Facilitating and hindering factors of community nurses' emergency and critical care treatment abilities: A qualitative study

Abstract

BACKGROUND

This study adopts a descriptive phenomenological approach to investigate the facilitators and barriers of community nurses' abilities in managing critical and emergency conditions. With the transition of healthcare systems to the community, the evolution of nursing practices, and the attention from policies and practices, community nurses play a crucial role in the management of critical and emergency conditions. However, there is still a lack of comprehensive understanding regarding the factors that promote or hinder their capabilities in this area.

AIM

To understand the facilitators and barriers of community nurses in managing critical and emergency conditions, exploring the fundamental reasons and driving forces influencing their treatment capabilities.

METHODS

This study utilized the destination sampling method between May 2023 and July 2023. It employed a descriptive phenomenological approach within qualitative research methodologies. Through objective sampling, 17 community nurses from 7 communities in Changning District, Shanghai, were selected as the study subjects. Semi-structured interviews were conducted to gather data, which were subsequently organized and analyzed using Colaizzi's seven-step analysis method, leading to the extraction of final themes.

RESULTS

The barrier factors identified from the interviews encompassed three topics: resource allocation, professional factors, and personal literacy. The facilitators comprised three themes: professionalism, management attention, and training and continuing education. We identified that the root causes of the barriers included the lack of practical treatment experience among community nurses, insufficient awareness of self-directed learning, and limited knowledge and technical proficiency. The professional quality of community nurses and management attention serve as motivation for them to enhance their treatment abilities.

CONCLUSION

To enhance the capability of community nurses in treating acute and critical patients, it is recommended to bolster training specifically tailored to acute and critical care, raise awareness of first aid practices, and elevate knowledge and skill levels.

Key Words: Community nurse; Acute and critical illness; Promoting factors; Obstacle factors; Qualitative study

Core Tip: This study used descriptive phenomenology to investigate the facilitating and obstacle factors that affect the ability of community nurses to treat acute and critical diseases. The study may reveal various barriers faced by community nurses in acute and critical treatment, and may include enlightening findings to improve the ability of community nurses in acute and critical treatment. Improving the allocation of community medical resources and personnel management, and strengthening the cultivation of the psychological quality of community nurses are also the key measures. By improving the acute and critical treatment ability of community nurses, the quality of community medical services can be improved and have a positive impact on the health and safety of community residents.

INTRODUCTION

Community medical care primarily addresses chronic diseases, but there are still patients with acute conditions in hospitals[1]. If primary medical and health institutions fail to provide a timely and effective response during emergencies, they often delay the optimal rescue window, which can result in the deterioration of the patient's condition and even endanger lives. Hence, community emergency medical services play a crucial role in the broader social emergency support system[2]. This type of service refers to the provision of rapid initial treatment by community healthcare professionals before pre-hospital emergency medical personnel arrive at the scene in life-threatening situations[3]. Timely on-site treatment by community health service institutions can significantly increase the success rate of rescue for critically ill patients[4]. As early as 2019, the National Health Commission issued the Guidelines for Evaluation of Service Capacity of Community Health Service Centers. These guidelines explicitly mandated community health service centers to offer first aid services alongside outpatient care. Additionally, they were required to provide preliminary diagnosis and emergency treatment for patients with common acute and critical diseases[5]. Therefore, the core focus of emergency medical services lies in the community, and the seamless implementation of community emergency care serves as a vital guarantee for the success of emergency medical services[6]. Community nurses are often the first responders to community emergency events. If they can administer timely and appropriate emergency measures during the critical "golden hour," they can buy valuable time for treatment at higher-level hospitals. This is of paramount importance in saving the lives of patients[7,8]. However, there is relatively little research both domestically and internationally on the critical care capabilities of community nurses, and we lack a comprehensive understanding of the factors that promote or hinder these capabilities. It is also necessary to further explore the underlying reasons and driving forces behind these factors. Therefore, this study utilizes a qualitative interview method to gain in-depth insights into the factors that promote or hinder the critical care capabilities of community nurses. This approach aims to uncover the fundamental causes and motivations of these factors, providing a more scientific basis for future community nurse training.

MATERIALS AND METHODS

Design

This study employed a descriptive phenomenological approach in qualitative research. After reviewing relevant domestic and international literature and consulting with experts to meet the study objectives, a preliminary interview outline was developed. Pre-interviews were conducted with two community nurses, and the outline was revised after discussion by the research group,and finalize the interview guide as follows: (1) Should community nurses possess the capability to manage acute and critical illnesses? Why? (2) What acute and critical conditions have you encountered in your practice? How do you navigate these situations? (3) In your opinion, what constitutes the most challenging aspect of treating acute and critical illnesses for community nurses? How can these challenges be addressed? (4) Do community nurses have adequate learning opportunities and resources to enhance their capacity in acute and critical care treatment? If not, how do you propose improvements? (5) Do community nurses experience psychological pressure when treating patients? How does this impact their ability to manage acute and critical illnesses? and (6) Apart from their duties, should community nurses actively engage in learning and training programs related to acute and critical illness treatment? Why?

Data collection and ethical considerations

Utilizing purposive sampling, we selected seven community nurses from community service centers in Shanghai's Changning District, spanning from May to July 2023, as research participants. Inclusion criteria comprised: (1) Active nurses with three or more years of service in community health centers; (2) nurses who have administered treatment to critical and emergency patients; (3) holders of registered nursing licenses; and (4) individuals capable of articulating their inner sentiments adequately and providing informed consent for study participation. Exclusion criteria involved: (1) Nurses currently engaged in training or rotational programs in other departments. Prior communication with the respondents facilitated the confirmation of interview schedules and locations. The in-depth interview method was employed, and to guide the interviews, semi-structured questions were presented in a natural setting without explicit guidance or prompts[9]. Each interview lasted approximately 30 min and was recorded simultaneously to ensure accurate documentation. Throughout the interview, I delved deeply into the meaningful topics raised by the interviewees and carefully observed and recorded their body language and facial expressions. Before each interview, we explained to the respondents the purpose and content of the interview, as well as the necessity of using coding instead of names to protect privacy. Subsequently, we utilized the 7-step analysis of phenomenological data to analyze the interview data[10]. The study underwent review and approval by the Beihua University Medical Ethics Committee [Approval No. 2023(03)]. Prior to enrollment, all research participants provided informed written consent. Interviewees retained the right to decline participation or withdraw from the interview at any juncture, with assurance that all interviewee data would remain confidential.

Data analysis

Within 48 h of the interview, we transcribed the recorded data and compiled the interview notes. For thematic analysis, we utilized Colaizzi's phenomenological 7-step analysis method[11]. The steps are as follows: (1) Read the initial interview materials carefully to fully understand the words and views of the interviewees; (2) Refine the meaningful statements related to the topic to identify important pieces of information; (3) Encode the repeated statements to ensure full coverage of key content; (4) Classify the codes with common characteristics to form themes, sorting out and classifying relevant information; (5) Connect the summarized themes to research phenomena and provide a detailed narrative to demonstrate the relevance of the topic to the research question; (6) Refine the narrative content, summarizing the essential structural framework to better understand and interpret the study results; and (7) Finally, to ensure the accuracy of the results, ask the respondents for confirmation to verify whether their views and words are correctly understood and presented. The general data of the interviewees were analyzed using SPSS 26.0, and are presented as mean ± SD.

RESULTS

A total of 17 community nurses agreed to participate in this study, all were women with a mean age of 40.94 ± 6.348 years and a mean years of care of 15.35 ± 5.926 years. Through data collection and analysis, we identified 6 themes with 3 themes for positive factors and 3 themes for barrierfactors. Table 1 describes the main socio-demographic data of the respondents. Through data collection and analysis, we identified 6 major themes and 10 sub-themes, revealing the promotion and barrier factors of community nurses' ability to treat acute and critical illness. Table 2 describes the six main themes and 10 sub-themes in this article.

Table 1 Sociodemographic data of respondents.

Respondent	Sex	Age	Educational background	Position	Years of nursing experience (yr)
N01	Female	48	Undergraduate	Co-chief superintendent nurse	23
N02	Female	48	Undergraduate	Co-chief superintendent nurse	21
N03	Female	50	Undergraduate	Co-chief superintendent nurse	25
N04	Female	42	Undergraduate	Nurse supervisor	17
N05	Female	37	Undergraduate	Nurse supervisor	12
N06	Female	42	Undergraduate	Nurse supervisor	16
N07	Female	35	Undergraduate	Senior nurse	11
N08	Female	36	Undergraduate	Senior nurse	10
N09	Female	33	Undergraduate	Senior nurse	9
N10	Female	32	Undergraduate	Senior nurse	7
N11	Female	42	Undergraduate	Nurse supervisor	18
N12	Female	36	Undergraduate	Nurse supervisor	10
N13	Female	42	Undergraduate	Nurse supervisor	16
N14	Female	48	Undergraduate	Nurse supervisor	16
N15	Female	32	Undergraduate	Senior nurse	7
N16	Female	50	Undergraduate	Co-chief superintendent nurse	25
N17	Female	43	Undergraduate	Nurse supervisor	18

Table 2 Themes and subthemes of the study.

	Themes	Subthemes
Disorder factors	Resource allocation	Incomplete emergency medical equipment
		Staff shortage
	Occupational factors	Knowledge and skills shortage
		Weak first aid awareness
	Individual qualities	Lack of proactive learning attitude
		Poor psychological resilience
Facilitating Factors	Occupational qualities	Recognition of the importance of critical care management abilities
		Have a certain amount of experience accumulation
	Management attaches importance to it	Regional medical consortium support and guidance
		Establishment of emergency response plans
	Training and continuing education needs

Disorder factors

Theme 1 resource allocation: Subtheme 1 incomplete emergency medical equipment: In comparison to specialized medical institutions, community health service centers generally have limited medical equipment and medication resources, which may restrict the means and effectiveness of nurses in critical care. Respondents' statements indicate that the lack of emergency equipment in the community negatively impacts the ability to provide treatment, such as the absence of gastric lavage machines, ventilators, and defibrillators. Insufficient facilities and equipment not only affect the improvement of service capabilities in healthcare institutions but also lead to the loss of patient resources. Regardless of whether there is a dedicated emergency department, community health service centers should establish standardized rescue rooms and equip themselves with emergency devices and medications[12].

The absence of gastric lavage machines in our community poses a significant challenge. In cases of poisoning, the lack of prompt treatment options can severely impact patient outcomes (N01).

The absence of ventilators and defibrillators in our area presents a notable limitation in our ability to provide critical care. While we have basic equipment, the lack of these essential devices may impede our ability to respond effectively to life-threatening situations (N02).

The availability of emergency medications in our community is not as comprehensive as in tertiary hospitals. We primarily have basic emergency medications, and the range is limited compared to what is available in specialized medical facilities (N05).

We have automated external defibrillators available, but we still lack professional defibrillators in our community (N07).

Subtheme 2 staff shortage: The smaller size of medical teams in community health service centers often results in a relative shortage of healthcare professionals, potentially leading to insufficient personnel for critical care. Respondents highlighted that community nurses experience heavy workloads, particularly with the increasing elderly population, which contributes to significant stress.

The increasing number of elderly individuals seeking medical care in the community, coupled with our limited number of nurses, is becoming overwhelming (N13).

We don't have a dedicated emergency team; the responsibility falls on whoever is on duty that day (N05).

The community falls short of the nurse-patient ratio specified by the Ministry of Health (N04).

Nurses in the hospital endure daily night shifts that can be extremely exhausting, significantly impacting their ability to provide emergency care (N17).

There is seldom organized cooperation between medical and nursing staff during emergencies. Each department trains its own nurses, and it remains unclear whether doctors and nurses in the community hospital can effectively collaborate in resuscitation efforts (N06).

Theme 2 occupational factors: Subtheme 1 knowledge and skills shortage: Community nurses primarily cater to the needs of community residents, and possessing pertinent knowledge and skills in public emergency care is pivotal for mitigating the mortality and disability rates of critically ill patients[13]. However, the interviewed community nurses generally expressed a perceived lack of adequate knowledge in treating critical conditions and encountered limitations in technical aspects.

There is a wealth of knowledge that I acquired in the past, but I find that I cannot recall some of it clearly (N11).

After working in the community, I have had fewer opportunities to encounter emergency situations, leading to a gradual decline in my related knowledge and skills (N17).

While I understand that CPR should be performed, I am uncertain about the specific depth of compression (N08).

Furthermore, some younger nurses may lack sufficient clinical experience and emergency care abilities. This knowledge and technical insufficiency may pose challenges in the treatment of critically ill patients (N15).

Subtheme 2 weak first aid awareness: Communities typically serve as primary gathering places for patients with chronic diseases. Therefore, one of the main responsibilities of community nurses is community health management and basic medical services. However, some nurses believe that treating critically ill patients does not fall within the scope of their community work, potentially leading to a lack of attention and awareness in this area. This weak awareness of emergency care may result in a lack of decisive response from community nurses during emergency situations, which can adversely affect the treatment of critically ill patients.

There aren't many critically ill patients in the community, so we don't have many opportunities to practically apply all that knowledge (N02).

Our community has a significant elderly population. However, in critical situations, family members often prefer to send them to larger facilities (N04).

Theme 3 individual qualities: Subtheme 1 lack of proactive learning attitude: Community nurses generally lack a strong initiative to actively pursue knowledge in critical care[14]. Respondents expressed that they typically only engage in learning during scheduled training and educational opportunities provided by hospitals, meanwhile lacking the motivation for self-directed learning in their daily lives. Community nurses commonly feel that multiple pressures, such as family responsibilities, limit their time and opportunities for additional learning. To enhance the capabilities in critical care, enhancing proactive learning awareness of community nurses and provide more flexible learning pathways is, to our belief, at very urge.

Currently, our department organizes training once every quarter, so we study when it's organized (N02).

Typically, we only engage in learning when it's mandated by the hospital. We don't actively seek out knowledge in this area (N13).

After work, there are numerous family matters to attend to, leaving me with little extra time to read books or search for information (N08).

In the community, there is less research, and I haven't considered making any achievements in emergency care. There is no role model in this field (N15).

Subtheme 2 poor psychological resilience: When faced with emergency situations involving critically ill patients, community nurses may experience high levels of stress and pressure[15]. They need to remain calm and take prompt and appropriate actions during such emergencies. However, many respondents expressed that they may lack confidence and psychological preparedness to handle these situations.

If there is a sudden need for emergency care right now, I'm uncertain if I can perform the procedures correctly (N09).

There is ongoing pressure during resuscitation. I fear treatment or resuscitation failure, which would lead to significant psychological stress and guilt. I feel helpless (N14).

Sometimes, the patient's condition is very distressing, and when their family members cry or express their emotions nearby, it makes me feel even more helpless and frustrated (N06).

Facilitating factors

Theme 1 occupational qualities: Subtheme 1 recognition of the importance of critical care management abilities: Community nurses are often revered as "angels in white," seeing saving lives and aiding the injured as their instinctual duty. Respondents generally believe that training to enhance their capabilities in critical care is necessary.

I believe it is crucial for community nurses to enhance their skills in critical care (N01).

Training is essential because sometimes we encounter sudden situations and are unsure how to handle them (N02).

It would be beneficial if we could enhance our abilities in critical care. Community nurses often have many blind spots in this area (N03).

The golden rescue time for many heart attack cases occurs within the community. Therefore, emergency care in the community is of utmost importance (N04).

There are many elderly patients with chronic and comorbid diseases in the community now. Their condition can rapidly deteriorate at any time and place, necessitating that community nurses possess expertise in critical care (N05).

Subtheme 2 have a certain amount of experience accumulation: The survey revealed that currently, the majority of community nurses have either transferred from secondary or tertiary hospitals to work in the community or have gained some emergency care experience during their tenure in hospitals. Those community nurses who have participated in resuscitation efforts exhibit greater confidence when dealing with sudden emergencies.

I previously worked in the emergency department of a tertiary hospital and was involved in the treatment of critical patients, which has equipped me with more knowledge in this area compared to other nurses (N01).

Those who have worked in the emergency department or have been involved in resuscitation definitely have stronger abilities (N02).

Theme 2 management attaches importance to it: Subtheme 1 regional medical consortium support and guidance: Community nurses receive support and guidance from the district-level medical consortium[16], enabling them to actively participate in community health management and emergency rescue work. Respondents stated that district-level hospitals dispatch nursing teachers to the community to teach them various emergency care operations.

Nowadays, nursing teachers from the district come to teach us emergency care operations (N01).

The nursing rounds organized by community hospitals now invite experts from higher levels to provide guidance (N02).

Subtheme 2 establishment of emergency response plans: The region where community nurses serve has established a relatively comprehensive emergency response plan system[17], encompassing various protocols for unexpected events and treatment procedures. This enhances the capabilities of community nurses in critical care. Respondents noted that the National Health Commission mandates the involvement of community nurses in emergency care. Moreover, medical institutions have developed various emergency plans, necessitating proficiency from community nurses.

Nowadays, the National Health Commission also requires our community nurses to participate in the treatment of critically ill patients (N01).

In our department, there are plans for sudden emergencies such as stroke and shock, which community nurses are expected to memorize (N02).

Now, the hospital leadership has formulated planning and guiding documents for emergency plans, clearly defining the responsibilities, tasks, and workflows of the emergency organization, as well as establishing the development and update cycles for the plans (N03).

Nowadays, there is greater collaboration between community and general hospitals. In extremely urgent situations, we closely coordinate with the hospital (N04).

Subtheme 3 training and continuing education needs: Some studies have identified a greater demand for training and ongoing education among community nurses[18]. Community nurses universally express the need for training and ongoing education, believing that it can enhance their knowledge and skills in critical care[19].

In our hospital, there is an organization of relevant emergency care operations and drills held every quarter, and nurses are required to participate (N01).

We consistently encourage nurses in our department to engage in learning, attend courses, and strive for self-improvement (N02).

Sometimes, when there are meetings organized by the district or other experts, we send out representatives from the community to participate and learn (N03).

DISCUSSION

Theme 1 the root causes of barriers impacting the critical care management abilities of community nurses

The ability of community nurses to handle critical care situations is constrained by various factors. The main underlying reasons include: (1) Inadequate educational background and training: The education and training of community nurses primarily focus on basic medical services, lacking specialized knowledge and skills in critical care; (2) Low frequency of critical care incidents: Compared to general hospitals, there is a lower demand for emergency care in the community, resulting in fewer opportunities for community nurses to encounter critical care situations, leading to a less urgent need for emergency care knowledge; (3) Lack of practical experience: Community nurses have limited practical experience, which may affect their ability to respond to critical care situations; and (4) Insufficient and untimely training: Community nurses receive infrequent emergency care training, and the content and format of the training may be inadequate to meet their learning needs.

Theme 2 the fundamental drivers for enhancing the critical care management abilities of community nurses

The promotion of community nurses' ability in critical care relies primarily on the following key driving forces: (1) Sense of professional responsibility and commitment: Community nurses recognize their duty to save lives and provide care, and this professional belief inspires their desire to improve their skills in critical care; (2) Support from administration: Support and attention from management serve as important motivators for community nurses to enhance their abilities in critical care; and (3) Regional support and guidance: Community nurses receive support and guidance from district-level hospitals, which helps them actively participate in community health management and emergency rescue work. Studies believe that the sound community nursing human resource management system (staffing, performance appraisal, pay benefits, responsibility management) can stimulate community nursing staff work enthusiasm, by improving the community health service institutions nursing work environment, help to improve the efficiency of work and quality of community nurses, ensure the community health service quality and safety[20,21]. Therefore, by improving the community nursing working environment, standardizing the community nursing service process, improving the quality control system, advocating equal attention to salary and performance, so as to mobilize the enthusiasm of nurses and improve the ability of nurses to treat acute and critical illness.

Theme 3 cultivating the knowledge and skills of community nurses in critical care management

To bolster the knowledge and skills of community nurses in critical care, the following strategies can be implemented: (1) Comprehensive education and training programs: Develop comprehensive training initiatives encompassing both theoretical knowledge and practical skills. These programs ensure that community nurses are equipped with the requisite expertise in critical care; (2) Regular updates and training: Offer frequent training sessions on critical care to ensure that community nurses stay abreast of the latest developments in emergency care practices; and (3) Incentive mechanisms: Introduce incentive structures to motivate community nurses to actively engage in enhancing their critical care competencies. This may involve rewards, career advancement opportunities, support for certification, or professional qualifications. By implementing these measures, community nurses can augment their proficiency in critical care, thereby laying a solid groundwork for the advancement of community critical care services and better serving both patients and the community at large.

CONCLUSION

To enhance the capability of community nurses in managing emergencies and critical conditions, it is advisable to reinforce training in emergency and critical care, promote first aid awareness, and elevate knowledge and skill levels. Additionally, optimizing the allocation of community medical resources and personnel management, along with strengthening the psychological resilience training of community nurses, are crucial steps. By improving the emergency and critical care capabilities of community nurses, the quality of community medical services can be elevated, thereby positively impacting the health and safety of community residents.

ACKNOWLEDGEMENTS

We express our gratitude to all the participants, as well as to the researchers and collaborators who contributed to this study.