PATIENT SAFETY RELATED TO NURSING CARE FOR PATIENTS WITH EMERGING DISEASES*
Kusman Ibrahim, S.Kp., MNS.,PhD Faculty of Nursing, Padjadjaran University
*Presented in The International Nursing Conference on Patient Safety, 4-6 October 2010, Bandung, Indonesia
Introduction
Many countries are witnessing signs of progress of improvement in health care development since the last couple decades. However, there are still a number of challenges which need to be seriously resolved in order to bring more people to have access to quality of health care services. We observe the facts that life expectancy and good health continue to increase in some parts of the world, yet it is fail to improve in others. The gaps of health status between the people in developed countries and developing countries is still obvious. The global vision of “Health for All” which firstly stated in “Alma-Ata Declaration” in 1978 and subsequently stressed in targets of the Millennium Development Goals 2015 seems remain an elusive goal to be brought into the reality.
The changes in life styles, climate and environmental, poverty, people mobilization as well as urbanization have reshaped population health problems. Rising food prices coupled with declining incomes as a result of economical crisis have increased the risk of malnutrition, especially among children. The malnutrition constitutes as an underlying cause in about one third of all child deaths (WHO, 2010). Maternal mortality is the health indicator that shows the widest gaps between richer and poorer, both between and within countries. Prediction made in 2005 shows that about half a million women, most of them in developing countries die each year of complications during pregnancy or child birth (WHO, 2007).
nations contribute to the worse of the outbreak by posing multidrug-resistant pathogen strains through overuse of antibiotics.
Emerging infectious diseases are estimated to continue in particular regions and groups around the world (Commission on Social Determinants of Health [CSDH], 2008). In 2008, there were an estimated 243 million cases of malaria causing 863 000 deaths; mostly of children under 5 years old (WHO, 2009b). Although the incidence rate of tuberculosis (TB) continued to slowly decline, multidrug-resistant TB and HIV-associated TB still pose considerable challenges. Globally, there were an estimated 0.5 million new cases of multidrug-resistant TB in 2007 (WHO, 2009a). In addition, more than one billion people are affected by neglected tropical diseases such as lymphatic filariasis, dracunculiasis, cholera, and leprosy.
To date, health problems are becoming more complicated due to rapid changing of humans’ life and environment. Caring for patients with emerging infectious diseases is daunting task among health care professionals. For example, patients with infectious diseases are vulnerable to expose to drug-resistant if the usage of antibiotics is not properly administrated. This condition may threat to the safety of patients which becomes a major concern among health care professionals in caring for patients with emerging infectious diseases. Nurses as the majority of health care professionals who work very close to patients, can play key roles related to patient safety in improving quality of nursing care. This paper aims to address some issues regarding patient safety particularly in the context caring for patients with emerging diseases.
Emerging and Reemerging diseases
greater human and animal traffic, greater population densities, increased susceptibility of the host population).
The basic definition of an emerging or re-emerging infectious disease is a disease whose incidence has increased in a defined time period and location. If the disease was unknown in the location before, the disease is considered to be emerging. However, if the disease had been present at the location in the past and was considered eradicated or controlled, the disease is considered to be re-emerging. Diseases considered as new emerging infectious disease such as avian flu, Ebola, SARS, Hantavirus, and Japanese encephalitis. HIV/AIDS is an example of emerging disease, whereas Malaria and TB are example of reemerging disease (Giriputro, 2009).
Emerging disease is commonly recognized with regard to its impact on populations: high morbidity, mortality or case-fatality of a syndrome, and/or ‘dramatic’ clinical disease signs. Emergence cannot be uniformly defined for all hosts and agents (Elvinger, 2010). A condition or agent may be emerging for a population, a subpopulation, a single host or group of hosts. An agent endemically present in one species may emerge in another species. A disease that has been successfully controlled in a population may reemerge. In order to be able to evaluate the impact of emerging disease (agent) in a population, and for the development and implementation of control measures, it is essential to clearly identify all host and agent components, and their interaction. Some questions can be addressed both qualitatively and quantitatively. Qualitatively we may ask, “who/what is the target population?” (Host), “what is the agent and how do we recognize it?” (Agent), and “what are the mechanisms of infection, transmission and what is the mode of propagation?” (Interaction). Quantitatively, we should calculate the magnitude of increase (incidence), the temporal pattern of increase and the duration of outbreak (time), and the location or area affected (space).
arthropod-borne infection), either by increasing proximity or, often, also by changing conditions so as to favor an increased population of the microbe or its natural host (Morse, 1996).
Nurses’ role in caring for patients with emerging diseases
Nurses are in the great position to contribute in prevention and care for patients with emerging (infectious) diseases. It can be implemented through the development of policies with regard to surveillance, prevention, and control, through applied research and nursing practice. For the nurse practitioner, the degree of involvement through nursing practice will depend on the nurse's scope of practice, expertise, and location. Nurses should incorporate an epidemiological perspective into their practice. Nurse educator should develop nursing education programs that provide thefoundation for knowledge in the area of infectious diseases.
Cohen and Larson (1996) pointed out some ways in which nurses may act to prevent or intervene the emerging diseases by doing the following strategies:
Educate clients about risks and personal hygiene, which can include guarding against tick exposure; cooking meat thoroughly and eating thoroughly cooked meat; using safer sex techniques; washing one's hands after using the toilet, changing diapers, or exposure to fecal matter; and appropriate use of antibiotics to decrease inappropriate use of over-the-counter drugs and inappropriate requests for antibiotics from a provider.
Use of infection control procedures; it is important that nurses have the ability to institute appropriate controls and to educate patients, visitors, family, and personnel about infection control and appropriate hand washing.
Maintain awareness of unusual disease clusters, outbreaks, or illnesses, and be especially alert for unexplained deaths in young people.
Institute or participate in immunization programs for adults and children, educate patients about the importance of immunization, and facilitate access to and availability of immunizations for those who need it.
Use techniques to enhance client adherence to medication regimens to prevent treatment failure and development of microbial resistance.
measures such as safe water, elimination of places where birds roost and sources of standing water, and rodent control.
Examine prescribing practices to ensure appropriate use of appropriate antibiotics. Be an advocate for clients in regard to environment.
Obtain thorough patient histories, including an assessment of travel history, recreational activities, and potential exposures in the workplace, home, and community; for example, the manner in which workplace clothing in certain environments is handled can be important in transmitting infections and toxins to the home.
Assess diet practices (for example, the use of unpasteurized milk) and teach clients about proper nutrition and food handling.
Promote breast-feeding in countries in which there is a high risk of contamination of milk or infant formula.
Train local people in health education and practices with use of culturally acceptable and locally accessible material and practices.
Nurses may play significant role in the field of emerging infectious diseases through actively participating in prevention, care, and rehabilitation of patients suffer from emerging infectious diseases. However, it could be realized if nurses have strong commitment, awareness, competence, and good leadership to play the role of nurses effectively in handling the problems of emerging diseases.
Patient safety aspect in caring for patients with emerging diseases
In the USA, Medical errors during the course of patient care are estimated to have caused approximately 238,337 potentially preventable deaths among Medicare patients between 2004 and 2006 and up to 24,000 deaths yearly in Canada (Feng, Bobay, & Weiss, 2008). Additionally, medication errors are the most common cause of adverse patient events in health care. These facts imply that health care practices may also potential to impose disadvantage effects, beside the expected positive outcomes of healing to patients. Therefore, patient safety, recently, become an important issue in health care organizations.
Caring for patients with emerging infectious diseases should be designed comprehensively and holistically with regard to patient safety. Patient safety is a critical indicator of healthcare system quality (Teng, Chang, & Hsu, 2009), and indicates the degree to which care does not have a negative impact on patient health. Nursing care has even been described as resting on a foundation of safe practice with safety as an integral part of this care (Richardson & Storr, 2010). This is also applied as nursing care is administered for patients with emerging diseases.
Due to limited evidences known in area patient safety related to patients with emerging diseases, lessons learned from other area related patient safety can be taken into account in delivering nursing care for patients with emerging diseases. Alfredsdottir and Bjornsdottir (2008) reported that nurses in operation room expressed feeling responsible for the well-being of their patients. Nurses often talked about their work as protecting the helpless, with prevention being of key importance in ensuring safety. Creating an environment of warmth, respect and safety for patients was essential to them, and they described how they try to create a quiet, relaxed and friendly atmosphere when greeting a patient. Focusing on the patient is central, and they try to keep conversations between themselves to a minimum while the patient is still awake. Three factors emerged as most important in enhancing patient safety: preventive thinking, knowledgeable and experienced workers supported by good teamwork, and mutual trust based on many years of co-operation. Moreover, a number of issues were identified as threats to patient safety including the fatigue that builds up over time, concentration difficulties, lack of control over situations, insufficient staffing and unclear expectations towards staff. The study highlighted that concerning patient safety must be an integrated part of nursing care regardless type of diseases including emerging infectious diseases.
Numerous researchers have measured patient safety using hospital records, such as patient mortality, failure-to-rescue (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002), pneumonia, pressure ulcers (Cho, Ketefian, Barkauskas, & Smith, 2003), medication errors, patient falls and infections (Blegen, Goode, & Reed, 1998). Record-based measurement can generate a complete list of health-threatening events, and is a useful and widely adopted approach. However, not all health-threatening events are reported (Potylycki et al., 2006). Barriers to reporting include fear, the desire to save face, and fear of punishment (Chiang & Pepper, 2006).
In the area of emerging diseases, researches related to patient safety are considerably sparse. Therefore, the new research field can be difficult to navigate for researchers new to the area. The WHO identified five research areas as framework in conducting research related to patient safety (WHO, 2010). The five areas are arranged around the research cycle (picture 1) which consisted of (1) measuring harm, (2) understanding causes, (3) identifying solutions, (4) evaluating impact, and (5) translating evidence into safer care.
Picture 1. A series of research cycle in each of the key areas to stimulate new research and debate in patient safety research
Conclusion
Despite remarkable achievements have been made in medical and health care practices during the last decades, infectious diseases remain among the leading causes of death worldwide for three reasons: (1) emergence of new infectious diseases, (2) re-emergence of old infectious diseases, and (3) persistence of intractable infectious diseases. Caring for the patients with emerging infectious diseases is a daunting task due to the complexity of the disease and the potential side effects of the treatment that may lead to threat patients’ safety. Patient safety and well being must be put as priority concern while caring for the patients with emerging infectious diseases. Research is still needed to understand the phenomena of patient safety in the patients with emerging infectious diseases, and to develop appropriate nursing care for the population.
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