PRINCIPLE GUIDELINE TWO: PROVIDE AN OPERATING PRACTICE ENCOMPASSING THE ENGAGEMENT, IMPLEMENTATION, AND EVALUATION PHASES OF THE TEAM NURSING CARE FRAMEWORK IN THE CRITICAL

CARE UNITS.

Rationale

In order to ensure successful implementation of the team nursing care framework, thereby optimizing the allocation of the staff within the nursing care team.

The following sub-guidelines, explained in table 4.2, provides a clear layout of how the guideline should be operationalized.

Table 4.2 Principle Guideline two

Sub-guideline Rationale for sub-guidelines Implementation

4.4.2.1

Engagement meetings to be held with all stakeholders.

 Meetings with all stakeholders prior to the roll out of the team nursing care framework will ensure that all management and staff are aware of the process of rollout.

 Organise and hold an introductory meeting with all stakeholders in the critical care unit prior to the rollout of the team nursing care framework.

 Discuss and highlight staff allocation in the critical care unit (Utilizing the nurses in the team nursing care framework and assigning specific role clarification of all nursing staff).

Sub-guideline Rationale Implementation  Time frames for the roll out are

agreed upon.

 During the roll out phase,

meetings between management and key stakeholders from the critical care unit will meet weekly to assess the progress of the rollout as well as the factors that hinder the rollout process.  On completion of the

implementation of the team nursing care framework it is

important to have regular quarterly follow-up meetings to:

- Ensure the sustainability of the team nursing care framework in critical care unit

- Discuss issues that negatively impact the framework

- Develop action plans and implement.

 Share information with the professional nurses about how the staff allocation will be implemented, to ensure quality patient care and sustainability of the team nursing care framework in the critical care unit.

 Schedule and hold weekly meetings with identified nursing staff from the critical care unit after the team nursing care framework in the critical care unit has been rolled out.

 Discuss and highlight problems that have arisen. Develop action plans to address and close out the problems.

Sub-guideline Rationale Implementation 4.4.2.2

Ensure optimal staffing and patient allocation.

 Allocation of staff is a

management activity and is done by the unit manager or shift leader before the beginning of each shift. Patient allocation entails a worker to work ratio i.e. nurse to patient ratio (Fagerstrom, 2009: 416). Research shows many various methods of staff allocation are utilized internationally to estimate the number of nurses needed to deliver care to critical care patients (Adomat & Hewison,

 Schedule quarterly meetings with stakeholders i.e. management and the unit manager from the unit. The agenda items will include:

- An overview of the problems that have been experienced during the quarter.

- Action plans implemented with resolution discussion. - New matters arising and the long-term sustainability. - Debate and discussion around the evaluation of the

framework.

 Minutes will be retained and distributed.

 Feedback to the staff quarterly by the unit manager.

 Allocate staff:

- The unit manager or professional nurse leading the shift to do the staff allocation before each shift, taking the competency of the nurses and the acuity of the individual patients into

Sub-guideline Rationale Implementation 2004:300). Bachan, 2005, (cited

in Rassin & Silner,2007:63) states that nurse to patient ratios sets the maximum number of patients that may be allocate to an

individual nurse with a particular skill set during a particular shift.  The patient acuity is key to staff

allocation, as staff are allocated according to the acuity of each patient. The TAS score (as described in chapter 1) is utilized to determine the patient acuity.

 Conduct a patient assessment and score the patient acuity using the TAS (as discussed in chapter one) at the beginning of each shift (i.e. 12 hourly) or whenever the patient’s condition changes.  The shift leader or unit manager to:

- Allocate one professional nurse to each major acuity

- Allocate the moderate patients. One professional nurse, the nurses, and care workers will look after the moderate patients, under the direct and indirect supervision of the professional nurse.

- Allocate 5 minor patients to a professional nurse, nurses and care workers. The team will assist the professional nurse to ensure that all basic nursing care is done. The nurses and care workers will work under the direct and indirect supervision of the professional nurse.

Sub-guideline Rationale Implementation The TAS score grades the patient

as follows:

 Major Acuity

- TAS score over 35. This patient is fully dependent on medical support for more than 2 major body systems, e.g. cardiovascular and respiratory systems.

 Moderate Acuity

- TAS score between 20 and 34 and this patient has more than one or more systems that are unstable and requires support.

 Minor Acuity

TAS score between 11 and 19 and this patient is stable, but requires continuous monitoring for possible acute deterioration.

 Provide nursing care:

- The nurses provide nursing care, under the direct and or indirect supervision of the professional nurse according to the care plan prescribed by the professional nurse. The nurses are responsible for implementing the following:

- Carrying out all basic nursing procedures

- Nursing care as it is prescribed by the professional nurse (nursing care plan)

- Completing the environmental control assessment by checking the individual patient bed space and any other routine

environmental activities as determined by the professional nurse.

Sub-guideline Rationale Implementation  The professional nurse

responsible for the allocation of patient: nurse ratio should take staff experience and competence level into account as this could affect the productivity of the individual nurse (Spence, Tarnow- Mordi, Duncan, Jayasuryia, Elliott, King & Kite, 2006:228).

 Incorrect staff allocation will result in poor quality nursing care, increased workload, stress and burnout of the professional nurse. The professional nurse is always responsible for the assessment and interpretation of the nursing care, whilst the nurses assist with the implementation of the nursing care plan.

 Evaluate the effectiveness of the team nursing care framework every quarter. This will be done as follows:

- Questionnaire to the doctors and professional nurses

- Monitor the number of patient and doctor complaints since the introduction of the team nursing care framework. In particular attention will be given to complaints regarding quality patient care.

- Assess the number of incidents will be assessed. - Assess the rate of absenteeism.

- Monitor staff turnover quarterly.

 Compile an action plan to address the gaps identified in the evaluation phase to ensure sustainability of the team nursing care framework in the critical care unit.

Sub-guideline Rationale Implementation

 Professional nurses, work as

knowledgeable independent practitioners, coordinating and managing the clinical care of the patient and are responsible and ultimately accountable, according to the Scope of Practice, for : - Assessment and Interpretation - Planning and co-ordinating

- Advanced nursing procedures

- Evaluation of the care rendered to the patient.  The other members of the team

will report any abnormalities or deviations in the patients’

progress to the professional nurse and it is their responsibility to act in accordance with the Scope of Practice, utilizing their advanced knowledge and critical analytical skills.

4.5 LIMITATIONS

The researcher recognized, as with all qualitative studies, that the sample size and specific nature of the sample and research context prohibit generalization. However, the richness of the data collected provided much insight into the lived experiences of the professional nurses, in the critical care unit, and the envisaged benefits of utilizing a phenomenological approach were therefore realized.

The specific limitations of the study were identified as follows:

 The interviews were conducted in only one critical care unit, as this is where the team nursing care framework had been rolled out. This study does not include experiences of other professional nurses involved in the team nursing care framework in other critical care units.

 The research study was conducted in one healthcare group.

 Although confidentiality was maintained, the anonymity of the participants was challenged due to the fact that only one critical care unit was utilized in the study. Staff that were not included in the study were aware of the professional nurses’ participation in the research study and could have affected the freedom of the professional nurses to share openly and freely with the researcher. However, this was not overtly evident.  There was a limited amount of literature available on this research topic.

 Due to the dynamic environment of the critical care unit, interviews had to be rescheduled on various occasions.

4.6 RECOMMENDATIONS

In the light of the research findings, and indicated limitations, the following recommendations for nursing practice, nursing education and nursing research were formulated: