative can have on critical care nurses.
      • Stokes-Parish J.
      • Barrett D.
      • Elliott R.
      • Massey D.
      • Rolls K.
      • Credland N.
      Fallen angles and forgotten heroes: a descriptive qualitative study exploring the impact of the angel and hero harritive on critical care nurses.
      This is followed by an original research article examining the impact of COVID-19 on the wellbeing of critical care health professionals
      • Elliott R.
      • Crowe L.
      • Pollock W.
      • Hammond N.E.
      The impact of the COVID-19 pancemic on critical care health professionals' work practices and wellbeing: a qualitative study.
      and the prevalence of burnout including in Australian and New Zealand ICU research coordinators
      • Yarad E.
      • Bates S.
      • Butler M.
      • Byrne K.
      • Eastwood G.
      • Stattan S.
      • et al.
      Job satisfaction and symptoms of depression, anxiety, stress and burnout: a survey of Australian and New Zealand intensive care research coordinators.
      and nurses in Saudi Arabia.
      • Alzailai N.
      • Barriball K.L.
      • Alkhatib A.
      • Xyrichis A.
      Factors that contribute to burnout among intensive care nurses during the COVID-19 pandemic in Saudi Arabia: a constructivist grounded theory.
      Fostering positive emotions, psychological wellbeing, and productive relationships is explored in a before and after study,
      • Lovell T.
      • Mitchell M.
      • Powell M.
      • Cummins B.
      • Tonge A.
      • Metcalf E.
      • et al.
      Fostering positive emotions, psychological well-being, and productive relationships in the intensive care unit: a before-and-after study.
      and sources of emotional distress and burdens carried by intensivists are reported.
      • Dennis D.
      • van Heerden P.V.
      • Knott C.
      • Khanna R.
      The nature and sources of the emotional distress felt by intensivist and the burdens that are carried: a qualitative study.
      Crowe et al
      • Crowe L.
      • Young J.
      • Smith A.C.
      • Vitangcol K.
      • Maydon H.M.
      Critical care staff wellbeing: a new paradigm for understanding burnout.
      report on wellbeing in critical care staff by proposing a new paradigm for understanding burnout.
      Patient aggression towards ICU staff
      • Patterson S.
      • Flaws D.
      • Latu J.
      • Doo I.
      • Tronstad O.
      Patient aggression in intensive care: a qualitative study of staff experiences.
      and the prevalence of bullying, discrimination, and sexual harassment in Australian and New Zealand nurses is reported for the first time.
      • Parke R.
      • Bates S.
      • Carey M.
      • Cavadino A.
      • Ferguson A.
      • Hammond N.
      • et al.
      Bullying, discrimination, and sexual harassment among intensive care unit nurses in Australia and New Zealand: an online survey.
      A number of authors report studies related to how best to handle surge staffing requirements during the COVID-19 pandemic including in nursing

      Topple M, Nursing workforce deployment and ICU strain during the COVID-19 pandemic in Victoria, Australia.

      and allied health professions,
      • Paykel M.
      • Ridley E.
      • Freeman-Sanderson A.
      • Ramanan M.
      • Booth S.
      • Cook K.
      • et al.
      Allied health surge capacity in Australian intensive care units during the COVID-19 pandeci: a cross-sectional survey.
      while others focus on a team approach
      • Phillips L.
      • Leggett N.
      • Miller J.
      • McKinlay L.
      • Mays K.
      • Haines K.
      Implementation of a novel team-based model of care using expert intensive care unit physiotherapists to supplement critical care surge demand.
      ,
      • Costa D.
      • Wright N.C.
      • Hashem O.
      • Posa A.M.
      • Juno J.
      • Brown S.
      • et al.
      Team dynamics in a COVID-19 intensive care unit: a qualitative study.
      and communication during the pandemic.
      • Digby R.
      • Manias E.
      • Haines K.
      • Orosz J.
      • Ihle J.
      • Bucknall T.
      Perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia.
      ,
      • Chen R.
      • Truong M.
      • Watterson J.R.
      • Burrell A.
      • Wong P.
      The impact of the intensive care unit family liaison nurse role on communication during the COVID-19 pandemic: a qualitative descriptive study of healthcare professionals' perspectives.
      An article on a novel method for monitoring staff and patient activity is reported.
      • Chan P.Y.
      • Tay A.
      • Chen D.
      • De Freitas M.
      • Millet C.
      • Nguyen-Duc T.
      • et al.
      Ambient intelligence-based monitoring of staff and patient activity in the intensive care unit.
      There are articles on education and training including a short-term training program for nonintensivist doctors in India during the COVID-19 pandemic,
      • Siddiqui S.S.
      • Saxena S.
      • Agarwal S.
      • Lohiya A.
      • Muzaffar S.N.
      • Saran S.
      • et al.
      The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: an experience from a population-dense low- and middle-income country.
      education and training challenges in an ECMO service in Australian ICUs,
      • Ross P.
      • Watterson J.
      • Fulcher B.J.
      • Linke N.J.
      • Nicholson A.J.
      • Ilic D.
      • et al.
      Nursing workforce, education and training challenges to implementing extracorporeal membrane oxygenation services in Australian intensive care units: a qualitative substudy.
      and a narrative review of training structure in advanced critical care practitioners in adult ICUs in the UK.
      • Denton G.
      • Arora N.
      • Whyman E.
      • Davies V.
      A narrative review of the training structure, role and safety profile of Advanced Critical CAre Practitioners in adult intensive care services in the United Kingdom.
      Specialty roles are reported including a proposed nurse practitioners service model in ICUs in Australia,
      • Webb S.
      • Butler J.
      • Williams E.
      • Harbour K.
      • Hammond N.
      • Delaney A.
      Intensive care nurse practitioners in Australia: a description of a service model in an adult tertiary intensive care unit.
      the role of ICU nurses in medical emergency teams,
      • Weatherburn C.
      • Greenwood M.
      The role of the intensive care nurse in the Medical Emergency Team: a constuctivist grounded theory study.
      and a proposed practical approach to critical care outreach service.
      • Williams G.
      • Pirret A.
      • Credland N.
      • Odell M.
      A practical approach to establishing a critical care outreach service: an expert panel research design.
      While the pandemic has highlighted the longstanding workforce issues present in critical care, as described in the articles in this issue, it also brings about a unique opportunity. Authors in this special issue have studied new and important problems afflicting the health and sustainability of our workforce. Continuing to move forward with robust and rigorous research to examine novel care delivery models that improve wellbeing, minimise turnover, and ensure we are better prepared for the next pandemic or next healthcare challenge is crucial. Remembering and thanking the critical care workforce for their contribution and continued commitments to work in a caring profession is not enough. In our path forward, we must figure out how to best support and sustain our workforce; the future of critical care hangs on it.

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        Job satisfaction and symptoms of depression, anxiety, stress and burnout: a survey of Australian and New Zealand intensive care research coordinators.
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        • Barriball K.L.
        • Alkhatib A.
        • Xyrichis A.
        Factors that contribute to burnout among intensive care nurses during the COVID-19 pandemic in Saudi Arabia: a constructivist grounded theory.
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        • Lovell T.
        • Mitchell M.
        • Powell M.
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        • Tonge A.
        • Metcalf E.
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        Fostering positive emotions, psychological well-being, and productive relationships in the intensive care unit: a before-and-after study.
        Aust Crit Care. 2023; 36: 28-34
        • Dennis D.
        • van Heerden P.V.
        • Knott C.
        • Khanna R.
        The nature and sources of the emotional distress felt by intensivist and the burdens that are carried: a qualitative study.
        Aust Crit Care. 2023; 36: 52-58
        • Crowe L.
        • Young J.
        • Smith A.C.
        • Vitangcol K.
        • Maydon H.M.
        Critical care staff wellbeing: a new paradigm for understanding burnout.
        Aust Crit Care. 2023; 36: 59-65
        • Patterson S.
        • Flaws D.
        • Latu J.
        • Doo I.
        • Tronstad O.
        Patient aggression in intensive care: a qualitative study of staff experiences.
        Aust Crit Care. 2023; 36: 77-83
        • Parke R.
        • Bates S.
        • Carey M.
        • Cavadino A.
        • Ferguson A.
        • Hammond N.
        • et al.
        Bullying, discrimination, and sexual harassment among intensive care unit nurses in Australia and New Zealand: an online survey.
        Aust Crit Care. 2023; 36: 10-18
      4. Topple M, Nursing workforce deployment and ICU strain during the COVID-19 pandemic in Victoria, Australia.

        • Paykel M.
        • Ridley E.
        • Freeman-Sanderson A.
        • Ramanan M.
        • Booth S.
        • Cook K.
        • et al.
        Allied health surge capacity in Australian intensive care units during the COVID-19 pandeci: a cross-sectional survey.
        Aust Crit Care. 2023; 36: 108-113
        • Phillips L.
        • Leggett N.
        • Miller J.
        • McKinlay L.
        • Mays K.
        • Haines K.
        Implementation of a novel team-based model of care using expert intensive care unit physiotherapists to supplement critical care surge demand.
        Aust Crit Care. 2023; 36: 159-166
        • Costa D.
        • Wright N.C.
        • Hashem O.
        • Posa A.M.
        • Juno J.
        • Brown S.
        • et al.
        Team dynamics in a COVID-19 intensive care unit: a qualitative study.
        Aust Crit Care. 2023; 36: 99-107
        • Digby R.
        • Manias E.
        • Haines K.
        • Orosz J.
        • Ihle J.
        • Bucknall T.
        Perceptions of care, and communication in the intensive care unit during the COVID-19 pandemic in Australia.
        Aust Crit Care. 2023; 36: 66-76
        • Chen R.
        • Truong M.
        • Watterson J.R.
        • Burrell A.
        • Wong P.
        The impact of the intensive care unit family liaison nurse role on communication during the COVID-19 pandemic: a qualitative descriptive study of healthcare professionals' perspectives.
        Aust Crit Care. 2023; 36: 127-132
        • Chan P.Y.
        • Tay A.
        • Chen D.
        • De Freitas M.
        • Millet C.
        • Nguyen-Duc T.
        • et al.
        Ambient intelligence-based monitoring of staff and patient activity in the intensive care unit.
        Aust Crit Care. 2023; 36: 92-98
        • Siddiqui S.S.
        • Saxena S.
        • Agarwal S.
        • Lohiya A.
        • Muzaffar S.N.
        • Saran S.
        • et al.
        The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: an experience from a population-dense low- and middle-income country.
        Aust Crit Care. 2023; 36: 138-144
        • Ross P.
        • Watterson J.
        • Fulcher B.J.
        • Linke N.J.
        • Nicholson A.J.
        • Ilic D.
        • et al.
        Nursing workforce, education and training challenges to implementing extracorporeal membrane oxygenation services in Australian intensive care units: a qualitative substudy.
        Aust Crit Care. 2023; 36: 114-118
        • Denton G.
        • Arora N.
        • Whyman E.
        • Davies V.
        A narrative review of the training structure, role and safety profile of Advanced Critical CAre Practitioners in adult intensive care services in the United Kingdom.
        Aust Crit Care. 2023; 36: 145-150
        • Webb S.
        • Butler J.
        • Williams E.
        • Harbour K.
        • Hammond N.
        • Delaney A.
        Intensive care nurse practitioners in Australia: a description of a service model in an adult tertiary intensive care unit.
        Aust Crit Care. 2023; 36: 133-137
        • Weatherburn C.
        • Greenwood M.
        The role of the intensive care nurse in the Medical Emergency Team: a constuctivist grounded theory study.
        Aust Crit Care. 2023; 36: 119-126
        • Williams G.
        • Pirret A.
        • Credland N.
        • Odell M.
        A practical approach to establishing a critical care outreach service: an expert panel research design.
        Aust Crit Care. 2023; 36: 151-158