exploring the role of the intensive care nurse in the antimicrobial stewardship team at a private

183 Pages·2016·2.01 MB·English

EXPLORING THE ROLE OF THE INTENSIVE CARE NURSE
IN THE ANTIMICROBIAL STEWARDSHIP TEAM
AT A PRIVATE HOSPITAL, ETHEKWINI, SOUTH AFRICA

Submitted to:

SCHOOL OF NURSING & PUBLIC HEALTH
COLLEGE OF HEALTH SCIENCES
UNIVERSITY OF KWAZULU-NATAL DURBAN
SOUTH AFRICA

In:
Partial fulfillment of the Requirements for the
Master of Nursing (Critical Care and Trauma)

BY
JOAN ROUT

SUPERVISOR
PROF P. BRYSIEWICZ

2015

DEDICATION

This study is dedicated to Dr Richard Burrows, an intensivist that I have been proud to work
with and to call a friend. Dr Burrows served the Critical Care Society of South Africa for
several decades and has been instrumental in creating a platform for the voices of ICU nurses
here in South Africa.

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ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to
 Dr J de Beer for her assistance in the early part of this study
 Professor Petra Brysiewicz, my supervisor, for her guidance and support
 Mrs Dorien Wentzel for her long nursing friendship
 Ms Reka Howbrook for her support as a fellow masters student
 Mrs Shirley Moon for her kindness in editing the research proposal
 Mrs Elizabeth Rocke for her steadfast patience in editing the manuscript
 The study hospital for allowing me to conduct this research
 The nurses and doctors who participated so willingly in this study
 The Critical Care Society of South Africa which inspires, educates and supports
nurses and doctors in their care of the critically ill patient here in South Africa
Finally, I would like to thank my family; my husband Chris, our children Kathryn, Jennifer
and Michael and my mother Marlene, for their understanding of the time that was spent on
this study.

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ABSTRACT

Background:
The care of the critically ill patient across the world has become progressively challenging
with increasingly resistant pathogens resulting in difficult to treat infections. This is
compounded by the decreasing effectiveness of many antibiotics. Severe infections increases
the length of time spent in an ICU, increases morbidity and mortality, and increases
healthcare costs. Antimicrobial stewardship (AS) has the aims of slowing resistance and the
protection of patients and the wider community through the promotion of correct
antimicrobial use by education and guidelines. Infection control measures are an essential
part of AS in preventing emergent resistant pathogens and hospital-acquired infections.
Research purpose:
The identification of the role of the ICU nurse in an AS team in a private ICU in South
Africa.
Research approach:
A qualitative approach was used in this study in order to obtain meaningful contributions that
a questionnaire may not have been able to provide. Purposive sampling was used to identify
participants from an ICU multidisciplinary AS team in a hospital in the private healthcare
sector. Semi-structured interviews were conducted with fifteen participants; ICU clinical
nurses, nursing management, surgeons, anaesthetists, physicians, microbiologists and
pharmacists. Data were analysed and categorised using content analysis.
Findings:
Perspectives of the various members of the multidisciplinary AS team identified the role of
the ICU nurse in an AS team as being organisational, advocatory, clinical and collaborative.
Suggestions were made to further develop this nursing role by supporting proactive
behaviour, teaching and learning, and teamwork. Concerns were raised about this role
relating to resource barriers, knowledge deficit, poor attitude towards work, ineffective
teamwork, working in isolation, and economic pressures. A limitation to this study is that it is
a small study in a single setting, which may limit generalizability.
Conclusion:
The ICU nurse’s role in AS is essential for the successful implementation of an AS
programme. Recommendations to develop this role are made for clinical practice, education,
research and policy development.
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TABLE OF CONTENTS
Page
DECLARATION ………………………………………. i

DEDICATION ………………………………………. ii

ACKNOWLEDGEMENT ………………………………………. iii

ABSTRACT ………………………………………. iv

TABLE OF CONTENTS ………………………………………. v

CHAPTER ONE: INTRODUCTION 1

1.1 INTRODUCTION ………………………………………. 1
1.2 BACKGROUND ………………………………………. 1
1.3 PROBLEM STATEMENT ………………………………………. 5
1.4 PURPOSE OF THE STUDY ………………………………………. 5
1.5 OBJECTIVES OF THE STUDY ………………………………………. 6
1.6 RESEARCH QUESTION ………………………………………. 6
1.7 SIGNIFICANCE OF THE STUDY ………………………………………. 7
1.7.1 PRACTICE ………………………………………. 7
1.7.2 RESEARCH ………………………………………. 7
1.7.3 EDUCATION ………………………………………. 7
1.7.4 POLICY DEVELOPMENT ………………………………………. 7
1.8 OPERATIONAL DEFINITIONS ………………………………………. 8
1.9 SUMMARY OF CHAPTER ………………………………………. 9

CHAPTER TWO: LITERATURE REVIEW 10

2.1 INTRODUCTION ………………………………………. 10
2.2 LITERATURE SEARCH STRATEGY ………………………………………. 10
2.3 ANTIMICROBIAL RESISTANCE ………………………………………. 10
2.3.1 ANTIBIOTIC/ANTIFUNGAL MISUSE ………………………………………. 10
2.3.2 DECREASED PRODUCTION OF ANTIMICROBIAL THERAPY ……………………. 11
2.3.3 PUBLIC HEALTH THREAT ………………………………………. 12
2.4 ANTIMICROBIAL STEWARDSHIP ………………………………………. 12
2.4.1 MONITORING OF INFECTIONS IN THE ICU ………………………………………. 13
2.4.2 HOSPITAL-ACQUIRED INFECTIONS IN THE ICU …………………………………. 13
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2.4.3 INFECTION PREVENTION AND CONTROL IN THE ICU …………………………… 14
2.5 THE ICU NURSE AS PART OF THE ANTIMICROBIAL STEWARDSHIP TEAM ………….... 15
2.6 SYMBOLIC INTERACTIONISM ………………………………………. 16
2.7 SUMMARY OF CHAPTER ………………………………………. 18

CHAPTER THREE: METHODOLOGY 19

3.1 INTRODUCTION ………………………………………. 19
3.2 RESEARCH PARADIGM ………………………………………. 19
3.3 RESEARCH APPROACH ………………………………………. 20
3.4 RESEARCH SETTING ………………………………………. 21
3.5 SAMPLING ………………………………………. 21
3.6 PARTICIPANT PROFILE ………………………………………. 22
3.7 DATA COLLECTION PROCESS ………………………………………. 22
3.7.1 DATA COLLECTION INSTRUMENT ………………………………………. 23
3.7.2 INTERVIEW PROCESS ………………………………………. 24
3.7.3 TRANSCRIPTION OF RECORDED MATERIAL ………………………………………. 24
3.7.4 DATA ANALYSIS ………………………………………. 25
3.8 ACADEMIC RIGOUR ………………………………………. 26
3.8.1 CREDIBILITY ………………………………………. 26
3.8.2 TRANSFERABILITY ………………………………………. 27
3.8.3 DEPENDABILITY ………………………………………. 28
3.8.4 CONFIRMABILITY ………………………………………. 28
3.9 ETHICAL CONSIDERATIONS FOR PARTICIPANTS IN STUDY ………………………………. 28
3.10 DATA MANAGEMENT ………………………………………. 28
3.11 SUMMARY OF CHAPTER ………………………………………. 29

CHAPTER FOUR: DESCRIPTION OF FINDINGS 30

4.1 INTRODUCTION ………………………………………. 30
4.2 PRESENTATION OF FINDINGS ………………………………………. 30
4.2.1 CATEGORIES AND SUB CATEGORIES ………………………………………. 30
4.3 RESEARCH FINDINGS ………………………………………. 31
4.3.1 THE “MASSIVE RESPONSIBILITY” OF THE ROLE OF THE ICU NURSE ………… 33
4.3.1.1 ORGANISATIONAL ROLE ………………………………………. 33
4.3.1.2 ADVOCACY ROLE ………………………………………. 34
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4.3.1.3 CLINICAL ROLE ………………………………………. 37
4.3.1.4 COLLABORATIVE ROLE ………………………………………. 41
4.3.2 “BEING PROACTIVE” IN THE DEVELOPMENT OF THE NURSE’S ROLE ………… 43
4.3.2.1 TAKING RESPONSIBILITY FOR SAFE PATIENT CARE …………………... 43
4.3.2.2 FURTHER EDUCATION OF THE NURSE …………………………………… 46
4.3.2.3 IMPROVED TEAM COLLABORATION …………………………………… 48
4.3.3 MULTIFACTORIAL BARRIERS TO DEVELOPING THE NURSE’S ROLE ………… 49
4.3.3.1 RESOURCE BARRIERS ……………………………………… 49
4.3.3.2 KNOWLEDGE DEFICIT ……………………………………… 50
4.3.3.3 POOR STAFF ATTITUDE ……………………………………… 51
4.3.3.4 COLLABORATION BARRIERS ……………………………………… 55
4.3.3.5 WORKING IN ISOLATION ……………………………………… 59
4.3.3.6 ECONOMIC BARRIERS ……………………………………… 64
4.5 SUMMARY OF CHAPTER ……………………………………… 67

CHAPTER FIVE: DISCUSSION OF FINDINGS 68

5.1 INTRODUCTION ……………………………………… 68
5.2 DISCUSSION OF FINDINGS ……………………………………… 68
5.2.1 THE “MASSIVE RESPONSIBILITY” OF THE ROLE OF THE ICU NURSE ………… 68
5.2.1.1 ORGANISATIONAL ROLE ……………………………………… 69
5.2.1.2 ADVOCACY ROLE ……………………………………… 71
5.2.1.3 CLINICAL ROLE ……………………………………… 76
5.2.1.4 COLLABORATIVE ROLE ……………………………………… 82
5.2.2 “BEING PROACTIVE” IN THE DEVELOPMENT OF THE NURSE’S ROLE ………… 83
5.2.2.1 TAKING RESPONSIBILITY FOR SAFE PATIENT CARE …………………. 83
5.2.2.2 FURTHER EDUCATION OF THE NURSE …………………………………. 85
5.2.2.3 IMPROVED TEAM COLLABORATION …………………………………. 88
5.2.3 MULTIFACTORIAL BARRIERS TO DEVELOPING THE NURSE’S ROLE …………. 89
5.2.3.1 RESOURCE BARRIERS ……………………………………… 90
5.2.3.2 KNOWLEDGE DEFICIT ……………………………………… 92
5.2.3.3 POOR STAFF ATTITUDE ……………………………………… 95
5.2.3.4 COLLABORATION BARRIERS ……………………………………… 98
5.2.3.5 WORKING IN ISOLATION ……………………………………… 106
5.2.3.6 ECONOMIC BARRIERS ……………………………………… 111
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5.3 SYMBOLIC INTERACTIONISM ……………………………………… 119
5.3.1 SYMBOLIC INTERACTIONISM AND ROLE DEVELOPMENT …………………….. 119
5.3.2 SYMBOLIC INTERACTIONISM AND TEAMWORK ………………………………… 119
5.3.3 CRITICISM OF SYMBOLIC INTERACTIONISM ……………………………………… 120
5.4 SUMMARY OF CHAPTER ……………………………………… 121

CHAPTER SIX: REFLECTIONS, SUMMARY, LIMITATIONS AND RECOMMENDATIONS 122

6.1 INTRODUCTION ……………………………………… 122
6.2 RESEARCHER REFLECTIONS ……………………………………… 122
6.3 SUMMARY OF STUDY ……………………………………… 123
6.3.1 RATIONALE FOR THE STUDY ……………………………………… 123
6.3.2 LITERATURE REVIEW ……………………………………… 123
6.3.3 METHODOLOGY ……………………………………… 124
6.3.4 OVERVIEW OF FINDINGS ……………………………………… 125
6.4 LIMITATIONS OF STUDY ……………………………………… 127
6.5 RECOMMENDATIONS ……………………………………… 127
6.5.1 RECOMMENDATIONS TO ADDRESSING RESOURCE BARRIERS ………………... 128
6.5.1.1 RECOMMENDATIONS FOR OPTIMAL STAFFING ………………………. 128
6.5.1.2 POSITIVE PRACTICE ENVIRONMENTS ………………………………… 128
6.5.2 RECOMMENDATIONS TO ADDRESSING KNOWLEDGE BARRIERS ……………. 128
6.5.2.1 CLINICAL PRACTICE IN ICU ……………………………………… 129
6.5.2.2 IN-SERVICE TRAINING ……………………………………… 129
6.5.2.3 NURSING EDUCATION ……………………………………… 130
6.5.2.4 CONTINUING PROFESSIONAL DEVELOPMENT ………………………… 130
6.5.3 RECOMMENDATIONS TO ADDRESSING PROFESSIONAL BARRIERS ….……….. 131
6.5.3.1 NURSE ATTITUDES AND POOR PERFORMANCE ………………………… 131
6.5.3.2 ANNUAL PERFORMANCE REVIEW ……………………………………… 131
6.5.3.3 POLICY DEVELOPMENT ……………………………………… 132
6.5.3.4 RESEARCH INTO THE ROLE OF THE ICU NURSE IN AS ……………… 132
6.5.4 RECOMMENDATIONS TO ADDRESSING COLLABORATION BARRIERS ………… 132
6.5.5 RECOMMENDATIONS TO ADDRESSING AS SUPPORT BARRIERS ……………… 133
6.5.6 RECOMMENDATIONS TO ADDRESSING ECONOMIC BARRIERS ……………… 133
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6.6 CONCLUSION ……………………………………… 133

REFERENCES 135

ANNEXURES 159

A INTERVIEW GUIDE ……………………………………… 159
B PARTICIPANT INFORMATION SHEET ……………………………………… 160
C CONSENT FORM ……………………………………… 162
D ETHICAL APPROVAL ……………………………………… 163
E PERMISSION REQUEST LETTER TO RESEARCH SETTING …………………………………. 164
F CONFIRMATION OF LANGUAGE EDITING ……………………………………… 165
G INTERVIEW TRANSCRIPT - PARTICIPANT 10 ……………………………………… 166

LIST OF TABLES

TABLE 3.1 DATA ANALYSIS ……………………………………… 25
TABLE 3.2 TRUSTWORTHINESS ……………………………………… 26
TABLE 4.1 PARTICIPANT PROFILE ……………………………………… 30
TABLE 4.2 CATEGORIES, SUB CATEGORIES, SUB SUB CATEGORIES ……………………. 32

LIST OF FIGURES

FIGURE 3.1 INTERVIEW PROCESS ……………………………………… 27
FIGURE 5.1 SYMBOLIC INTERACTION PROCESS …………….………………………... 120