5.2 DISCUSSION OF FINDINGS
5.2.3 MULTIFACTORIAL BARRIERS TO DEVELOPING THE NURSE’S ROLE
5.2.3.3 POOR STAFF ATTITUDE
95
96
evolved in many hospitals: everyone on the team comes to expect and accept impossible workloads, poor interdisciplinary collaboration, ineffective communication, and treatment errors’ (Dracup and Bryan-Brown, 2006:537).
Participants identified the lack of ‘attention to detail’ of some nurses in the ICU as a barrier to the development of the nurse’s role in antimicrobial stewardship. The lack of ability or will to take the initiative, poor organizational ability in documentation and filing and poor communication skills was perceived to lead to difficulties in receiving timely information regarding important antibiograms and critical adjustment of antimicrobial therapy. In all cases the participants were referring to the ‘floor nurse’ allocated to the bedside clinical care of a patient in the ICU. The ‘floor nurse’ allocated to a particular patient in this unit could be a registered nurse or an enrolled nurse with the allocation decision made by the previous shift leader according to staff availability and perceived patient acuity.
Some of the nursing participants gave the impression that there was a lack of self-direction. A nursing participant suggested that some ICU nurses, mainly junior nurses, regarded knowledge about antibiotics as over and above what was expected of them with their nursing duties. Interprofessional learning can result from interactions between members of different professions (Kvarnstrom, 2008), however some nursing participants appeared to expect doctors to teach them during the short periods that the doctors are at the patient’s bedside.
Requests for explanations at ward rounds is important to clarify decision-making however to expect teaching at this time is unlikely to be successful, and reinforces the perception that some doctors may have that nurses are passive recipients of knowledge and lack self- direction in equipping themselves with the necessary tools for working in an intensive care environment. Disinterest may be linked with a sense of loss of autonomy. Papathanassoglou, Karanikola, Kalafati et al. (2012) found that intensive care nurses rated their sense of autonomy with these statements, “I am responsible for my decisions concerning nursing care”, “I am responsible for developing my knowledge base” and “I am responsible for developing my nursing skills”. ICUs need to be supportive workplaces with innovative leadership that encourages the development of workers (Danielson and Berntsson, 2007).
A study by Schluter, Seaton and Chaboyer (2011), aimed towards understanding nursing work patterns within a changing working environment, found that nurses were working below their level of expertise and many activities could be carried out by lesser skilled nursing staff or support staff. Activities that required no judgement or critical thinking and
97
consumed much of the registered nurses’ time were; running medications between departments, restocking the medication cupboard, cleaning, moving beds, making refreshments for patients, answering phones and other clerical work. Recommendations made by the participants included optimizing the working environment of the ICU in order to provide an environment that supported the development of confidence and the development of good attitude. Standards for a healthy work environment in critical care include authentic leadership, appropriate staffing, true collaboration, effective decision-making, skilled communication and meaningful recognition (American Association of Critical Care Nurses, 2005).
Participants suggested that it was important to ensure the appointment of suitable nursing staff and the active acknowledgement, support and retention of good staff by acknowledgement of the value of experience. The greatest asset of any organisation is its people and opportunities have to be created in order to develop this asset (Richards, 2007).
Nurses in the private healthcare sector in South Africa felt that career development was a problem (Pillay, 2009). The successful retention of nurses, and improving patient outcomes, in certain hospitals in America (despite a shortage in the 1980s) was described as a phenomenon named ‘magnetism’. The essentials of a ‘Magnet hospital’ are seen to be a working environment which shows the following; improving RN staffing, moving to a more educated nurse workforce, and improving the care environment (Aiken, Clarke, Sloane, Lake and Cheney, 2008). Kramer and Schmalenberg (2008) added important features of a ‘Magnet hospital’ as; working with clinically competent nurses, effective team relationships, autonomous decision making, nurse management support of clinical nurses, appropriate staffing of clinical areas and a culture which prioritized the patient.
There is concern about nursing not being chosen as a career by young people. The average age of nurses has been found to be rising, with 63.7% of the nursing population found to be above the age of 40 years (George, Quinlan and Reardon, 2009). A report by the Human Sciences Research Council (HSRC) of South Africa found that nurses below the age of 25 make up only 1.3% of the nursing workforce and that the majority of this age group is entering nursing at an enrolled and auxiliary level (Wildschut and Mqolozana, 2008). Poor working conditions, poor salaries and poor career paths contribute to a negative perception of nursing. The view of nursing as a respected and attractive choice of profession must change in order to recruit future nurses into the profession (Wynd, 2003). Both nursing and non-
98
nursing participants suggested that it was important to employ the right kind of people to work in an area like an ICU. This reference was made not only to the type of professional qualification that the nurse had but also to the nurse’s personality. Van der Colff and Rothmann (2009) suggest that the personality of nurses who manage well in the intensive care arena may be linked to resilience. Certain personality traits such as openness, agreeableness and conscientiousness are linked to self-coping strategies (Burgess, Irvine and Wallymahmed, 2010) and may enable the ICU nurse to engage with others successfully.