6.5 RECOMMENDATIONS
6.5.2 RECOMMENDATIONS TO ADDRESSING KNOWLEDGE BARRIERS
Implications for nursing practice are the development of good clinical practice in ICU nurses that minimizes antimicrobial resistance in critically ill patients and in the ICU by in-service training, annual performance review, development of clinical policies and the development of teamwork. All ICUs should have an antimicrobial stewardship programme in place and all ICU nurses caring for the critically ill should participate in this initiative. Clinical support can be delivered by clinical nurse facilitators who are in a position to identify learning needs.
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In order to effectively contribute to the antimicrobial stewardship initiative, ICU nurses need to be able to:
- administer antimicrobial therapy correctly according to pharmaceutical administration guidelines for different antimicrobial/antifungal treatments in order to minimise microbial resistance
- prevent hospital-acquired infection by adhering to universal evidence-based infection control principles for hand washing, care of invasive lines and minimising conditions under which ventilator-associated pneumonia can occur
- monitor the critically ill patient diligently for any changes in the patient’s vital signs that may indicate the onset of infection i.e. blood stream infection/VAP
- monitor the condition of invasive lines and when these should be changed/removed - monitor positive laboratory results that indicate infection
- monitor the duration of antimicrobial therapy and understand the importance of de- escalation of therapy
- effectively communicate changes in the patient’s condition to the relevant member of the healthcare team
6.5.2.2 IN-SERVICE TRAINING
In-service training should be an on-going part of clinical nursing. Hospital and nursing management need to ensure that time and adequate staffing should be allocated in order to facilitate this. Nursing leadership in intensive care units needs to ensure that nurses are aware of antimicrobial initiatives being carried out in those units and that these form the foundation of an antimicrobial stewardship programme. Because of the high turnover of nursing staff working in ICUs, in-service training should be carried out regularly. Training schedules that address the needs of ICU nurses with regard to awareness, competencies, and skills can be compiled with feedback from nursing staff. ICU nurses caring for the critically ill need to:
- be taught evidence-based infection control procedures such as hand washing, the correct management of invasive lines, and critical interventions to minimise the occurrence of VAP
- be taught how to diligently monitor for signs of infection in their patients by carefully observing wounds, documenting significant changes in vital signs, performing careful chest auscultation, and noting changes in endotracheal secretions
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- be aware of the importance of laboratory reports such as infective markers and blood cultures in guiding the antimicrobial treatment of the patient
- be aware of the roles that the other members of the antimicrobial stewardship team play in providing optimal evidence-based care of the patient
- be aware of the worldwide challenges that face healthcare today with bacterial resistance and comprehend that a nurse has a wider responsibility than just the immediate care of patients in the intensive care unit
6.5.2.3 NURSING EDUCATION
The South African Nursing Council (SANC) is well placed to develop nursing policy regarding nursing training in response to healthcare needs within South Africa. Nursing needs to be developed to address changes in the world and ICU training needs to be relevant to current clinical practice with emphasis on optimal infection control practices. Basic nursing education should include teaching about antimicrobial stewardship and nurses’
responsibilities within this initiative such as optimal infection control, current public health issues such as bacterial resistance and how the overuse of antibiotics in the community impacts upon patients within hospitals. Intensive care educational curriculums need to be reviewed to ensure that they meet the needs of clinical practice and that they equip future ICU nurses with relevant knowledge, competencies and skills. This should include teaching about environmental resistance and the need for careful consideration of the indication for and choice of antimicrobial therapy in the critically ill patient.
6.5.2.4 CONTINUING PROFESSIONAL DEVELOPMENT
ICU nurses need to ensure that knowledge and competencies are kept up to date in accordance with SANC requirements for continuing professional development. Hospitals should ensure that they fulfil their responsibilities to both nursing staff and patient safety by providing learning opportunities within the hospital environment and supporting other means of providing necessary education. Nursing institutions in South Africa should create appropriate short courses in addition to the provision of certification courses for distance learning in intensive care nursing. There may be a place for the Critical Care Society of South Africa to provide a forum for nursing learning activities. Consideration should be given to the inclusion in the South African Journal of Critical Care (SAJCC) of a nurse directed page for ongoing learning which could result in achieving CPD points. CPD initiatives could be:
- short distance learning courses that contribute to CPD points
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- nurses’ quizzes in South African online journals that contribute to CPD points - reading journal articles and answering short questions which contribute to CPD
points
- provision of hospital learning opportunities that contribute to CPD points