4.3 RESEARCH FINDINGS
4.3.3 MULTIFACTORIAL BARRIERS TO DEVELOPING THE NURSE’S ROLE
4.3.3.6 ECONOMIC BARRIERS
64 (Non-nursing participant)
... the European structure and the United States structure in terms of how they manage the health care system... like the NHS... It is a different structure here... There the doctors work for the hospital. Here the doctors are private... (Non-nursing participant)
I would think in the private sector... in the South African private sector... it would be difficult... because the doctors don't like being told. (Non-nursing participant – Hospital Management)
... the problem is still the doctor and physician buy-in culture in South Africa. (Non- nursing participant – Hospital Management)
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Participants identified certain factors that contributed to difficult working conditions which impacted on patient care and opportunities for learning. One nursing participant said nursing was based on shift work and that it was not possible to get ICU nurses to come into the hospital on their days off duty for training. In-service training was also seen as difficult in the ICU with distractions and unstable patients
I know there is always a lack of time, or a lack of... You know when you want to do something but it is usually with the people on the shift... You know to get people from their homes to come in for an hour. It doesn't happen… (Nursing participant – Hospital Management)
...you try and do it while everybody is on duty and then the phone is ringing and doctors are coming and the patient’s unstable so it is difficult to get them all together. (Nursing participant – Hospital Management)
...because, I mean, we are always busy. So it is a matter of making a sort of a timetable that maybe once a month we are doing blood result training... how to read a blood result, how to identify an abnormality from a blood result. (Nursing participant)
A non- nursing participant suggested that training of nurses is a responsibility of the hospital.
…teaching and training has to become part and parcel of the hospital's... private sector's responsibility. The idea that the private sector can just go and poach nurses from the public sector... Those days are gone... we have got to train our own nurses... train them up in the culture of the hospital... train them up to the standards that we would like and expect. (Non-nursing participant – Hospital Management)
I mean... Sometimes, there is even a staff nurse looking after your patient. I mean... you can't expect a staff nurse to know anything... They are just there just really to make sure, you know, that the wheels don't come off completely, you know. Other than that, they are not adding anything really of value... but that is the reality of it. You know, we have got a critical shortage of trained staff... Often we don't know who's trained and who isn't. So your expectations influences your... your lack of expectations...It influences your interaction with the nurses. (Non-nursing participant – Hospital Management)
Participants said that increased cost to patients, families and health care systems was seen to be a consequence of poor antimicrobial management and poor infection control which could result in increased hospital-acquired infections.
The cost of an infection would mean a longer stay for the patient in hospital, so cost in terms of nursing hours, nursing salary, cost in terms of... If the patient needs to go back
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to theatre, costs involved in theatre time, surgeons’ time and so forth. Pain and suffering for the patient, pain and suffering for the family. Loss of work for the patient, if it is a person who is working… Reputation, which I think is the biggest one to the hospital...
where it dampens... dampens the image... The reputational image of the hospital which in the bigger scheme of things, I think is actually the worst cost... or biggest cost. (Nursing participant – Hospital Management)
Lack of pharmacist support was identified by nursing participants as impacting on antimicrobial stewardship. A representative of the pharmacy department was concerned that due to inadequate staffing in this department they were not able to spare a pharmacist to participate actively in antimicrobial stewardship meetings.
… the pharmacist is not actively involved in the programme. I have been told that it is not happening... because the pharmacy is too busy and we don't have enough pharmacists... (Nursing participant – Hospital Management)
I haven't been involved too much in antibiotic stewardship here and I should be. I should be. We... I have had challenges here and I still have challenges in terms of mainly dispensing and having enough pharmacists to do normal daily dispensing. (Non-nursing participant – Hospital Management)
I don’t think I could handle the clinical function as well... I would love... to get involved with it because it's what we studied. The clinical pharmacist... I would employ a pharmacist dedicated to do that function... Financially, we can't support that role...
(Non-nursing participant – Hospital Management)
A non-nursing participant said that the policy in this unit is to use original antimicrobials. The use of generic antimicrobial therapy in the ICU setting was generally seen to be problematic and was opposed by nursing and non-nursing participants.
…that is ICU policy... we don’t use generics. Simple! (Non-nursing participant- Hospital Management)
…we had a problem with intravenous [original] versus [generic]... As you know about that case, the patient did really badly and we still thought it was truly original [ ]…
there would have been a chance. (Non-nursing participant)
It’s because of the abuse of antibiotics, because of the generics that, you know, are being abused and because of the inappropriate choices of antibiotics. We are seeing increasing trends of resistance of organisms… so ESLB rates are increasing... our Carbapenem lactamase resistance bacteria are coming in... You know, are coming to KZN as well. And apart from that, we’re seeing an increasing trend of Candida infection
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and even amongst the Candida... the resistance is increasing. And this is all because of the inappropriate choices, the inappropriate duration… the inappropriate combinations of antibiotics that’s also tending towards the increase of resistance. (Non-nursing participant)
Non-nursing participants referred to pressure from medical aid companies to reduce the costs of caring for patients in ICU by using cheaper antimicrobials.
The medical aids, although they paying... are always onto the hospital about costs. So there is pressure... although they are paying, there is pressure. They are saying, you know what... your hospital spends 10 cents on every patient for... and the industry average is 8 cents... why? (Non-nursing participant – Hospital Management)
...there’s also financial factors that come into play and there’s a drive from the medical aids to go as cheap as you can. But as you know when you are in ICU, that's the one place you don't want to do that. (Non-nursing participant)
They don’t look at outcome... they don't look at all the other things that don't happen and say. Well, you know what, you have got no infections, you have got no superbugs you have got no this and that... and therefore in the long term... the patient outcome... The stats, because if you look far into the future the picture looks quite fine... They don’t care... remember medical aids... are not about helping the patient. They are about making money for themselves... and that's the truth. (Non-nursing participant – Hospital Management)
One non-nursing participant supported the use of generic antimicrobial therapy.
...native drugs are not the same product as ... how shall I put it... Augmentin that was registered 10 to 15 years ago, and registered as that... It is not the same Augmentin anymore. So how do you differentiate what is a generic and what is not? So, if you look at generic substitution, of course you look at quality. If you look at a company like Sandoz... it is a Novartis based company with high standards, so it is a company you would use. The smaller companies that are not that well-known, maybe you would be a bit sceptical about. (Non-nursing participant – Hospital Management)