TEORIA PSICOANALITICA

Mayeng and Wolvaardt (2015:1) argue that quality care is a comprehensive, multifaceted concept. The attributes related to quality nursing care delivery could be defined through various lenses. Mayeng and Wolvaardt (2015:1) suggest that quality could be measured against the effectiveness of nursing care delivery to maintain continuity and safety in care provision. Mosadeghrad (2014:77) defines quality as ‘value’, ‘excellence’, ‘conformance to specifications and requirements’ ‘meeting and exceeding customers’ expectations; thus, providing services according to functional requirements when meeting and exceeding the customer’s healthcare needs. When monitoring patients’ safety expectations and experiences, quality measurement aims to evaluate and improve the quality of care (Kieft, De Brouwer, Francke & Delnoij 2014:1; Mayeng & Wolvaardt 2015:1).

Research conducted over the last decade proposes a wide range of factors and predictors which affect the quality of nursing care delivery and patient outcomes within the clinical practice environment. Awases, Bezuidenhout and Roos (2013:1) concur that the quality, efficiency and equity of healthcare services are subject to the availability of a competent workforce with appropriate training to deliver the required standard of healthcare service. Mayeng and Wolvaardt (2015:1) agree that quality patient care is influenced by various factors, many quality determinants of which reach beyond the control of nurse

findings of Armstrong et al (2015:2) in acknowledgement of well-documented global evidence that the numbers, competencies and effectiveness of nurses are critical predictors of patient outcomes and the quality of care in hospitals.

Studies conducted on the broad causes of nursing errors in a hospital setting cite an array of probabilities to account for the factors that affect quality in nursing care delivery. Kieft et al (2014) address the nursing work environment as a determining factor in patients’ experience of the quality of nursing care. A study by Choi, Pang, Cheung and Wong (2011) address staffing levels, work responsibility management, co-worker relationships and job and professional incentives as stabilising or destabilising forces that influence the nursing work environment in the context of quality nursing care delivery. Sanders et al (2013:347) acknowledge that fatigue of nurses in the work environment has been identified as a significant barrier to safe patient care delivery. Sanders et al (2013:347) refer to the study of Barker and Nussbaum pertaining to the relationship between fatigue, performance and the work environment, but state that their study results indicate that nurses perceive their fatigue more in terms of mental than physical fatigue. Sanders et al (2013:34) maintain that all types of fatigue correspond to negative work performance. The findings of the current study address the following challenges that the registered nurse faces in attempting to support basic nursing care delivery.

 Insufficient time to enhance professional socialisation

Ryan, Powlesland, Phillips, Raszewski, Johnson, Banks-Enorense, Agoo, Nacorda- Beltran, Halloway, Smith, Walczak, Washington and Welsh (2017:183) emphasise the importance of taking enough time to inform and educate staff to sustain quality in care delivery. In the current study, the participants suggested that the lack of time to teach and remediate other nursing personnel in the nursing unit might contribute to adverse effects, with a negative reflection on the competence of the registered nurse.

The registered nurse as first-line manager and leader of the nursing team is a functional role model in the clinical practice environment and should demonstrate competence when managing work quality through interaction with the workforce to enhance quality in nursing care delivery. Dinmohammadi, Peyrovi and Mehrdad (2013:27) indicate that work quality could be enhanced when lower nurse categories physically observe the standards of professionalism during patient interaction. Socialisation is an intended and unintended

consequence of the educational process and work experience (Dinmohammadi et al 2013:27). Professional socialisation is defined as the process of developing and internalising a professional identity through the acquisition of knowledge, skills, attitudes, beliefs, values, norms and ethical standards (Dinmohammadi et al 2013:26). These authors (2013:26-27) suggest that these competencies are critical in fulfilment of the professional responsibilities towards the patient. The most positive outcomes of professional socialisation include the acquisition of a professional identity, ability to cope with professional roles, professional and organisational commitment and thus improvement in the quality of nursing care provision (Dinmohammadi et al 2013:32). Ryan et al (2017:181) suggest that nurses progress through transitional emotional and motivational developmental phases to develop the desired attributes which are consistent with nursing competence. Nurses socialise into competent practitioners as they gain knowledge, skills and experience (Ryan et al 2017:181). The findings of the current study suggest that the registered nurses are not able to optimise their legal mandate to socialise lower nurse categories to the expected professional standards and desired competencies at the bedside of the patient.

 Nursing workload

The findings of the current study suggest that the registered nurse experiences her roles and responsibilities as unrealistic, perceiving herself as working under tremendous pressure and stress to keep up with the workload. Various studies confirm the relationship between the work environment, nursing workload, work satisfaction and patient experiences of quality nursing care delivery (Aiken et al 2012:4; Choi et al 2011:1290; Cucolo & Perocca 2015:123; Khamedi, Mohamaddi & Vanaki 2015:476; Izumi 2012:3; Wang, Dong, Mauk, Li, Wan, Yang, Fang, Huan, Chen & Hao 2015:5). A study done by Abdollahzadeh et al (2017:8) relates nursing workload to work-related stress and pressure with the probability of raised workplace incivility. Nurses’ psychological comfort facilitate a better tolerance to stress and enhances better behaviour that result in the prevention of workplace incivility and conflict between doctors and nurses (Abdollahzadeh 2017:8).

The findings of this study correspond to the findings of Khamedi et al (2015:476) in the suggestion that workload pressure is related to the lack of professional preparedness and

personnel. The current study raises the need for training to enhance professional preparedness to enable the registered nurse to cope with the professional and personal expectations and requirements underlying quality nursing care delivery. The suggestion of Doherty et al (2010:30) that ward sisters may not have the necessary expertise to perform the managerial aspects of their role with competence and confidence echoes the outcry from the participants for skills-based training, a need which was recurrently conveyed during the focus groups. Doherty et al (2010:30) reiterate that registered nurses should be empowered with sufficient support from management to re-establish their role from ‘nurturing mothers’ to leaders of entrepreneurial teams, fitting the profile expectation of professionalism and competence.

 Role conflict, role strain and role overload

Role overload occurs when professionals are faced with reasonable requirements, but due to time constraints find it impossible to meet all the demands (Palomino & Frezatti 2016:168-169). Yunis and Mahajar (2015:19) and Moustaka and Constantinidis (2010:212) argue that role overload, role ambiguity and role conflict may cause occupational stress. Moustaka and Constantinidis (2010:212) explain that role conflict exists when conflict arises between the professional roles of a nurse. Role conflict is strongly related to the nature of professional training (Palomino & Frezatti 2016:168). The findings of the current study show the existence of role conflict, role strain and role overload that manifest in multiple managerial-clinical responsibilities that remove the registered nurse from nursing care delivery and direct support of “Back to basics” at the bedside. The accounts from participants do not portray professional role ambiguity; the data that were elicited during the focus groups did not suggest a lack of information with regard to work requirements, or uncertainties about the scope of work, responsibilities or specific nursing care activities that ought to be performed in the absence of adequate information and guidelines. In this study the expectation of quality in basic nursing care delivery is perceived as a challenge because the registered nurse is operationally compromised and unable to increase her physical bedside presence.

Palomino and Frezatti (2016:176) suggest that job satisfaction and personnel retention will be enhanced when organisational policies and practices enable professionals to deal with role conflict while performing their duties. Policies and work practices should provide clarity of roles and definition of responsibilities as contained in the work objectives

pertaining to the position of the worker. Within the healthcare arena, with specific reference to role conflict due to role overload in the clinical practice environment, Yunis and Mahajar (2015:18) indicate that nurses in the Malaysian healthcare environment, with inadequate nurse staffing levels, found it difficult to provide safe and efficient patient care in the face of unrealistic nurse workloads, resulting in role overload and eventual burnout. Yunis and Mahajar (2015:19) had hypothesised that role ambiguity and role overload had no relationship with burnout, but the correlation analysis of their study confirmed that role overload and role ambiguity do have a significant influence on burnout and that negative organisational factors undeniably lead to poor emotional health (Yunis & Mahajar 2015:19-20). The literature provides significant evidence with regard to the probability that registered nurses in the current study experience role conflict due to the nature and extent of their managerial-clinician roles and responsibilities in the clinical practice environment.