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The six sub-themes of Theme One will now be discussed in detail.

Sub-theme One: Professional nurses experience the nurses as being inadequately trained (theoretical and practical) to work in the critical care unit:

Figure 3.3: A Diagrammatic Representation of Sub-theme One

The professional nurses experienced the nurses as lacking in fundamental nursing knowledge, including basic, practical and theoretical knowledge. The nurses needed to be trained once they had commenced working in the critical care unit. Their knowledge of nursing care and basic nursing skills was not assessed prior to their placement in the critical care unit. The Concise Oxford English Dictionary (2009:1529) defines to train as “Teach (a person or animal) a skill or type of behaviour through regular practice and instruction”.

THEMES THEME 1 THE PROFESSIONAL NURSES EXPERIENCED

THE TEAM NURSING CARE FRAMEWORK IN

THE CRITICAL CARE UNIT AS A BURDEN Sub-theme 1 Professional nurses experience the nurses as being inadequately trained (theoretical and practical) to work in the critical care unit

Nursing training produces a skilled individual who is knowledgeable and willing to work (Mellish, Brink & Paton, 2001:6). The nurses in the critical care unit were willing to work; however, they were not skilled and therefore placed an additional burden on the professional nurses. As nursing is an art and a science, nurses are expected to have mastered specific skills and should be knowledgeable about how to care for patients. Nurses should also have appropriate values and moral integrity and must have the ability to think critically and make decisions and judgements (Mellish et al, 2001:6). The training which occurs in the critical care unit is described as clinical teaching. In clinical teaching the student or nurses, working in the critical care unit, learn to apply the theory of nursing so that there will be an integration of theoretical knowledge and practical skills in the clinical situation and this then becomes the art and science of nursing (Mellish, Brink and Paton. 2001:207). Training in the nursing arena can be described as formal training, informal or on the spot training. Nursing training that is done at the bedside or in the clinical environment of the critical care unit is termed clinical teaching. Clinical is derived from the Greek word Klinikos, which means bed. This shows that clinical teaching originated from the bedside as the patients receiving clinical care are in bed (Mellish et al, 2001:207). On the spot training was needed in the unit and this was done by the professional nurses as there was no clinical facilitator dedicated to the critical care unit.

Clinical teaching is a necessity in the critical care unit as it ensures that the recipient i.e. the patient, is given competent nursing care, to which the patient is entitled. Clinical teaching may also occur as situational teaching when the teaching moment occurs. Due to the fact that nursing care takes place 24 hours per day, the clinical instruction will depend on the staff member responsible for patient care and their availability to training (Mellish et al, 2001:214). The clinical teaching is carried out by a clinical facilitator or preceptor. A preceptor is described by the Concise Oxford English Dictionary (2009:1129) as “a teacher or instructor”.

Prior to the nurses being placed in the critical care unit, training was not conducted, nor competency assessed. There was limited orientation and the nurses were expected to function competently within the critical care environment. Some of the nurses who were placed in the critical care environment were seconded to the unit from the general wards and had no specialised training in high care nursing, prior to them starting in the unit. There was also no clinical facilitator specifically assigned to the critical care unit.

As a result, the training that took place rested on the shoulders of the professional nurses within the unit, creating an added responsibility and resulting in increased stress level and burnout. This will be discussed in sub-themes 2 and 3.

The participants found the lack of training as a great hindrance to the implementation of the team nursing care framework in the critical care unit as reflected in their experiences which follow:-

“Hulle weet nie hoekom ‘n pasient se temperatuur hoog is nie.” (They don’t know why a patient’s temperature is high.)

“Half of these people they get here are not trained to work here. They don’t even understand what’s the difference between a low pulse and a fast and they don’t know when the patient doesn’t wee.”

The nurses could not recognize abnormal readings in the vital data including blood pressure and temperature; which demonstrates that their fundamental theoretical and practical knowledge was not in place. During basic nursing training all nurses are trained in and acquire basic clinical skills, this is mandatory in nursing syllabi which require that nurses acquire certain clinical skills (Bradshaw & Merriman, 2008:1267). As the nurses did not have the ability to recognize abnormalities in vital data, they were unable to alert the professional nurses when a problem was first identified. In many cases the professional nurses were only alerted to the fact that there was a problem with a patient when the vital data was severely abnormal or the patient severely compromised. The basic fundamental knowledge was lacking and this was evident when it was established that the nurses could not differentiate for instance between a bradycardia and tachycardia. Normal vital signs, and the interpretation thereof, is a skill which is learnt by the nursing auxiliary at the beginning of the auxiliary programme.

“you don’t have time to train them. That’s why they should have a decent grasp before they get here.”

“I think the problem was these people they just pushed them in here without training them. That was the MAIN problem. They should have sent them on a course for a year and then

At the initial contact session with management, the professional nurses were informed that all the nurses who would be seconded to the unit would be adequately trained and competent in caring for the critically ill patient prior to their placement in the critical care unit. However, when the nurses were seconded to the critical unit, it was discovered that many of the nurses had not received any form of training related to critical care, nor were they competent in fundamental principles of nursing care.

“They don’t know what is Aminophyline so they just flush it and then you sit with a patient with a tachycardia and you don’t know why then you see oh but Aminophyline was flushed you know”

“They don’t understand the medication and it all goes back to TRAINING”.

The professional nurses experienced the nurses to have a large knowledge deficit when it came to medication, including the method of administration and the dangers, side effects and contra-indications of the medication.

“Um and so they didn’t know it I mean, it meant nothing to them if I said a patient with pneumonia is coming in It meant absolutely nothing to them they didn’t now how to make beds up. They didn’t know how to clean beds……… Um you know I’m talking about real basic stuff here, not rocket science.”

The perception created was that the nurses did not know basic disease diagnosis like pneumonia and the knowledge regarding the basics of how to prepare for the admission of such a patient was lacking leading to frustration and burnout of the professional nurses.

Sub-theme 2 Professional nurses experience an increased workload and change in responsibility

The professional nurses working in the critical care unit found that there was an increase in their daily workload since the introduction of team nursing care framework into the critical care unit.

A diagrammatical representation of sub-theme two will now follow.

Figure 3.4: A Diagrammatic Representation of Sub-theme Two

The professional nurses working in the critical care unit found that there was an increase in their daily workload since the introduction of the team nursing care framework into the critical care unit. The lack of competency of the nurses directly impacted on the increased workload of the professional nurses as well as having to take on added responsibility of the nurses.

Workload is defined by The Oxford English Dictionary defines workload as “the amount of work to be done by someone or something” (2009:1662). Workload in this study pertains to the amount of work or responsibilities to be done by the professional nurse in the critical care unit. The professional nurses experienced an increase in their daily workload since the introduction of the nurses into the critical care unit. The professional nurses felt that the increased workload could be attributed to the fact that the nurses were not competent to work in the unit. Some of the nurses had been working in the general wards up until such time that they were seconded or transferred to the critical care unit. The nurses were not competent in the basic tasks of nursing and could not be left to look after a patient safely. This resulted in the professional nurses having to look after their own allocated patient, who often was the most critically ill patient in the unit, and observe what the nurses were doing with their allocated patients. This resulted in a definite increase in the workload of the professional nurse. Nursing workload is not only an increase in patient care demands but also due to the fact that nursing workload is closely related with patient

THEMES THEME 1 THE PROFESSIONAL NURSES EXPERIENCED

THE TEAM NURSING CARE FRAMEWORK IN

THE CRITICAL CARE UNIT AS A BURDEN Sub-theme 2 Professional nurses experience an increased workload and change in responsibility

There is a correlation between patient mortality and workload in the critical care unit and can be attributed to inadequate supervision of patients and errors committed by nursing staff. Nursing shortage results in an increase in workload and leads to compromised quality patient care (Pangiotis, Brokalaki, Manolis, Samios, Skartsani & Baltopoulos, 2007:34-35).

The professional nurses experienced and increase workload and a change in responsibility as reflected in their experiences which follow:

“mostly the night staff they complain because they feel that they’ve got more work on their hands”.

“Suddenly the trained sister is looking after her patient plus the staff nurses patient and the staff nurse is going to walk around with her hand in her pocket. She is unable to look after that patient”

“I think a lot of responsibility for the RN because you have got your own patient. These people they also have their own patient then you have to look at your patient, then their patients as well. So I think it was like I don’t now a bit challenging though but a bit hectic to have to look after your patient and and usually as an Rn you get like a heavier patient you know”.

“I cannot look after a fresh case and run around checking on them like a policeman’’.

The participants experienced an increase in workload when the patient, who was looked after by the allocated nurse changed or deteriorated. Necessitating that the professional nurse takes over the deteriorating patient as well as her allocated patient. It is evident that the nurses are not in control of this situation due to external factors which are preventing them from doing what is best for their patient (Cronqvist & Nostrums, 2007: 459) External factors are described as decrease trained workforce and a decrease in the number of professional nurses.

“1 or 2 staff nurses and then, if I’ve got a bypass I can even look after another ventilator as long as I have got the backup of another sister. Like tonight (name omitted) will take over my patient when I am not in. If I’ve got to go for a resus she will take care of both the ventilated patients for a very short time. But if she is not here then it is a disaster”

The professional nurses in the critical care unit are part of the emergency care back up for the general wards in this hospital and are summonsed to the wards in the event of an emergency or resuscitation. The workload is specifically heavy when the professional nurse has to leave the unit to assist in resuscitation or to assist with an emergency in the hospital, as there are fewer professional nurses and more nurses at any one time in the critical care unit. The nurses are not competent to then take over the critically ill patient and therefore an added workload is placed on the professional nurse who is remaining in the critical care unit. Understaffing as a result of professional nurses leaving the critical care unit for a period of time leads to a decreased patient surveillance and a hindrance of early detection of changes in the patients condition (Kikas, Sakellaropoulos, Brokalaki, Manolis, Samios, Skartsani & Baltopoulos, 2008:386)

“Where before we might have looked after 2 patients on our own we were now looking after 4 patients on our own”.

“As it put a lot of pressure on us as the RN’s basically because now we have to supervise more people and many patients”

“Having to look after 4 patients and doing on the patient and things that the junior staff can do.”

“Is that the moment you give them 2 patients you have to guide them, you have to be there. The shift leaders here have to take patients and we take 1 patient which is ventilated patients, we sometimes have 2 patients”

“We have to train them. We don’t have time for that number one and we don’t have the the the the energy or the time. You are busy and you can see limited amount of trained people are working here. You cannot work with this this is my patient and I give you another patient but I’m actually responsible for 3 or 4 patients.

It doesn’t work; it doesn’t work because if you want to look after a patient in the whole you have to be with that patient for 12 hours, you cannot be here and running around having a bleeding patient.”

A nursing study conducted by Kikkas, Brokalaki, Manolis, Samios, Skartsani and Baltopoulos (2007:34), indicated that the number of nursing staff required on a daily basis and the matching of staffing to patient needs (patient acuity), should be determined by the number of patients as well as the amount of care required by each patient.

The nurses work according to a set Scope of Practice which is regulated by the Nursing Act of South Africa (Act No. 33 of 2005). The professional nurses’ experience was that the nurses were working beyond their scope of practice when they were expected to look after ventilated patients. Working out of a scope of practice is illegal and poses a safety risk to the individual patient and increases the burden of the professional nurse as they have to monitor the nurses as errors may occur.

Sub-theme 3 Professional nurses experience an increase in their stress levels due to the introduction of the framework

Professional nurses experience an increase in their stress levels due to the introduction of the team nursing care framework. A diagrammatical representation of the first central theme and sub-theme 3 will follow.

Figure 3.5: A Diagrammatic Representation of Sub-theme Three

THEMES THEME 1 THE PROFESSIONAL NURSES EXPERIENCED

THE TEAM NURSING CARE FRAMEWORK IN

THE CRITICAL CARE UNIT AS A BURDEN

Sub-theme 3 Professional nurses experience increase in theirstress levels

due to the introduction of the

The professional nurses experienced increased stress levels due to the introduction of nurses into the critical care units. The Concise Oxford English Dictionary describes stress as “Pressure or tension exerted on a material object. A state of mental or emotional strain or other strain” (2009:1427). When confronted with a situation which is a threat or a challenge then the following takes place: The sympathetic nervous system is responsible for the fright and flight mechanism which converts stored energy to usable energy. When a stressful situation is perceived then the hypothalamus stimulates the sympathetic nervous system and the pituitary gland (Olofsson, Bengtsson & Brink, 2003:351). The sympathetic nervous system is also responsible for increasing the heart rate and dilating the pupils (Oxford Dictionary of Nursing, 2008:483). Karasek, 1979, (cited in Olofsson, Bengtsson and Brink, 2003:352) states that there are 3 critical factors which promote negative stress in the work environment. Firstly, employees lack of confidence in the ability they have to deal with their work demands. Secondly, the lack of personal control and thirdly social support e.g. feelings of exclusion from the group and the lack of confidence in co-workers. The professional nurses experienced negativity towards the team nursing care framework in the critical care unit and immediately saw the nurses as a burden and an obstacle to quality patient care. The professional nurses did not trust their own abilities to cope with the extra work demands i.e. the increasing demand that the nurses would have on them as a result of not being trained prior to being seconded to the critical care unit. The lack of personal control is evidenced by their experiences of irritability and screaming at patients, visitors and staff alike. Thirdly there was a lack of confidence in the nurses. Cartledge, 2001 (cited in Cronqvist & Nystrom, 2007:459) states that stress is the most dominant factor when critical care nurses choose to leave their jobs. During the interviews some professional nurses expressed that they had sourced alternative work.

During the interviews, the participants relayed their experiences that were stressful to them as a result of the introduction of the team nursing care framework in the critical care unit in the following quotes.

“And that’s why I am leaving because I’ve go tireder and tireder and tireder and I cannot any more. I can’t I need a rest; they wouldn’t give me a sabbatical so I am leaving”.

“Suddenly the trained sister is looking after her patient plus the staff nurses patient and the staff nurse is going to walk around with her hand in her pocket. She is unable to look after that patient. Um then you are responsible for whatever goes wrong with both those patients”.

“And ratio of staff it doesn’t make sense to me. So we are being frustrated by that”.

“The doctor said give 80mg of Sotacor and she (the nurse) drew it up in front of him and he just stood and watched her. In the nick of time, in a heart beat I stopped her from pushing it in. You are just you just stood there totally bewildered. An um so they are a danger, an absolute danger if they don’t call you they are an absolute danger and they don’t know why you are losing you mind when lines are flushed”.

“They don’t know why when Trandate is stopped while they go and have their tea before they mix another one and you are about having an apoplexy, because they don’t understand the medication”.

Lack of adequately trained nurses’ leads to an increase in stress levels in the professional