TEAM COLLABORATIVE RELATIONSHIPS
The research findings indicate that the participants experienced the need for multidisciplinary team collaborative relationships; for doctors to be m o r e approachable regarding the withdrawal of treatment; for hospital management to be more supportive; and have diverse relationships with nursing colleagues.
3.6.1. Nurses experienced the need for doctors to be approachable regarding withdrawal of treatment
In the ICU, the care of the critically ill patient involves collaboration of the multi- disciplinary team. The participants throughout the study emphasized the need for improved communication amongst the health team members. Participants expressed that they feel as though they are not part of a team working toward a common goal for each patient.
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“...of course you would not want to suggest to certain people what they should and should not do, but I will say, what are we doing…are we going, you know...are we doing something doctor, are we going to get somewhere…what do you think…and I mean certain ones I will definitely not approach.”
“No. There’s...I can, there’s one doctor that I will speak to and also if I thought it through properly. And um, he will listen to a certain extent what you have to offer, but the rest of them I don’t even think they will listen, truly listen to what you have to say.”
“I feel comfortable discussing this with family, yes, but honestly, no, I don’t feel comfortable discussing this with the doctors...I find that your feelings...or you are not really kind of taken into consideration as the nurse, you know.”
Calvin, et al (2009:215) identified that differing opinions among the medical team caring for the patient was identified by nurses as an obstacle to optimal end-of-life care. Festic, et al (2010:154) concur that conflicting opinions about the prognosis of the patient and the goals of treatment affect the quality of end-of-life care. Furthermore, Festic, et al (2010:154) state that this conflicting information is often transferred to the family of the dying patient. It is the nurse who is left to deal with these conflicting opinions and explanations to the family, which is a cause of further distress for the nurse.
Ranse, et al (2011:7) stated that the uncertainty and ambiguity surrounding the prognosis of a patient and decisions to withdraw treatment may result in greater distress not only for the patient and family, but also for the health care professionals Communication between team members appeared to be the largest cause of internal conflict for the professional nurses. Festic, et al (2010:154) concludes that improved communication and consistency in what is communicated to the patient and the family is important in delivering optimal end-of-life care. It is therefore essential that there is good communication between the members of the multi-disciplinary team when caring for the patient on whom treatment is being withdrawn. In their study it was found that effective communication between nurses and physicians was identified
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least as a barrier to efficient end-of-life care. In the study by Festic, daily ward rounds were done with the multidisciplinary team including the dietician, pharmacists and case managers. The daily ward rounds appeared to enhance the communication between multi-disciplinary team members.
As participants generally expressed in this study that it was difficult to approach doctors regarding the withdrawal of treatment from a patient, it appeared as though communication between the doctors and the nurses needs to be improved.
3.6.2. Nurses experienced the need for hospital management to be more supportive.
The management structure in the hospital where the study was conducted comprised a hospital management, unit management, physicians and surgeons, and shift leaders. Participants related the need for hospital management to be more supportive. Participants felt that they were unable to approach management when they had issues regarding dealing with withdrawal of treatment. Participants expressed feelings of being looked down on if they were unable to cope with the demands placed on them in the ICU. The lack of support is illustrated by the following quotes.
“They are still so scared of all the issues surrounding it. They feel they need...maybe management should be supportive also. But for me I take it as in my position now I should actually be part of the management. I am senior enough to know what’s right or wrong. So really from my side it is enough, but for a junior person I think they need more support.”
“And you go that far...you feel weak, as if you cannot handle what your profession...a part of your profession. It’s part of what we do every day. And um, the best support that I get from management during this was “ag shame”. You know...you are, I am an extremely emotional person. And if I go talk about it. “ag shame” is the best that you get.”
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participants in their research were unable to identify specific policies and procedure guidelines to assist in dealing with end-of-life issues. They also stated that nurses felt that organisational support was needed to assist nurses in dealing with end-of- life issues in the intensive care unit. Organisational support was identified by the participants as guidance and encouragement when dealing with end-of-life issues in the ICU. A definite need for emotional and organisational support should thus be provided when delivering end-of-life care to critically ill patients.
3.6.3. Nurses experienced diverse relationships with nursing colleagues
Participants reflected contradicting experiences with regard to receiving support from colleagues in the intensive care unit. Senior nurses found that emotional support from colleagues was readily available and suitable for their needs, whereas junior nurses found support from colleagues lacking. Although there were contrasting experiences of support in the intensive care unit, none of the participants acknowledged the use of policies or procedures to assist them in dealing with end- of-life issues or how to access support systems available to them. Generally the emotional support that was available, particularly for junior nurses, was found to be inadequate to deal with the complexity of end-of-life issues in the intensive care unit. Some participants acknowledged that they are aware of the support systems that are available to them, yet they are reluctant to use these facilities.
“So it’s nice in this ICU, because we support each other a lot. If you’ve got a problem you never sit alone with a dying patient. There will be times that someone will come and pat your shoulder, to say how you, or can is I bring you a cup of coffee or do something for you.”
“...but I can honestly say that the girls are very supportive of one another. And because most of the people working here have got 10 plus years‟ experience and have dealt with this thing a lot, I can clearly say, I can truly say that the girls are very supportive. Anybody would come and especially if they know you’ve had a hard time with the family with this whole situation, come and give you a hug and, besides helping you clear up and whatever, they are there to say, ag things will be better tomorrow.”
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“But generally speaking, no I don’t feel that I get a lot of support from colleagues or even doctors for that matter. And I feel that my support really comes more from my friends, you know.”(Quote from a novice nurse)
Ranse, et al (2010:7) found that participants in their study relied on their colleagues for support which was not necessarily available for junior nurses who still had to build relationship networks within the intensive care unit. It was also found that nurses were aware of support services at their institutions, yet these were not accessed. It appeared as though nurses did not feel comfortable speaking to strangers regarding their experiences of end-of-life issues in the ICU.
Assistance from colleagues appeared to be a valuable strategy for nurses who had already developed support networks. Those who had only recently started working in the ICU found it difficult to obtain support from nursing colleagues as relationship networks were still being formed. Nurses who had been in the unit longer and had developed relationships with fellow colleagues found that they were able to draw support from their colleagues.