PROFESSIONAL NURSES EXPERIENCES OF A TEAM NURSING
CARE FRAMEWORK IN CRITICAL CARE UNITS IN A PRIVATE
HEALTHCARE GROUP
By
JEANANNE DUNSDON
Dissertation submitted in fulfilment of the requirements for the degree of
MAGISTER CURATIONIS
In
Nursing Science
In the
FACULTY OF HEALTH SCIENCES
At the
NELSON MANDELA METROPOLITAN UNIVERSITY
SUPERVISOR: Professor RM van Rooyen
CO-SUPERVISOR: Mrs. P. Jordan
I DEDICATE THIS STUDY
To
THE MEMORY OF
My mother
YVONNE DUNSDON
(1934 – 2002)
YOU WERE ALWAYS MY ROLE MODEL AND,
MENTOR. YOU BACKED AND SUPPORT ME IN
ALL I DID
AND TO
ALL CRITICAL CARE NURSES PAST AND
PRESENT
I SALUTE YOU FOR YOUR DEDICATION AND
PASSION
DECLARATION
In accordance with Rule G4.6.3,
4.6.3 A treatise/dissertation/thesis must be accompanied by a written declaration on the part of the candidate to the effect that it is his/her own work and that it has not previously been submitted for assessment to another University or for another qualification. However, material from publications by the candidate may be embodied in a
treatise/dissertation/thesis.
I, Jeananne Dunsdon with student number 206532920, hereby declare that the dissertation for “Magister Curationis” is my own work and that it has not previously been submitted for assessment to another University or for another qualification.
Signature:
ACKNOWLEDGEMENTS
I would like to express my sincere gratitude to the following people for their valuable contribution to this study:
Professor Dalena van Rooyen, for your patience, encouragement, and support. For always being there to help me pick up the pieces and carry on and your faith in me that I could achieve this. Without you, I would never have completed this study.
Portia Jordan, for your assistance and support, inspite of the pressure of completing your own study.
The Professional Nurses who participated in the study. Thank you for your time and input into this study. Without your input this study could not have been completed. Colette Telford-Smith, for editing this study. For giving up your time and for your
support and guidance.
Charlene Giraudeaux, for formatting this study. Your capability and skill gave the end product its shape.
Mrs. M. A. van der Westhuizen, for committing your time for doing the independent coding.
Rinette Dickinson, for your invaluable support and assistance.
Dr Tertia Nieuwoudt, my manager, for your unwavering support of this study. For your encouragement and for giving me as much time off as needed to complete this study. My Family and Friends: Dad, Megan, Gillian, Amanda, Merilyn, Avryl, and Sharmain.
Thank you so much for your support, understanding, and all your prayers. At times that was all that kept me going.
Maralize, Aletta, Fahmida, Khozi, Natalie, Anneli and Pat, my unit managers, for your ongoing support and understanding.
Nancy Shubane, thank you for your input, support, and assistance with research material.
Lourens Rothmann, for your daily support and guidance. Your continual encouragement and pushing for me to complete the study.
Alan Klette, for retrieving lost data when the memory stick crashed. You saved my study, thank you.
ABSTRACT
A critical care unit is a dynamic and highly technological environment. Professional nurses who have been working in the critical care unit for a period of time are passionate about the environment in which they work. They find their on duty time challenging and stimulating. The critical care environment is slowly changing. Due to the fact that there are fewer professional nurses with an additional qualification in critical care available to work in the critical care units. The utilisation of an increasing number of agency nurses leads to an increase in sub-standard nursing care as well as dissatisfied doctors and patients.
The shortage of critical care staff has resulted in the need to find an alternative human resources framework and still provide cost effective, safe quality patient care. This leads to the design and implementation of a team nursing care framework for critical care.
The research objectives for this study were:
To explore and describe the experiences of professional nurses with regard to a team nursing care framework in private critical care units.
Develop guidelines to optimize the team nursing care framework in critical care units in a private hospital group.
The research is based on a qualitative, explorative, descriptive and contextual research design. The study is based on a phenomenological approach to inquiry.
Eleven in-depth semi structured face-to-face phenomenological interviews were utilized as the main means of collecting data. A purposive, criterion based, sampling method was used. Specific inclusion criteria were met and consent was obtained from the participants and from the management of the private clinic where the research was conducted.
Two central themes were identified:-
Theme One: The professional nurses experienced the team nursing care framework in the critical care unit as a burden. Six sub-themes were identified.
Theme Two: Professional nurses made recommendations for improvement of the team nursing care framework in the critical care unit.
By describing the lived experiences of the professional nurses in the critical care units, based on research interviews, the researcher painted a clear picture of the team nursing care framework in the critical care unit. Guidelines were developed based on the identified themes. The broad guidelines are aimed at ensuring that the nurses are competent to care for critical care patients prior to them commencing work in the critical care unit.
The researcher concludes this study by making recommendations for Nursing practice, education and research.
KEY WORDS: Nurses, professional nurses, critical care, team nursing care framework, guidelines, experiences, training, stress, workload, management, quality nursing care, allocation.
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS i
ABSTRACT ii
CHAPTER 1 OVERVIEW OF THE STUDY:
1.1 INTRODUCTION AND BACKGROUND 1
1.2 PROBLEM STATEMENT 13
1.3 RESEARCH OBJECTIVES 14
1.4 TERMINOLOGY 14
1.5 RESEARCH DESIGN AND METHOD: 16
1.5.1 Research Design 16
1.5.2 Research Method: 17
1.5.2.1 Phase One: Data Collection 17 1.5.2.2 Phase Two: Data Analysis 17
1.5.2.3 Phase Three: Guidelines 17
1.6 MEASURES TO ENSURE TRUSTWORTHINESS 18
1.7 ETHICAL CONSIDERATIONS 18
1.8 CHAPTER DIVISION 19
1.9 CHAPTER SUMMARY 19
CHAPTER 2 RESEARCH DESIGN AND METHOD: 20
2.1 INTRODUCTION 20
2.2 RESEARCH OBJECTIVES 20
2.3 RESEARCH DESIGN AND METHOD: 20
2.3.1 Research Design: 21 2.3.1.1 Qualitative research 21 2.3.1.2 Exploratory research 22 2.3.1.3 Descriptive research 22 2.3.1.4 Contextual research 22 2.3.1.5 Phenomenological approach 23
Page
2.3.2 Research Method: 23
2.3.2.1 Research population 24
2.3.2.2 Sampling strategy 24
2.3.2.3 Data collection activities 25
2.3.2.4 Data collection method 28
2.3.2.5 The role of the researcher 29
2.3.2.6 Communication skills 29
2.3.2.7 The interviews 30
2.3.2.8 Analysis of data 33
2.3.2.9 Literature control 34
2.3.2.10 Phase Two 34
2.4 MEASURES TO ENSURE TRUSTWORTHINESS: 35 2.4.1 Truth-value 35 2.4.2 Validity 35 2.4.3 Objectivity 36 2.4.4 Authenticity 36 2.4.5 Criteria to ensure trustworthiness of the study 37
2.5 ETHICAL CONSIDERATIONS 40
2.5.1 The researcher protected the participants from harm 41
2.5.2 The researcher assured the right of self-determination of the
participants 41
2.5.3 The researcher ensure that the confidentiality and anonymity
of the participants would be protected: 42
2.5.3.1 Anonymity 42
2.5.3.2 Confidentiality 42
2.5.4 The researcher ensured the participants were treated justly 43
Page CHAPTER 3 DISCUSSION OF DATA ANALYSIS AND LITERATURE
CONTROL 45
3.1 INTRODUCTION 45
3.2 OPERATIONALISING OF DATA ANALYSIS AND
LITERATURE CONTROL 45
3.3 IDENTIFIED THEMES 46
3.4 DISCUSSION OF THEMES AND LITERATURE CONTROL 48
3.4.1 THEME 1: THE PROFESSIONAL NURSES
EXPERIENCED THE TEAM NURSING CARE FRAMEWORK IN THE CRITICAL CARE UNIT AS A BURDEN
50
3.4.1.1 Sub-themes of Theme One 52
3.4.2 THEME 2: PROFESSIONAL NURSES MADE
RECOMMENDATION FOR IMPROVEMENT OF THE TEAM NURSING CARE
FRAMEWORK IN THE CRITICAL CARE UNIT. THE TEAM NURSING CARE FRAMEWORK FOR CRITICAL CARE MUST BE
ADEQUATELY PLANNED.
75
3.5 CHAPTER SUMMARY 77
CHAPTER 4 CONCLUSION, GUIDELINES, LIMITATIONS AND
RECOMMENDATIONS 78
4.1 INTRODUCTION 78
4.2 OBJECTIVES 78
4.3 SUMMARY OF RESEARCH FINDINGS 79
4.4
BROAD GUIDELINES TO OPTIMIZE THE TEAM NURSING CARE FRAMEWORK IN CRITICAL CARE UNITS WITHIN A PRIVATE HEALTHCARE GROUP
Page
4.4.1 PRINCIPLE GUIDELINE ONE: 85
Ensure a relevant and appropriate knowledge case for staff nurses and auxiliary nurses working in the Critical Care environment.
4.4.2 PRINCIPLE GUIDELINE TWO: 90
Provide an operating practice encompassing the
engagement, implementation and evaluation phases of the Team Nursing Care Framework in the Critical Care Units.
4.5 LIMITATIONS 97
4.6 RECOMMENDATIONS: 97
4.6.1 Recommendations for Nursing Practice 98 4.6.2 Recommendations for Nursing Education 98 4.6.3 Recommendations for Nursing Research 99
4.7 CHAPTER SUMMARY 99
BIBLIOGRAPHY 100
TABLES
TABLE 2.1 Data collection activities 25
TABLE 2.2 Strategies to ensure trustworthiness 37
TABLE 3.1 Identified themes related to the professional nurses experiences of a Team Nursing Care Framework in the Critical Care Units
47
TABLE 4.1 Principle Guideline One 85
Page FIGURES
FIGURE 3.1 A diagrammatic representation of Theme One and
Sub-themes 49
FIGURE 3.2 A diagrammatic representation of Theme Two 49 FIGURE 3.3 A diagrammatic representation of Sub-theme One 52 FIGURE 3.4 A diagrammatic representation of Sub-theme Two 56 FIGURE 3.5 A diagrammatic representation of Sub-theme Three 59 FIGURE 3.6 A diagrammatic representation of Sub-theme Four 64 FIGURE 3.7 A diagrammatic representation of Sub-theme Five 67 FIGURE 3.8 A diagrammatic representation of Sub-theme Six 72 FIGURE 3.9 A diagrammatic representation of Theme Two 75 FIGURE 4.1 Summary of Research Findings – Theme One and Two 80
ANNEXURES
ANNEXURE A The researchers application to conduct a research study
within the Clinical of a Private healthcare Group 106 ANNEXURE B Letter of permission to conduct research from the Hospital
Manager 107
ANNEXURE C Acceptance from Nelson Mandela Metropolitan University
Human Ethics Committee of research proposal 108 ANNEXURE D Example of participants consent form 109 ANNEXURE E Example of an interview conducted with one of the
participants 110
ANNEXURE F Critical Care documentation (chart) 111
ANNEXURE G TAS Document 112
TAS Guidelines
ANNEXURE H Example of Nursing Auxiliary competency assessments 113 ANNEXURE I Guideline for the Critical Care documentation (chart) 114
CHAPTER 1
OVERVIEW OF THE STUDY
Mans mind stretched to a new idea never goes back to its original dimensions.
Oliver Wendell Holmes
1. INTRODUCTION AND BACKGROUND
Critical care units evolved as a result of the need to manage patients with acute life threatening conditions away from patients in a general medical or surgical unit. In the early 1900’s, at the Johns Hopkins Hospital in Baltimore, the first 3-bedded postoperative critical care unit was opened. Following this, a premature infant critical care unit was opened in Chicago. Mechanical ventilation was introduced in 1950 and all patients receiving this form of medical treatment were grouped together from then on. By 1997, the United States had in critical care units, 5000 available beds (Urdan & Stacy, 2002:3).
Critical care nursing has only been a speciality practice for the last 40 years. Previous to that critical care nursing was practiced wherever critically ill patients were placed in a hospital. Over time physicians depended more and more on nurses to watch for critical changes in their patients’ condition and to initiate emergency medical treatment. As technology advanced, it became very important to have nurses observe and monitor the critically ill patient. These patients’ were then nursed together in separate units, namely critical care units. This was done in order to make more efficient use of nursing staff and equipment. These units were further organised into medical and surgical critical care units. In the 1960’s nurses began to specialise into, for instance coronary care, nephrology and critical care. Because this group of nurses had new advanced knowledge and expertise and were trained in these speciality fields, they often assumed functions and responsibilities, which previously had only been reserved for physicians (Urdan & Stacy, 2002:4). The critical care units cater for patients with a variety of diagnosis and are nursed in a highly technological environment using ventilators, advanced haemodynamic monitoring and virtually every system in the body can be monitored and often manipulated
The professional nurse working in the critical care unit needs to have a critical analytical thinking ability and are most often critical care trained, by completing a post basic or post graduate programme in critical care nursing science. This programme is either one-year or two-years in duration at an accredited nursing school or university. There are also professional nurses working in the critical care environment, who are not critical care trained. They are working in the critical care unit as a professional nurse with critical care experience; which they have gained whilst working within the critical care environment.
Historically patients nursed within a critical care environment were nursed with a nurse patient ratio of 1:1. (This is where there is one nursing staff member, a professional nurse, caring for one patient and can also be called total patient care). According to nurses in the private health care sector, if the patient is ventilated, then the ratio of professional nurse to patient is 1:1. Non ventilated patients, both critical care and high care, are then allocated to nursing staff on a ratio of 1:2 or even 1:3. This ratio does not only include the professional nurse, but also nurses (with 2 years training, staff nurses) who are being utilised in the critical care unit.
At present in the private sector, the non-ventilated patients are delegated to the nurses (For the purpose of this study, nurse, applies to staff nurses and auxiliary nurses defined under the Nursing Act No 33. of 2005) The ratio can be as much as 3 patients to one nurse. It is becoming more and more difficult to maintain the ratio of 1:1 nursing. In the United Kingdom (UK) health care assistants are used as additional work force in the critical care units including paediatric intensive care units (King & Crawford, 2009:48). However the professional nurse is still responsible for the assessment, planning and evaluation of care. In the United States of America (USA) the Synergistic Model is used in establishing a staffing ratio of 1:1. In the Synergistic Model 8 nurse characteristics are linked to 8 patient characteristics, and results in patient-centred care and better use of resources (Hartigan, 2000:1).
In South Africa the majority of staff working in the critical care units are professional nurses, with most units employing a limited number of nurses as well. The nurses function within the critical care unit is limited. This is due to the existing scope of practice for nurses, which are set out by the Regulation of Scope of Practice R2598, which is directly governed by the Nursing Act No 33 of 2005. At present nurses work under the direct and indirect
The Australian Nursing and Midwifery Council (2007:2) states that direct supervision is when the supervisor, or in the context of this study, the professional nurse, is present, observes, works guides and directs the nurse. Indirect supervision is where the professional nurse works in the same ward or unit as supervised staff member (in the context of the study this pertains to the staff nurse and auxiliary nurse), but the professional nurse does not constantly observe the nurses’ activities.
This is set to change due to the amendments that have been made with the promulgation of the Nursing Act No. 33 of 2005. Under this act, the new Scope of Practice has been promulgated, but no regulation for practice has as yet been accepted. Until such time, all nurses are still working within the Scope of Practice No R2598, as amended. Based on the fact that the nurses (staff nurses and auxiliary nurses) have a limited scope of practice and need to work under the direct or indirect supervision of the professional nurse. There has been resistance from both professional nurses and doctors to the nurses working in the critical care unit. It is believed that the practical and theoretical knowledge of the nurse is not at a level required to work in a critical care unit. In spite of this, when the nurses worked within the critical care units the doctors and professional nurses had an unrealistic perception whereby they expected the nurse to perform at the same level as that of a professional nurse working in the critical care units.
Historically the professional nurses did not want to take on the responsibility for the nurses in the critical care units. Due to the specialised nature of the critical care unit, it has always been preferable to have professional nurses caring for critically ill patients. As the patients are are often unstable and their condition is ever changing, the nurse caring for the patient needs to have advanced (nursing) theoretical and clinical skills. These advanced skills are required as the critical care nurse needs to make rapid and accurate decisions to manage the patient’s condition promptly. The nurse working in the critical care units make life and death decisions and they find the environment of the critical care unit very demanding and stressful.
Occasionally, there may also be a nurse (with one year of training) who will assist the professional nurse with some aspects of the basic nursing care of the patient e.g. bed bath and rendering pressure care. Currently it is the practice that the professional nurse, who is allocated for the care of the patient, is 100% responsible for the nursing care, using critical
The professional nurse is ultimately responsible for advanced nursing care as well as all basic nursing care e.g. mouth care and bed baths, as well as carrying out medical management prescribed by the doctor. In the critical care unit, there may be a professional nurse who is supra numeri, i.e. who is not involved directly with patient care and who has not been allocated a specific patient. The role of this professional nurse is one of shift leader or supervisor. It is the responsibility of the shift leader to ensure the smooth running of the shift and to ensure that the prescribed medical and nursing care has been carried out and is also responsible for the co-ordination of the shift. The shift leader is the contact person when there is a request by a doctor for an admission to the unit, and with whom the nursing manager and other doctors liaise.
However, the method of 1:1 professional nurse to patient ratio and related skill mix is rapidly becoming more expensive and difficult to maintain due to certain constraints. These constraints are:
Shortage of critical care trained professional nurses.
o This is due to a large proportion of professional nurses leaving the country to work abroad or taking non-nursing positions e.g. with medical aid companies and pharmaceutical companies.
According to the South African Nursing Council (SANC) the number of professional nurses in the advanced programmes e.g. critical care, have decreased from 3100 in 1996 to 2537 in 2005 (Subedar, 2006:42-45).
According to the SANC the profession is shrinking and, the production of nurses has not been sufficient to expand and strengthen the numbers in the profession in relation to needs in the country. There has also been minimal growth in the number of student nurses and pupils enrolled for training. In 1996, there were 1216 student nurses and 1309 students in 2005 (Subedar, 2006:42-45).
The Hospital Association of South Africa states that there is a decline in the number of nurses graduating in most categories.
o The total number of professional nurses with post basic qualifications (critical care nursing) on the SANC Register have decreased from 3100 in 1996 to 2537 in 2005 (HASA, 2008:10).
A total of 38149 professional nurses were trained between 1996 and 2005. The number of professional nurses graduating through the bridging programme (staff nurses bridging to become professional nurses) increased from 1169 in 1996 to 2352 in 2005, which
There is an aging nursing workforce, which has also been complicated by the fact that many nurses have taken voluntary severance packages from the public health care sector and nurses have also left South Africa for lucrative overseas markets (Fouche, 2002:36).
Shortage of professional nurses with critical care experience.
o Even with the shortage of this category professional nurses are still more freely available than the trained critical care professional nurses. The professional nurse with critical care experience has limited knowledge of critical care and are not always able to look after the critically ill patients, as they do not have the advanced critical care knowledge.
Increase number of critical care beds within the private health care sector.
o Within the hospital, where the research study will be conducted, the number of critical care beds increased form 21 beds to 40 beds in one year, thus requiring more staff.
It is also becoming more expensive to employ a majority critical care trained professional nurses. When this was discussed with a unit manager from the private sector, she stated that there is a difference of between R2,500 –R3,000 per month between the salaries of the critical care trained professional nurse and the critical care experienced professional nurse.
Professional nurses interviewed verbalised that their stress levels are increasing dramatically and this leads to burnout (See chapter 3). The critical care environment is highly technological and fast paced and the professional nurse has to deal with life and death situations daily, which is very challenging for the staff.
Administrative burden
o The administrative burden on the professional nurses, (mainly the critical care trained nurses) is very high.
o Due to the increased awareness of the general public to litigation, over time, there has been an increase in documentation (paper work) as the nurses have to document more and more, and this is becoming very timeous.
Long and very unsociable hours (including weekends, public holidays and night duty). This is a factor which deters young school leavers form entering the profession and is also a contributing factor to nurses within the profession leaving for areas where there are more sociable hours e.g. doctors rooms, medical aid companies etc (Fouche, 2002:36).
Abuse factor:
o Abuse is an area that is coming to the forefront more and more, and nurses are learning to speak out about this. The abuse includes medical practitioners swearing directly at the nurses and about them. The major sources of verbal abuse of nurses are from doctors, other healthcare workers, patients, and families. Verbal abuse is a real problem in the healthcare industry. Abuse can be devastating to the nurse concerned and can be psychologically and physiologically damaging. Nurses experience verbal abuse due to their subordinate status compared to doctors. Verbal abuse and conflict is directly related to staff turnover (Rowe & Sherlock, 2005: 242-247).
Critical units are staffed with both permanent and agency employed nursing staff. Agency employed nursing staff can be grouped into two groups. Group one, are nursing employees who are not permanently employed by a health care group or specific hospital and work exclusively through an agency. Group two, are nursing employees who are permanently employed by a healthcare group, specific hospital or public sector and who work overtime through the agency. In so doing supplementing their monthly income. Agency employed nursing staff are registered or employed with a specific nursing agency. They are freelance staff booked through the individual nursing agency, and paid by the nursing agency. Agency staff may work at a specific hospital and unit for a period of time. The period can be for just a 12-hour shift or can be booked on a regular basis (permanent agency).
The use of agency nursing staff in the adult critical care units, in the hospital where the study is to be conducted, was 52% for the period January to October 2005 with an occupancy of 89%, Compared to the general wards, in the same hospital, where for the same period of time, the occupancy was 60% and the agency staff utilisation was 20%. Demonstrating a high need for agency staff to meet the occupancy rate of the critical care units (Life Healthcare Group. Gauteng. Nursing data 2005).
In the private hospital where the study is to be conducted, there are many full time posts in the critical care unit that are vacant and there is an ongoing battle to fill these positions. It has been necessary to utilise agency staff more and more and it is even difficult at times to find agency staff to cover the shifts.
The researcher has first hand experience that when attempting to obtain staff through the nursing agencies, the agencies battle to provide critical care staff, especially critical care trained staff. This is due to the shortage of this category of professional nurse. Whilst talking to the unit managers, they stated that agency staff is not always reliable and are often not as experienced as permanent critical care unit employees and they need more supervision by the permanently employed professional nurse. Patients and their families complain about the care and the doctors are less satisfied and are often nervous about leaving their patients in the hands of the agency employed professional nurses. The problems are often exacerbated during the night shift, where unfortunately the patients are often nursed exclusively by agency staff. The hospital, were the study is to be conducted, has limited or no permanent staff on duty during night shift in one of the critical care units.
Staffing levels in the critical care units are linked to patient acuity levels. The particular private healthcare group in which the study was conducted, stipulates acuity as the level of care required for each patient depending on the level or grade of seriousness of the patient’s condition. Nursing care and staffing are planned according to the level of care required. The existing acuity document used in the critical care units, did not meet the needs of the critical care patient and resulted in acuity being incorrectly assessed. Subsequently resulting in insufficient staff being available in the critical care unit, which led to the incorrect level of care being rendered to the patient. Because of the inadequate assessment, it was decided to look at another method of assessing the acuity needs of the critical care patient. A new document was designed; namely the Therapeutic Assessment Score (TAS) for critical care. The assessment document developed was based on the International Therapeutic Intervention Scoring System (TISS). The TAS was trialled in six different critical care units in four different hospitals within the private healthcare group in which the study was conducted. The new acuity assessment document helped to accurately grade the severity of the patients condition and is directly linked to staff utilisation and therapeutic interventions. Through trial of this document, the acuity document for critical care units was changed and refined. Seven drafts were used before the desired product was achieved i.e. a document which adequately reflected the acuity of all critical care patients.
The Therapeutic Assessment Score (TAS – Annexure G) acuity document gives a more accurate acuity level of patients’, and therefore, the staffing of the critical care unit is more
In the TAS the patients are grouped as follows: Major patient Acuity (Specialised Critical Care)
o Scoring >35
Patients who are fully dependent on medical support for more than 2 major systems.
The skill mix requires the expertise of a critical care trained professional nurse.
The activities of daily living can be done with the help of the nurses e.g. The professional nurse as well as the nursing auxiliary will do the bed bath of the patient.
Moderate patient acuity (Critical Care) o Scoring 20 – 34
Patients who have one or more systems that are unstable and require support.
The skill mix will include a professional nurse with critical care experience with the help of nurses for activities of daily living.
Minor patient acuity (High care) o Scoring 10 – 19
Patients that are stable, but require continuous monitoring for possible acute deterioration
The nurses who are supervised by the critical care trained professional nurse can predominantly care for the patient. The professional nurse is responsible for critical analytical thinking, prescribing nursing care and for overseeing the care that is rendered by the nurses as well as evaluating and re-planning where needed according to the change in acuity.
In the private hospital where the team nursing care framework was piloted, the following process was used prior to roll out of the framework (As per management presentation). The processes consisted of Five Phases in the project activity or the Journey of the roll out and are as follows:-
Phase 1:
o Project Introduction, which involved the stakeholder engagement and project planning.
Staff work sessions.
Defining roles and responsibilities within the critical care unit team nursing care framework.
Coaching of unit managers and management team. Phase 2:
o Involved a task analysis based on disciplines and identification of training requirements. Critical care documentation was revised and developed during this stage (Critical care flow chart and development of the TAS).
o Development of guidelines for the new critical care documentation (ICU chart, including the TAS.
o Development of competency assessment tools for each category of nurse. o Introduction of new critical care documentation (ICU chart).
o Training and coaching on the TAS
Phase 3:
o Implementation of the team nursing care framework o Competency based training and assessment. o Introduction of academic rounds
Phase 4:
o Evaluation of the team nursing care framework
Phase 5:
o Closeout of the pilot project
o Implementation of sustaining actions
The critical care team consists of employees who deliver appropriate care according to their scope of practice to patients in the critical care units. The care is risk and acuity based and is driven by the patient physical assessment and TAS. The team consists of the following:
- Professional nurses trained in critical care, function as team leaders and are responsible for:
o All critical analytical activities e.g. interpretation of arterial blood gases and chest x-rays.
o Advising the experienced professional nurse and nurses of further steps to be taken in the management of the critical care patient.
o Co-ordinate all advanced critical care aspect of patient care.
- The nurses (in the context of this study the staff nurses and auxiliary nurses) are responsible for:
o The routine care in conjunction with other members of the team and they function under the direct and indirect supervision of the professional nurse. o Assisting with basic nursing care as planned for by the professional nurse. o Simple nursing procedures including bed bathing the patient, mouth care,
pressure part care
o Administration of some medication o Observation of vital data.
o Routine environmental activities
- Care givers (Hospitality attendants) who are not nurses, and who have no scope of practice, assist the nursing team with non-nursing and hospitality tasks or functions.
Functional nursing was adopted after the second world war and this was purely task allocated nursing. Tasks were assigned to nurses and the less skilled workers were assigned routine tasks, with the professional nurses addressing more complex needs and tasks. This was found to be unsuitable as it resulted in fragmented nursing care (Aylward, 2010:34). In the 1950’s team nursing was developed and resulted in nurses working in groups or teams allocated to patients and responsible for total care of those patients (Aylward, 2010:34).
The patients in the critical care unit are divided into major, moderate, and minor patients according to their acuity which is obtained by completing the TAS. The physical assessment is also conducted and the problems of the patient are identified and nursing care is planned. The unit is staffed according to the results of the TAS and the quantity of staff is guided by means of the team staffing Tool (A computer staffing programme used by the healthcare group to assist in critical care staffing). This is done with the aid of the TAS, taking anticipated discharges and transfers in and out of the unit into account. The team composition is then obtained using the said computer programme.
The unit manager and shift leader are “supra numeri” of the actual team, but are involved with the management of the unit and supervise and co-ordinate total care rendered by the team. As an example to show how the team is divided up, an example of a critical care unit which has 14 patients is used. The acuities of the patients are as follows:-
- 3 patients with a major acuity (TAS >35).
- 4 patients with a moderate acuity (TAS 20 – 34). - 7 patients with a minor acuity (TAS 10-19).
The three patients who have a major acuity will each be nursed by a professional nurse. The professional nurse is not necessarily critical care trained. Thus a 1:1 ratio. The four patients with a moderate acuity will be nursed by a professional nurse (one professional nurse for every four moderate patients) with the assistance of the nurses. Seven minor patients will be nursed by one professional nurse (one professional nurse for every five minor patients) with the assistance of nurses. The care worker will assist in all areas with non-nursing activities.
During the introduction of the team nursing care framework into the critical care unit, it was found that the existing critical care-nursing chart was inadequate for the team nursing care framework. A new critical care chart was developed to accommodate the allocation of the nursing team (Annexure F). The shift leader allocates all aspects of patient care that is depicted on the chart according to the category of staff and this is documented on the space provided on the document. The frequency of all nursing care is prescribed on the document and this is done when the nursing care of the patient is planned by the professional nurse. The shift leader / professional nurse signs off on this document as she has co-ordinated or approved nursing care which was rendered. A critical care nursing guideline for using the critical care document was developed and is available on the Healthcare Group’s intranet and available to all critical care units to ensure that the staff is trained in the use of the new critical care document (Annexure I).
When the team nursing care framework was rolled out to the hospital, it involved competency based training and assessment. In the team nursing care framework for critical care units it is imperative for the employees working in the critical care unit to be competent. It was important therefore, to ensure that the nurses were competent to function within the critical care unit. As stated earlier the critical care unit is a foreign
Competency assessment tools for each category of nursing staff was developed, utilising the Scope of Practice. All nursing activities within the critical care unit that would be carried out by each of these nurses was listed. Once this was done working teams (Teams of Excellence – TOE) were selected from different critical care units. Members of this TOE were then grouped according to the different categories of nurses. Each team then worked through the activities for each category and compiled a continuous professional development competency assessment tool for each activity. An example of the contents of the Continuous Professional Competency Assessment tool for nursing auxiliaries is as follows (Annexure H).
Admission of a patient Preparation for admission Evaluating the care of a patient
o Monitoring vital data o Urine testing
o Perform a 12-Lead Electrocardiogram (ECG) o Measure blood glucose levels
Giving Health Education
o Health education regarding foot care o Health education regarding wound care Laying out of a corpse / caring for the deceased
o Unnatural causes o Natural causes Equipment
o Defibrillator and Emergency Trolley o Suction apparatus
o Cardiac monitors o ECG machine o Infusion pump
Continuous Professional Development Competency tools were developed under the following headings:
o Expected outcomes and resources o Guidelines and evaluation instrument o Record of experience / exposure
o Outcome i.e. competent / not yet competent
o Remedial action i.e. the action, the responsible person and the re-assessment date.
The clinical facilitators were given a mandate to ensure that the staff, working in the units, were competent to assess competency in conjunction with the unit managers, using the continuous professional development competency tool. It was necessary for clinical facilitators to spend time in the critical care units giving on the spot training to ensuring that the nurses were safe practitioners capable of rendering competent nursing care. The nurses who were new to the critical care environment were to attend the critical care orientation programme which exposed the employees to different aspects of critical care. The nurses are also encouraged to attend the Further Education and Training High Care Programme (FET High care) which is run by the nursing college of the healthcare group.
1.2 PROBLEM STATEMENT
The current shortage of critical care trained professional nurses and the high utilisation of agency employed staff is not conductive to quality patient care delivery and is also no longer financially viable. The agency employed professional nurses are unreliable and show little or no loyalty to the hospital or unit in which they work. It has become necessary to source an alternative method of staffing the critical care unit. This resulted in the introduction of the team nursing care framework. The team composition is based on the results of the patient assessment and the TAS. After implementation of the framework, it was deemed necessary to explore and describe how professional nurses experienced this alternative framework of staffing critical care units. The professional nurses expressed their concern regarding the team nursing care framework, and the efficacy thereof as it is currently implemented. Quality patient care and the increased workload is a growing concern for the professional nurses.
In the light of the above, the following research questions were formulated:
What are the experiences of professional nurses working in critical care units in relation to the implementation and utilization of a team nursing care framework in the critical care units?
What guidelines can be developed to optimize this framework in order to provide safe, cost effective, and quality patient care?
1.3 RESEARCH OBJECTIVES
The research objectives are:
To explore and describe the experiences of professional nurses with regard to a team nursing care framework in private critical care units.
Develop guidelines to optimize the team nursing care framework in critical care units in a private hospital group.
1.4 TERMINOLOGY
The terminology applicable to this research is as follows: Critical care (Intensive Care)
o The Oxford Dictionary of nurses (2008:256) defines intensive care (critical care) as “Specialised and monitored health care provided for critically ill and immediately postoperative patients by specialist multidisciplinary staff in a specially designed hospital unit.”
Nurse
o The Oxford Dictionary of nurses (2008:343) defines a nurse as “A person who has completed a programme of basic nursing education and is qualified and authorised in his or her own country to practice nursing..”
o According to the Nursing Act of South Africa (Act No. 33 of 2005) a nurse means a person registered in a category under section 31(1) in order to practice nursing or midwifery.
o For the purpose of this study, nurse applies to staff nurses and auxiliary nurses as defined under the Nursing Act of South Africa (Act No. 33 of 2005).
Professional Nurse
o According to the Nursing Act of South Africa (Act no. 33 of 2005) a professional nurse is “a person who is qualified and competent to independently practice comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice”.
Staff Nurse
o According to the Nursing Act of South Africa (Act No. 33 of 2005) “the staff nurse is a person educated to practise basic nursing in the manner and to the level prescribed”.
Auxiliary Nurse
o According to the Nursing Act of South Africa (Act No. 33 of 2005) “an auxiliary nurse or auxiliary midwife is a person educated to provide elementary nursing care in the manner and to the level prescribed”.
Nursing
o According to the Nursing Act of South Africa (Act No. 33 of 2005) “nursing means a caring profession practised by a person registered under section 31, which supports, cares for and treats a health care user to achieve or maintain health and where this is not possible cares for a health care user so that he or she lives in comfort and with dignity until death”.
Scope of Practice
o According to the New Nursing Act of South Africa (Act No 33. of 2005) scope of practice means “the scope of practice of a practitioner that corresponds to the level contemplated in section 30 in respect of that practitioner”.
Team Nursing
o The Oxford Dictionary of nurses (2008:490) defines team nursing as “a method of organising nursing care in which a team of nurses is responsible for the assessment, planning, implementation, and evaluation of a patient’s hospital stay and subsequent discharge from the hospital.” In the context of this study, the team will together deliver appropriate quality care.
The professional nurse will act as the team leader and the enrolled and nursing auxiliaries will assist in the care of the patients by carrying out the nursing care plan under the supervision of the professional nurse.
Skill mix
o The Oxford Dictionary of nurses (2008:457) defines skill mix as “various skill levels of health-service staff required either within a particular discipline or for the total staff within a health authority to provide effective care”.
Care Giver
o This is a person, who is not a nurse, who assists the team in the context of a team nursing care framework. A caregiver is responsible for non-nursing functions and hospitality functions e.g. reading to patients, a runner to pharmacy and other departments etc.
Human resource planning
o Grobler and Warnich (2006:554) describe human resource planning as “a process of systematically analysing and identifying the need for and availability of human resources to ensure that the required number of employees, with the required skills, are available when they are needed to enable the organisation to meets its objectives”
1.5 RESEARCH DESIGN AND METHOD
A brief overview of the research design and method will now be presented. A more detailed discussion will follow in chapter two of this study.
1.5.1 Research Design
Mouton (2005:55) states that the research design is the blueprint or the plan of how the researcher intends conducting the research or study. In this research study, a qualitative, explorative descriptive and contextual research approach to enquiry was used to explore and describe the experiences of professional nurses with regard to a team nursing care framework in private critical care units.
1.5.2 Research Method
The research method describes how the researcher plans to go about collecting and making sense of the data collected (Hansen, 2006:60). The research method comprises two phases. Phase one, involves the description of the professional nurses experience of the team nursing care framework in the critical care unit, data collection and analysis. Phase two, involves the development of broad guidelines relating to the team nursing care framework in critical care.
1.5.2.1 Phase One: Data Collection and Data Analysis
As a means of collecting data, the researcher performed individual interviews with professional nurses working in critical care units of a particular private hospital group that were utilising the team nursing care framework. Interviews are a method of data collection in which an interviewer obtains responses from a participant in a face-to-face encounter and are the most direct method in which the researcher can obtain information from the participant (Brink, 2006:151). The questions are open ended, and conducted in such a way that there is a mutual understanding of the participants experience (Burns & Grove, 2007:376-377)
Data analysis occurs in three phases, description, analysis and interpretation (Burns & Grove, 2007:79). During data analysis the data which has been obtained is broken up into themes. The relationships between the themes are identified and trends or patterns are identified (Mouton, 2005:108). Data analysis will be discussed in depth in chapter two of this study.
1.5.2.2 Phase Two: Development of Guidelines
This phase entailed the development of guidelines based on the data analysed to optimise the team nursing care framework in critical care units in a particular private healthcare group.
1.6 MEASURES TO ENSURE TRUSTWORTHINESS
Trustworthiness in qualitative research means methodological soundness and adequacy (Holloway & Wheeler, 2002:254). The methods of trustworthiness implemented in the study will be discussed in detail in chapter two of this study.
1.7 ETHICAL CONSIDERATIONS
The nurse researcher is responsible for conducting the nursing research in an ethical manner. To do this the nurse researcher must ensure that the research is carried out competently and resources must be managed honestly. Ethical considerations are aimed at protecting the research participants from any harm when they are involved in the research study and also involve a high level of integrity and commitment of the researcher to basic ethical principles of respect for persons, beneficence and justice (Hansen, 2006:30).
The professional nurse in the critical care unit will decide if they want to participate in the study, and they will also have the right to withdraw from the study at any time. The following ethical considerations will be discussed in-depth in chapter two of this study:
Protecting the participants from harm (Beneficence) Right of self determination of the participants
Right to just treatment of the participants Confidentiality
Throughout the research study, the researcher ensured that the individuals involved in the research were protected, in that the information given by them remained confidential and ensured that the participants were not harmed, exposed or exploited and were protected them from physical, emotional, and social harm.
1.8 CHAPTER DIVISION
The research study will be discussed under the following chapters: Chapter 1: Overview of the study
Chapter 2: Research Design and Method
Chapter 3: Discussion of Data analysis and literature control
Chapter 4: Conclusion, Guidelines, Limitations, and Recommendations.
1.9 CHAPTER SUMMARY
The researcher endeavoured to accurately voice the experiences of the critical care professional nurse with regard to the development and implementation of team nursing care framework for critical care units in the private sector, utilising team nursing. In so doing the researcher made recommendations to optimise the team nursing care framework in all critical care units in a particular private hospital group and assisted in the contribution to safe, cost effective, and quality patient care within the adult critical care units.
CHAPTER 2
RESEARCH DESIGN AND METHOD
Man will occasionally stumble over the truth, but most times he will pick himself up and carry on
Sir Winston Churchill (1874 – 1965)
2.1 INTRODUCTION
In chapter one an overview was presented of the research study and the research objectives where described. Data was collected by in-depth individual interviews with professional nurses, both critical care qualified and critical care experienced, working within an adult critical care unit of a private hospital group.
There was limited research literature available with regard to the team nursing care framework within the context of private critical care units in South Africa. This research study formed the basis for guidelines to optimize the team nursing care framework in critical care units in a particular private hospital group.
2.2 RESEARCH OBJECTIVES
The research objectives are:
To explore and describe the experiences of professional nurses with regard to a team nursing care framework in private critical care units.
Develop guidelines to optimize the team nursing care framework in all critical care units in a particular private hospital group.
2.3 RESEARCH DESIGN AND METHOD
2.3.1 Research design
In this study a qualitative, explorative, descriptive and contextual design based on a phenomenological approach to inquiry was used to reflect the experiences of professional nurses working within a team nursing care framework in private critical care units.
2.3.1.1 Qualitative research
Qualitative research is a form of social enquiry, focusing on the way that people, in this case the professional nurses, interpret their experiences (Holloway & Wheeler, 2002:3). The team nursing care framework brought about a change in the mindset of the professional nurses, who historically believe that there is no place for other category of nurses in the critical care unit and that they, the professional nurses, are fully equipped with both advanced and basic knowledge and are therefore able to care for their patients in entirety. Due to the change and conflict, qualitative methodology is useful as it explores change and conflict (Holloway & Wheeler, 2002:3). Qualitative research brings about a deep understanding of a phenomenon and this is achieved through a narrative description. The measurement in qualitative research is based on open ended questions and interviews (Portney & Watkins, 2009:18) McSherry, Simmons and Abbot state “Qualitative research is research that seeks to tell stories” ( McSherry, Simmons & Abbot, 2002:30). The researcher will tell the story of the professional nurses’ experiences of the team nursing care framework in critical care. Qualitative research involves fieldwork. Fieldwork is where the researcher obtains the information necessary for the study from outside a laboratory, and obtains firsthand experience of the participants involved in the study. In the study the researcher went to the critical care unit of a private hospital where the professional nurses involved in the study work, in order to gather the necessary data. The data was obtained by interviewing the participants (Holloway & Wheeler, 2002:143 – 144). There are various research methods within qualitative research. As the researcher has described the lived experiences of the participants, a phenomenological research approach is applicable to this study. The aim of phenomenological study is the description of the experienced as lived by the participants. These experiences are then interpreted by the researcher (Burns & Grove, 2001:31).
2.3.1.2 Exploratory research
Exploratory research is aimed at obtaining more information about a situation or occurrence. It arises from a lack of information on the situation or new area of interest (De Vos, Strydom, Fouche & Delport, 2002:109). Feedback was obtained from the professional nurses around their experiences, having worked within the team, in the critical care environment.
2.3.1.3 Descriptive research
Descriptive research is rooted in philosophy and human science (Holloway & Wheeler, 2002:7). Descriptive research portrays an accurate description of the group or situation, in this instance it gives an accurate description of the professional nurses in the situation of the team nursing care framework in the critical care unit. Through descriptive research the researcher can discover new meaning, describe what already exists and determine the frequency of which something occurs. Descriptive research can be carried out when little is known about a subject (Burns & Grove, 2001:30). Descriptive research gains more information about the participants and may be used to identify problems during the process of descriptive research. The researcher may utilize different approaches to obtain the data needed e.g. interviews and observation (Burns & Grove, 2001:30). Throughout descriptive research, the researcher turns to the participants for guidance, control and direction (Holloway & Wheeler, 2002:7). In the proposed study the professional nurses experiences of the team nursing care framework will be described in order to obtain complete and accurate information.
2.3.1.4 Contextual research
Contextual research refers to the environment or the conditions in which the study takes place. The setting is the physical location and the environment in which the people that are being studied find themselves (Holloway & Wheeler, 2002:34). In this study, the environment is the ward in a hospital or clinic where the research takes place. The location where this study was conducted was a private 360 bed multi disciplinary private hospital, covering all major disciplines. In this private hospital there are 5 adult critical care units with a total of 40 adult critical care beds. Most of the professional nurses working in this
It was decided to interview the professional nurses working in the 5 bedded cardio thoracic and 6 bedded surgical critical care unit. In these units they utilized the team nursing care framework to care for the critical care patient.
The researcher needed to respect the context and the culture in which the study took place. As well as the conditions, including locality and time of day in which the actions were described (Holloway & Wheeler, 2002:11).
2.3.1.5 Phenomenological approach
A phenomenological study describes the lived experiences of people involved in a situation (Burns & Grove, 2007:64). The purpose of a phenomenological study is to describe the experiences of people regarding a certain occurrence, including how they interpret the experience or what meaning the experience has for them. During the phenomenological study the researcher focuses on what is happening in the life of the participant i.e. the professional nurses in the critical care unit. The researcher then ascertains what is important in the situation and what changes can be made to the situation (Brink, 2006:113). In this study the lived experiences of professional nurses regarding the team nursing care framework in critical care is explored and described and what recommendations can be made to improve the experience of the professional nurses.
2.3.2 RESEARCH METHOD
The research method describes how the researcher plans to go about collecting and making sense of the data collected (Hansen, 2006:60). The research method involves the collection of data to obtain the experiences of the professional nurses working within the team nursing care framework. This was done through an identified, research method, population sampling, data collection and data analysis. Phase One, involved the exploration and description of the professional nurses experience of the team nursing care framework in the critical care unit, data collection and analysis. Phase two, involved the development of broad guidelines relating to the team nursing care framework in critical care.
2.3.2.1 Research Population
Research population is the individuals or objects which meet the inclusion criteria for inclusion in the study (Burns & Grove, 2003:43) The research was limited to professional nurses who are trained in critical care nursing and professional nurses with critical care experience of 1 year or more, working within the identified critical care units, as they were exposed to the introduction of team nursing care framework in these critical care units.
2.3.2.2 Sampling Strategy
A sample is a part of a whole which is selected by the researcher to take part in the research study (Brink, 2006:124). A purposive, criterion based, sampling method was used by the researcher. Homogenous sampling was used. Homogenous sampling is where the participants all belong to the same unit or particular group e.g. specialist nurses (Holloway & Wheeler, 2002:123). The sampling for this study was purposive and not random. According to Barbour, (cited in Hansen, 2006:52) purposive (or theoretical) sampling offers a degree of control rather than being at the mercy of any selection bias inherent in pre-existing groups such as clinical populations. Purposive sampling can be referred to as selective sampling where the researcher purposely selects participants for the study as it is the best way to gain insight and in-depth understanding of the professional nurses experience of a team nursing cared framework in critical care (Burns & Grove, 2003:255). The researcher has an in depth knowledge of critical care and critical care units, staffing and methods of nursing care. In order for the participants to be part of the study the following specific inclusion criteria needed to be met:
Professional nurses with a critical care training registration with the South African Nursing Council
Professional nurses with critical care experience of more than a year
Professional nurses must have been involved in the team nursing care framework for at least 3 months
A purposive sample was drawn from available professional nurses working in the selected critical care unit and the above mentioned inclusion criteria was utilized thus preventing sample bias.
2.3.2.3 Data collection activities
Data-collection is a process which involves the precise systematic collection of information relevant to the research study (Burns & Grove, 2003:656). Data collection is the way in which data is collected and may include interviews as a method of data collection (Holloway & Wheeler, 2002:36). The following table demonstrates data collection activities of this research study.
TABLE 2.1 DATA COLLECTION ACTIVITIES
Data Collection Activities Phenomenological Tradition Application to Research Topic Who was being studied?
Multiple individuals who have experienced the phenomenon
Professional nurses working in a critical care unit within a private healthcare group were the focus of the study.
What were the access issues?
Locating individuals who had experienced the phenomenon.
Access was limited to professional nurses working in the selected critical care unit within a private healthcare group.
Due to the in-depth nature of the study, it was convenient for the researcher to interview professional nurses who were working in the critical care unit and who had experience of the team nursing care framework.
Written permission was obtained from the professional nurses who were willing to share their experiences with the
Data Collection Activities Phenomenological Tradition Application to Research Topic How were individuals selected for the study?
Locating individuals who had experienced the phenomenon, a criterion sample
Criterion sampling was most successful as all individuals participating represented people who had experienced the
phenomenon. Only
professional nurses working in the specific critical care unit and who met the specific sample criteria were interviewed. Specific sampling criteria was
formulated (refer to section 2.3.2.2)
What type of information was typically collected?
In-depth interviews were conducted and data saturation determined the sample size. Data saturation occurs when additional sampling provides no new information to the study (Burns & Grove, 2007:348)
The researcher collected data until saturation had occurred. This is where new data collected no longer sparked new insights into the
phenomenon related to the professional nurses’
experiences of the team nursing care framework in critical care.
Data Collection Activities Phenomenological Tradition Application to Research Topic How was information obtained?
Well described interview protocol. The goal of the researcher was to obtain information and insight into the issues relevant to the general aims and specific question of the research study.
The process of information collection involved in-depth interviews to ensure that the experiences of a group of individuals, professional nurses experience of the team nursing care
framework in critical care, was described in detail. Each interview took no
longer than an hour. Each interview was audio
taped and transcribed verbatim.
What were the common data collection issues?
Bracketing one’s experience. Burns and Grove (2003:275) state that bracketing is when the researcher sets aside what is known about an experience being, studied. It is the process whereby prejudice beliefs are removed from influencing the research (Holloway & Wheeler, 2002:173).
The researcher’s role in the interview process was
magnified due to the fact that the interviewer herself was the main instrument in obtaining knowledge. The researcher put aside
any personal knowledge and experience of the team nursing care framework in critical care units so as to avoid any misrepresentation regarding this phenomenon.
Data Collection Activities Phenomenological Tradition Application to Research Topic
How was data analyzed? How was information stored? Cassette tapes Transcriptions of interviews Computer files
A computer was utilized to aid this study.
2.3.2.4. Data collection method
Data collection is the process of acquiring subjects and collecting data for the study (Burns & Grove, 2007:391). The researcher made use of in-depth, semi-structured individual face-to-face phenomenological interviews as a main means of data collection. Interviews can be classified as structured, semi-structured, unstructured in-depth and informal interviews (Hansen, 2006:98-192). Semi-structured one-to-one interviews gain a detailed picture of a participant’s account of a particular topic. This gives the researcher more flexibility. The interviewer has a set of predetermined questions on an interview schedule, but is largely directed by the schedule (De Vos et al, 2002:302). Questions utilized in this study were open ended questions. The participants also had the freedom to discuss issues beyond the confines of the question put to them and many of them mentioned other issues which impacted on the team nursing care framework.
The following questions were posed to each of the participants:
“Tell me how you experienced the team nursing care framework in the critical care
unit?”
“What hindered the process of team nursing in the critical care unit?” “What facilitated the team nursing care framework in the critical care unit?
2.3.2.5 The role of the researcher
The interviewer facilitates the discussion. The interviewer should be flexible, open minded and able to elicit information from the participants (Holloway & Wheeler, 2002:115). In Qualitative research the researcher is described as “the instrument” and the researcher’s presence is a fundamental paradigm, no matter how lengthy or brief the interaction is. During the interview, the interviewer and the participant are actively engaged in constructing a version of the world (of the professional nurse) resulting in a deep mutual understanding of the topic (the experiences of the professional nurse of the team nursing care framework in critical care). During this time the researcher assisted in the unit, where necessary, at the time of the interviews, e.g. helped to turn patients, answered the telephones and also gave informal teaching to the nurses or ICU students. It was the researcher’s responsibility to obtain an authentic insight into the experiences of the professional nurses (Burns & Grove, 2003:376). The researcher encouraged the participants to share their experiences of the team nursing care framework and in so doing the researcher had to put aside her own preconceived knowledge about the topic. This is known as bracketing. Burns and Grove (2003:380) describe bracketing as a “means of laying aside what the researcher knows about the study which is being undertaken”.
2.3.2.6. Communication skills
The key to a thorough interview where the accurate representation of the lived experiences of the professional nurses are obtained is through the ability of the researcher to communicate. Active interviewing is not confined to asking questions and receiving answers. As with any conversation exchanges of information rely on mutual attentiveness, monitoring and responsiveness (De Vos et al, 2002:294-295). The researcher used the following communication techniques during the interview process as described by De Vos et al (2002:294-295):
Minimal verbal response: During parts of the interview as appropriate the researcher made the following occasional responses e.g. mmm, I see, ok which coincided with movements e.g. nodding the head.
Paraphrasing: This is where the researcher states the participants’ words in another form so as to enhance the meaning of what is being said.
Clarifying: This was used by the researcher where clarity is required especially where the statement made by the participant is unclear. For example “Could you tell me more about that…”.
Reflection: The researcher reflected back on something important that was said to gain meaning e.g. “So you believed that the nurses required more training…”.
Encouragement: The researcher encouraged the participants to relay more about what was said e.g. “Tell me more about the allocation of the nurses…”.
Reflective summary: At the end of the interview or as needed in the interview the researcher summarized what the participant had said, highlighting important points. Reflective summary can also stimulate the participant in adding more information.
Listening: It is very important for the researcher to have excellent listening skills.
Probing: The purpose of probing is to deepen the response to a question. In so doing increasing the richness of the data obtained. It also persuades the participant to give more information about the topic under discussion.
2.3.2.7 The Interviews
The Little Oxford English Dictionary (2006:365) defines an interview as “a meeting at which a journalist asks someone questions about their work or their opinions, to ask someone questions in an interview.” An interview is a conversation which is set up by the interviewer. The interviews were set up to obtain information as to how the professional nurses experienced the team nursing care framework in the critical care units.
Setting the scene
The participants who were included in this study were professional nurses identified with the help of the unit manager as they had been involved in the roll out of the team nursing care framework. The following steps were followed:
o The researcher made contact with each participant.
o The objectives of the study were explained to all the participants and they were invited to join the study.
o The researcher obtained consent from the participants before the interviews commenced and this was to protect the participant from harm (Annexure D).
