key: cord-0771220-ie5yyem7
authors: Alshammari, Muna; Vellolikalam, Chitra; Alfeeli, Sadiq
title: Perception of other healthcare professionals about the nurses' role and competencies in veno‐venous extracorporeal membrane oxygenation care: A qualitative study
date: 2021-11-28
journal: Nurs Open
DOI: 10.1002/nop2.1137
sha: cfa2a79cd5d7bf14698631aa281a4b52954032e6
doc_id: 771220
cord_uid: ie5yyem7

AIM: This study aimed to explore the perception of other healthcare professionals, including the doctors, physiotherapists and perfusionists, about the nurses' role and competencies in veno‐venous extracorporeal membrane oxygenation. BACKGROUND: Extracorporeal membrane oxygenation is considered as a challenging clinical activity that requires critical decision and rapid response from nurses, particularly in emergencies. It was observed that nurses are primarily responsible for bedside management of these patients, and teamwork was found helping the nurses to manage this high‐acuity care. However, little is known on the perception of other healthcare professionals about the nurses' roles and competencies, which would contribute to further improvements in quality extracorporeal membrane oxygenation care. DESIGN: This was a qualitative descriptive study. METHODS: One‐to‐one in‐depth interviews were conducted with nine healthcare professionals working in extracorporeal membrane oxygenation care in an adult intensive care unit of a general hospital in Kuwait. RESULTS: Participants reported that nurses play critical and multiple roles and responsibilities in the insertion, maintenance, weaning, and retrieval of extracorporeal membrane oxygenation, plus providing general nursing care, and performed their roles competently. Heavy workload, less recognition and support, and individual differences in competence were reported as possible barriers to the nurses' performance. CONCLUSION: Other healthcare professionals recognize continuous training, having experience, teamwork, and increased staffing as measures that can promote the nurses' role in extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a complex and invasive treatment that allows the lungs to rest and recover from respiratory failure while minimizing further iatrogenic ventilator-induced lung injury associated with conventional systems and can improve survival rates and outcomes of patients with severe acute respiratory distress syndrome (ARDS) (Paolone, 2017) . ECMO is a hyperadvanced technology that can take over heart and lung function for people who are critically ill and is commonly administered in the ICU setting (Mosier et al., 2015) . Previous viral illnesses in recent times such as MERS and H1N1 have shown to present good results from ECMO (Savarimuthu et al., 2020) . According to the Extracorporeal Life Support Organization (ELSO), the technique could save up to half of the seriously ill COVID-19 patients for whom ventilation is not working (Beyls et al., 2020) . WHO recommended that expert centres consider ECMO support in COVID-19-related ARDS with refractory hypoxemia if lung protective mechanical ventilation was insufficient to support the patient (Barbaro et al., 2020) . This intervention, therefore, is strongly considered in patients with severe lung injury secondary to COVID-19 (Savarimuthu et al., 2020) .

In COVID-19 patients with severe ARDS, veno-venous (VV) ECMO was a rescue therapy that allowed ultraprotective ventilation and improved patient oxygenation (Jozwiak et al., 2020) .

The role of the intensive care nurse is continually expanding to incorporate these technological advances in the intensive care setting over the past few years (Botsch et al., 2019) . ECMO may save a life by providing pulmonary support for the critically ill patient with severe respiratory distress and present an awarding challenge to the intensive care unit nurse (Gay et al., 2005) .

Effective care and positive outcomes of the ECMO patient necessitate optimal interdisciplinary management from the healthcare team, including expert care from specially trained registered nurses (RNs) (Botsch et al., 2019) . Recently 23 nurses from an adult intensive care unit in Kuwait underwent specialized training in ECMO following the Ministry of Health ECMO committee policy, which was formulated as per ESLO guidelines. Nurses as extracorporeal membrane oxygenation specialists are becoming a trend nowadays as this improves patient outcomes (Hackmann et al., 2017) .

According to ESLO, the ECMO specialist is 'the technical specialist trained to manage the ECMO system and clinical needs of the patient on ECMO under the direction and supervision of an ECMOtrained physician (extracorporeal life support organization (ELSO), 2013). Internationally, specialists come from a range of professional backgrounds, including perfusion, nursing, physiotherapy, and medicine . ECMO specialist is responsible to manage the ECMO system and the clinical needs of the patient on ECMO under the direction and supervision of a licensed ECMO-trained physician (ELSO Guidelines 2010). The use of extracorporeal life support (ECLS) worldwide has increased exponentially, and educating bedside nurses to manage ECLS circuits broadens the availability of trained providers (Hackmann et al., 2017) . With the recent COVID-19 outbreak, ECMO has been found very useful for the treatment of severe forms of COVID-19 and has been successfully implemented in various hospitals (Alshammari et al., 2020) .

The growing demand of ECMO care necessitates the need for more specialized nurses. As ECMO specialists, nurses have significantly more autonomy and responsibility in managing all aspects of patients' care needs on a 24-hr basis, and to have the technical skills and knowledge to safely manage the ECMO circuit with perfusion backup for the more complicated aspects of circuit management . Nurses viewed themselves as competent to perform their role, and this competency was attributed to training, experience and teamwork (Alshammari et al., 2020) .

Extracorporeal membrane oxygenation management requires multidisciplinary teamwork (Alshammari et al., 2020; Ratnani et al., 2018) , and ECMO nurses require the support of other colleagues and management to be able to adequately execute their role (Alshammari et al., 2020) .

Despite nurses reporting that teamwork played a key role in enabling them to provide ECMO care and to achieve favourable outcomes (Alshammari et al., 2020) , they viewed themselves as being disrespected when communicated to harshly by some colleagues, which they considered a negative influence on their work relationships and output (Alshammari et al., 2020) . Many of the nurses also felt overwhelmed due to the absence of team spirit and high expectations placed upon them when encountering new and challenging clinical scenarios even when lacking experience (Wellman, 2017) .

Furthermore, it is recommended that nurses who provide frontline care be acknowledged and rewarded for their selfless effort to boost their morale (Alshammari et al., 2020; Honey & Wang, 2013) .

Literature on perceptions of the role of ECMO nurses by other healthcare professionals is limited in the area; however, existing literature in other fields has shown their role to be appreciated by OHCPs. In a study by Oyetunde et al. (2014) that explored the perception of patients and other healthcare professionals about the attitude and behaviour of nurses working at one university college hospital, the authors reported that the quality of care provided by the nurses in terms of behaviour and attitudes was appreciated by both other healthcare professionals and patients.

Other healthcare professionals and nurses work together as a team, and one cannot work alone without the other as teamwork is very crucial to manage the complex critical ECMO care. In this context, examining the perceived roles and competencies of nurses and the perceived gaps from the perspective of other healthcare professionals who would be in day-to-day contact with the nurses will give more insight into the role of nurses in ECMO. As nurses need adequate preparation and adaptation to deal with this complexity of care, scrutinizing their role and competencies can be used to discern and describe how effective they are in carrying out their duties as professionals. In addition, this helps in identifying areas that may need improvement and to facilitate safe and quality care provision.

A descriptive qualitative approach was adopted, using tape-recorded interviews. Semistructured interviews were used to allow for flexible data collection that resulted in a rich detailed description of the perceptions of other healthcare professionals regarding the roles and competencies of nurses in ECMO care.

The study was conducted in a general hospital under the Ministry of Health (MoH) in Kuwait. The hospital was selected because it offers VV ECMO (which is the focus of the current study). This hospital provided education and training to prepare nurses and other healthcare providers to become specialized in ECMO.

Purposive sampling was adopted for the selection of participants.

The study sample included a total of nine other healthcare professionals who worked in the adult section of the ICU at the respective hospital. We approached nine OHCPs who all accepted to take part in the study. Participants' biodemographic characteristics are provided in Table 1 below.

The researcher introduced herself to the participants before the commencement of interviews and explained the purpose of the study to them. To ensure privacy of all nformation, only authorized individuals were allowed at the interview sessions. A semistructured interview guide was used during the interview procedure, and every participant got interviewed only once. All interviews were in the English language and lasted between 30 and 50 min. An audio recorder was used to record the interviews after which they were transcribed verbatim. The first author, who was a PhD student at the time, an experienced qualitative researcher and a chronic disease expert, transcribed the interviews. To ensure anonymity of participants, all identifiable materials were removed from the interview transcripts before analysis. Co-authors cross-checked all transcribed material to ensure their accuracy. Key insights from the interviews were captured as field notes and were incorporated in the analysis.

To maintain rigor, all authors were involved in the coding process.

The lead researcher's background could have an influence on the research, and this was put into consideration throughout the data analysis and interpretation. Member checking, which could have provided more strength to the research, was not done due to resource constraints.

Data analysis was guided by Braun and Clarke's 15-point checklist (Braun & Clarke, 2006) , following the outlined strategies, that include the following: (a) data preparation and organization, (b) coding and condensing of codes into resultant themes and (c) data presentation in the form of a discussion. Data analysis was initiated by getting familiar with the data through reading and re-reading of the text. Throughout the data analysis process, memos and other explanatory notes were captured. The initial phase of data analysis followed an inductive thematic analysis approach, which generated codes that guided further analysis. NVIvo12 software was used to manage the data analysis process. Regular meetings among the researchers were held to discuss the emerging analysis and to conclude on the generated themes. Data saturation, where further analysis did not generate new codes, guided the number of participants that were included in the study. We also concluded the data collection after the generated data had addressed the objectives of the study. and written informed consent was provided by all study participants.

Participant's confidentiality was ensured by using codes to identify them and by restricting access to all study information to only the research team. Hard copies of all materials regarding the study will be kept in a lock-protected cupboard at the primary author's office for 7 years after the study closure.

The findings of the current study suggested that ECMO nurses play a critical role in the management of VV ECMO. We have a list of nurse competency policy. While training nurses for ECMO, some of them will understand the concepts quickly by one day itself and some of them will take two weeks to understand ECMO. So, if she/he could not reach the competency, she/he is not capable of being an ECMO nurse (OHCP -2).

Continuing education is given to the nurses to refresh and update them on new innovations. This is undertaken as compulsory drills every 3 months and includes theory and practical workshops.

The specialized trainings and experiences enabled nurses to develop critical decision-making skills and to make rapid responses during emergencies, sometimes independent of other healthcare staff as OHCPs report.

There was a situation when the system stopped. Soon the nurse discovered there is air bubble, and she did the right thing like clamping, oxygenation and managed perfectly till the saturation returned to 95% while that time she called the perfusionist to arrive.

OHCPs appreciated the nurses' work and their cooperation and confidence to deal and cope with the daily tasks. The nurses' competences in the management of ECMO was generally attributed to the adoption of adequate protocols, continuous training and ongoing experience received during their practice.

OHCPs observed that several factors affect the nurses' work while providing ECMO. These mainly include heavy workload, a lack of appreciation from colleagues and supervisors, and variation in competence of the individual nurses.

The majority of participants in the study acknowledged that nurses working in ECMO are overloaded with duties due to a shortage of staffing in the unit. Generally, it is recommended that an ECMO nurse will be assigned to only one patient, and each ECMO patient is cared for by an ECMO nurse and a bedside nurse. However, in 

Some participants expressed a concern of lack of support for nurses from colleagues and supervisors. The effort nurses invest in man- 

The present study aimed to establish how other healthcare professionals working in ECMO perceived the roles and competencies of ECMO nurses. In general, OHCPs perceived the nurses' role to be very important and critical in the ECMO team. Nurses manage both patients and the ECMO machines, which are key aspects in ECMO care. As Daly (2017) explains, the ECMO specialist nurse is expected to understand and manage both the patient and circuit, and the potential patient-circuit interaction. The current study demonstrated that ECMO nurses possess the qualities of a competent ECMO specialist nurse, through their diverse roles such as setting and running the ECMO machine, troubleshooting, assisting in insertion, stabilizing the patient, retrieval and bedside management of the patient. In addition, OHCPs described the majority of nurses as competent in maintaining the functionality of the ECMO equipment, which promoted patient recovery. It is observed that good functionality of the ECMO equipment ensures highly protective ventilation (Courtin et al., 2012) and achieves the desired patient outcomes. OHCPs in the current study reported that nurses ensured optimal functioning of ECMO equipment, which contributed to good patient outcomes.

The findings of the current study indicated that OHCPs perceive ECMO nurses as competent professionals capable of working independently. It is observed that the highly trained ECMO specialist possesses advanced knowledge and skills to manage troubleshooting and to ensure that the care provided to ICU patients is timely, safe and reliable (O'Connor & Smith, 2018) . It is also recommended that ECMO staff should be highly competent in intensive care, ECMO physiology and physics, cannulation and intensive care transport (Broman et al., 2015) . Providing nurses with advanced ECMO management skills and engaging them in refresher trainings will empower them to continue to provide safe care to the patients (Hackmann et al., 2017 ).

In the current study, the nurses' competence was evaluated on the basis of their knowledge and skills, and OHCPs viewed them as competent and confident while dealing with complications arising during ECMO. In a recent study that evaluated the nurses' perspectives in ECMO care, nurses also viewed themselves as competent and attributed their competency mainly to the training received and to the experience spent providing ECMO care (Alshammari et al., 2020) . Similar to Alshammari et al. (2020) 's study, participants in this study attributed the nurses' competence in ECMO management to their specialized training and continued experience in the ICU setting, which empowered them to manage ECMO care through early detection of complications and taking appropriate measures to resolve the identified issues.

Previously ECMO was considered as mainly the role of a perfusionist, but currently the nurses' role is important and integrated in ECMO management. The current study reported that nurses work as part of a team, and their contribution was highly rated. Our findings align with other research, which suggests that continued education of nurses in ECMO management improves their competence and performance, providing more qualified staff for ECMO management (Hackmann et al., 2017) . Due to their scope of work, additional training and experience, nurses are reported to possess unique knowledge and skills to safely manage the ECMO circuit, with perfusion backup for the more complicated aspects of circuit management , in addition to attending to other needs of the patient. In current practice, a "two carers" approach is adopted in many centres where the ECMO specialist nurse works collaboratively with a bedside nurse (Daly, 2017 (Hijjeh, 2017) . Moreover, ECMO patients require regular/constant observation and care, which requires a standby nurse (Boling et al., 2016; Hijjeh, 2017) .

Multidisciplinary roles and teamwork are essential in ECMO management (Alshammari et al., 2020) . In their role as ECMO specialists, nurses have significantly more autonomy and responsibility in caring for patients and the ECMO machinery (Wellman, 2017 (Courtin et al., 2012) and be skilled in recognition of risk factors involved in the patients (Broman et al., 2015) . As team players, ECMO nurses should, however, keep the rest of team members updated on the progress of the patients to the rest of the providers (Botsch et al., 2019) .

OHCPs expressed their concerns regarding the ECMO nursing shortages and the negative effects that could arise out of these shortages.

The scarcity of ICU nurses consequently affected the workload of ECMO nurses. In a previous study, ECMO nurses were working on an average of 1:3 patients as opposed to the recommended average of 1:1 or 1:2 nurse-patient ratio (Alshammari et al., 2020) . The nursing shortages have been reported to lead to errors and higher morbidity and mortality rates (Botsch et al., 2019) . It has been reported that nurses working in hospitals with lower staffing levels experience exhaustion and lack of job satisfaction compared with those with adequate staffing levels, and this might result into poor care to the patients (Haddad et al., 2021 (Courtin et al., 2012) . These findings highlight the need to train more ICU nurses on ECMO management to improve staffing levels in ECMO care.

It was also reported in the current study that a lack of recognition/appreciation by colleagues and/or supervisors was a demotivating factor to the work of ECMO nurses. Observation has shown that despite the efforts nurses put into carrying out their duties, the acknowledgment of a job well done by co-professionals still leaves much to be desired (Honey & Wang, 2013; Oyetunde et al., 2014) .

Nurses should be provided with a favourable and supportive environment to facilitate their role (Alshammari et al., 2020) . Giving appropriate recognition and motivation to the nurses can minimize the staff turnover in ECMO units.

Although OHCPs in the current study acknowledged that ECMO nurses were competent in their role, at an individual level, there are differences observed in the levels of competence. This could have resulted from individual motivations for the role, experience in EMO care and trainings received. As highlighted by Mosadeghrad (2014), there are personal differences or factors such as experience and individual abilities and personalities that influence the services provided by healthcare team members. Efforts to continuously improve the competencies of all nurses in ECMO management is therefore required to ensure delivery of high-quality care.

Our study was conducted in a single institution, which limits the application of the findings to other institutions. It is therefore necessary that similar studies are conducted in other ECMO centres in Kuwait and other countries to inform improvements in the management of ECMO. We also acknowledge that ECMO is a relatively new intervention, and considering its adoption in COVID-19 management, further research in the area is highly recommended. We also acknowledge that being a qualitative study, we included a small sample of participants, which limits generalizability of the study results. However, despite the small sample size, the data material was rich, and the study participants represent different medical specializations.

The introduction of extracorporeal membrane oxygenation in ICUs expanded the role of the ICU nurses to ECMO specialists.

Nurse-managed ECMOs will allow for an increased availability of appropriately trained providers to accommodate the exponential increase in ECMO patients without negatively affecting outcomes. ECMO nurses are regarded as a valuable part of the team and are highly demanded. Understanding their roles and competencies through self-assessment and evaluation by other healthcare professionals of the multidisciplinary team is essential to make necessary improvements in the practice. 

The authors wish to thank all the participants who took part in this study.

There is no conflict of interest associated with this publication.

Data related to this study can be availed on request from the first author of this manuscript.

https://orcid.org/0000-0002-7286-3556

Chitra Vellolikalam https://orcid.org/0000-0003-0376-6397

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Perception of other healthcare professionals about the nurses' role and competencies in veno-venous extracorporeal membrane oxygenation care: A qualitative study