'Surge nurses' undertrained for ICU units as virus worsens

Clinical nurse manager Serena O’Brien

Catherine Fegan

The redeployment of non-critical care nurses into daunting critical care roles is bringing intensive care units under increasing pressure as hospitals run out of options amidst increasing Covid-19 admissions.

It comes as hospitals across the country reach into their surge capacity by converting surgical wards and resuscitation areas into intensive care areas to accommodate patients needing critical care.

In St James's hospital in Dublin, where 18 Covid-19 patients were receiving intensive care treatment, demand for critical care nursing is currently outstripping supply, resulting in the reallocation of staff from other disciplines into the highly specialised area of critical care.

"Ultimately, there are less staff around for an increased amount of work," said Dr Enda O'Connor, director of ICU at St James's hospital in Dublin.

"An intensive care nurse is a very specialised member of staff and you can't just magic an intensive care nurse out of the ether.

"What we are having to do is, we are reallocating staff from non-intensive care parts of the hospital to work in intensive care. We are very grateful and delighted to have these staff and I want to be clear about that.

"They get training in the core aspects of looking after critically ill patients. But these are people who are working outside their comfort zones.


"A lot of these staff are specialists, but in a different area. But that's what we have to do, we have to do the best we can."

At the Mater hospital, Dublin, nurses who trained in critical care up to a decade ago and later went into other specialties are being "pulled back in" to deal with the crisis.

The hospital, which has activated its surge plan by caring for some critically ill patients in its high dependency unit, is currently dealing with significant staffing issues.

Serena O'Brien, clinical nurse manager in critical care at the hospital, said the prospect of staffing an ICU with "surge nurses" - nurses redeployed from other areas of the hospital - was a daunting one.

"When we talk about staffing with surge, we are taking nurses into intensive care who have not got intensive care experience and I cannot begin to tell you how scary that is," she said.

Ms O'Brien, who is also chairperson of the Irish Association of Critical Care Nurses, acknowledged that some nurses around the country, who received limited training after the first surge will be plunged into daunting intensive care environments due to the third wave of Covid-19.

It is understood that staff in smaller hospitals have already been redeployed to intensive care nursing roles.

"Critical care nursing is a highly skilled profession," she said.

"You are asking a nurse to come in and look after a ventilator. They have never seen one. They haven't a clue.

"They wouldn't even know where the on/off button is. How would they?

"We are asking them to come into a completely different environment which is much more high-tech.

"Then we are going to throw a dialysis machine at them as well, then we are going to put them in PPE for 12 hours and tell them they can't come out of the room.

"If they're struggling, they have to wave at somebody walking by for help. This is scary."

In emphasising the complexities of the critical care nursing role, Ms O'Brien pointed out that staff undertake years of intensive education and training and that caring for an ICU patient requires one to one, 24/7 expertise.


"A ventilator needs to be cared for and monitored 24/7," she said.

"There are parameters on that machine set specially for each patient and their lung condition at that time.

"We are recording those values on an hourly basis. That is just for supporting their lungs.

"They might also be on medication for blood pressure or dialysis because their kidneys often fail, particularly with Covid.

"That's why you need one nurse, 24/7, because it's not just caring for the patient, it's a multitude of devices surrounding the patient and supporting all of their organs around the clock."

On Monday, Dr Michael Power, HSE clinical lead for intensive care, said 1,300 nurses have received intensive care training since last April and they are now being identified so they can be approached and redeployed.

Meanwhile, in St James's, management initiated surge plans last week, according to Dr O'Connor.

"It's a phased process," he said.

"A step-wise plan, usually with five or six phases, depending on the hospital.

"We are actively planning the more advanced stages. What that means is that the intensive care is expanding into parts of the hospital at the moment that really, traditionally, are not intensive care areas at all."

Dr O'Connor said this involved reconfiguring areas like surgical wards into areas that can accommodate Covid patients, including critically ill patients on ventilators.

"It is essentially turning wards into temporary intensive care areas," he said.

"These are temporary, they are not as good as proper intensive care beds, for the simple reason that intensive care beds are strategically and purpose-built for the management of critically ill patients.

"We are doing the best we can with the limited infrastructure that we have.

"We have all the vital equipment that we need at the minute, things like ventilators and dialysis machines.

"The infrastructure is there, but it's suboptimal, there is no doubt about that.


"The equipment is there, but staffing is our biggest issue."

With a pummelled workforce that has already endured almost a year of battling Covid-19, there are concerns about the impact of sending inexperienced staff into intensive critical care environments.

"We have done a survey here locally and there was a high level of stress and anxiety for these nurses who were surge nurses during the first wave," said Ms O'Brien.

"That said, we do provide them with some basic education to help them get through. We have surge training ongoing, it's happening in all of the ICUs across the country.

Catherine Motherway, head of the ICU at the Mid-Western University Regional hospital in Limerick, warned that hospitals here are currently three weeks behind London.

"It is potentially very grim," she said.

"I think people need to look at what is happening in London because we are about three weeks behind them, but we can stop this.

"The only people who can stop this is the public. All we can do (healthcare staff) is respond to it."