4.3 RESEARCH FINDINGS
4.3.1 THE “MASSIVE RESPONSIBILITY” OF THE ROLE OF THE ICU NURSE
4.3.2.1 TAKING RESPONSIBILITY FOR SAFE PATIENT CARE
A non-nursing participant felt that a shift in doctor/nurse roles was happening. Another non- nursing participant said that self-determination was key to nursing self-development. Both nursing and non-nursing participants said that the ICU nurse had a responsibility to act proactively within the antimicrobial stewardship role. This related to communication with doctors regarding changes in the patient’s condition, antimicrobial therapy, and correct administration of antimicrobial medication. Nursing participants referred to evidence-based practice such as ‘Best Care, Always’. A nursing participant felt that present healthcare workers have a responsibility to future healthcare workers.
… it is our responsibility as medical staff, who are around now...to ensure that we are not handing over something that is totally uncontrollable to future generations of medical staff. That we are solving problems not creating one… (Nursing Participant) A non-nursing participant identified a shift in the doctor/nurse relationship as an interesting development in team dynamics.
Traditional doctor/nurse roles... You know... the nurse came a long way. In the old days, probably they... their education was a basic one, that in the past decade or two it became quite a science, and there is quite an overlap between doctor and nurse, even in the teaching schools. So there... there is going to be a new paradigm shift on basically which role they are going to play in management and in advice. (Non-nursing participant) A non-nursing participant felt that ICU nurses needed to recognise that self-development was integral to improving nursing practice.
... it’s all about self-development at the end of the day. (Non-nursing participant – Hospital Management)
... I think it’s the integral... do I want to do it...? Do I want to better myself...? Do I want to understand...? (Non-nursing participant – Hospital Management)
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A nursing participant felt that all nurses working in ICU should actively contribute to antimicrobial stewardship. A non-nursing participant identified engagement with doctors as part of the ICU nurse’s responsibility in antimicrobial stewardship.
I think more commitment from all staff regarding antibiotic stewardship because... it is not just a handful of peoples’ role. It is every bedside nurse’s role. (Nursing participant) I think it’s... when it comes down to responsibility. I mean, if it’s your patient... it’s your patient as well... If the patient has been on a certain antibiotic for two weeks... and then I think it’s your responsibility to ask... ’ this patient has been on this for two weeks... is it still appropriate to keep them on this? Can’t we stop it or change it... can’t we switch it’
or ’the MC&S showed this’... whatever the case may be... It’s your responsibility as well... (Non-nursing participant)
Participants said that changes noticed by the ICU nurse should be communicated to the specialists caring for the patient. Nursing participants felt that ICU nurses needed to behave proactively when noting changes in laboratory results or the patient’s clinical condition.
They should be picking up the phone and say ‘Listen Doctor, you were here this morning... the results have now come through and there’s something.’ (Non-nursing participant – Hospital Management)
You, as the nurse, have to say ‘Doctor, have you seen this’... and if you didn't tell him it won’t be treated. (Nursing participant)
And liaising with the doctors where we can, you know, to update them on changes to the inflammatory markers and update them on culture results as we receive them because they... they are not always aware of the positive cultures... the doctors. (Nursing participant)
So they've got not only to write it down but actually to have some input in it as well. We are still getting there, I think. I don't think hundred percent proactive but it's much better than it was. But ja... to just not only to write down... to sort of have some insight into it.
Why I am doing it? What can I do to help? You know, that kind of thing. (Nursing participant – Hospital Management)
So, if we work as a team and if the nurse picks up early that this patient is deteriorating...
we have to act... and there is an early warning system... so in that way, you know that nurses are empowered. They understand more about sepsis in the patient. Whether the patient is improving/deteriorating... they understand what lab tests to do in that particular case... Clinically they think that that patient is deteriorating? And then they liaise with the clinician as well and we liaise with the clinician as well. (Non-nursing
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Well... I think that the nurse has a lot... has a lot to say. Yes. Because if we... if we don't come across the culture results... we’re the ones like... usually, like most of the time…
pick up the culture results. Because it comes from the lab to us and we, the nurse, are the first ones to see it and we’ll say... we’ll point it out to doctor. ‘Look... this is what was cultured... Doctor, have you seen this... and it does say that the patient is resistant to whichever antibiotic... and the patient’s is on it’. Or we actually give the doctor a call...
some of us we do take the initiative... to phone the doctor and to say... you know what, the patient is resistant to this one, for example antibiotic A and he is sensitive to antibiotic B... and he’s cultured that, that and that. What antibiotic can we use?’ So yes...
we do play a very important role when it comes to antibiotics and ja... antibiotic stewardship and actually finding out... and having something to do with it because the doctors do rely on us a lot. (Nursing participant)
Participants identified improving the ICU nurse’s ability to read and comprehend reports as important.
The different types of infection markers and bugs... you know we put on different antibiotics to deal with all those sensitivity and because some nurses don't know what that means... sensitivity. (Nursing participant)
Nursing and non-nursing participants felt that ICU nurses should be careful to prepare the medication correctly.
…certain antibiotics you have to give regularly and certain ones you have to give over a prolonged period... so the nurses’ function is to make sure that the correct antibiotic has been given and it has been correctly given. (Non-nursing participant – Hospital Management)
I think that we should, as nurses, we could focus a little bit more on how we mix things.
Because I think we... Everyone likes a 50 ml bag sometimes... so we don't really pay too much attention when we should be. Or, for example... if the doctors would write a correct order as to giving the antibiotics... that they need diluting... that they would correctly write what they must be diluted in. I know they say they don’t have time but actually it is their responsibility... isn’t it...? In the same breath it’s ours to know what exactly to mix it in... (Nursing participant)
Nursing participants referred to bundles within the ‘Best Care, Always’ infection control campaign used to guide nursing practice in this ICU.
… we go onto bundle compliance. Okay. We have ‘Best Care, Always!’... We go under
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different types of headings… We look at the patients, at the lines that they’ve got; the central line, the urinary catheter, the peripheral line or arterial line. How many days it is and how many days it should... at what day it should be changed and was it changed.
And if it wasn't changed... we need to do something about it. So... that is with regard to the line changes. Then we’ll get the other things like we look at their ventilator-acquired pneumonia and the patient's chest x-ray when they first came to hospital and the most recent one. We see... changes... we look at the differences... in... Has the patient developed ventilator-acquired pneumonia since he’s been in hospital? So there’s a lot of things we look at, besides the lines, the VAP... Surgical site for example... we look at the wound, if it's healing... if there is any redness around there. When the person last did the dressing and what was the wound looking like. If a pus swab was taken. (Nursing participant)