Perceptions and experiences of registered professional nurses in the recognition of unexpected clinical deterioration in children in wards

Wortley, Suzanne (2013-03)

Thesis (MCurr)--Stellenbosch University, 2013.

Thesis

ENGLISH ABSTRACT: Unnoticed deterioration in the clinical condition of children in ward areas can lead to near or actual cardiopulmonary arrest. Children suffering from a cardiac arrest in hospital often display abnormal physiological parameters hours prior to this event occurring (i.e., within a 24 hour period). Prevention of cardiopulmonary arrest in the wards lies in the ability of nursing and medical staff to be able to identify these abnormal physiological parameters, i.e., early signs of deterioration, and to intervene prior to this event. This study aimed to identify nurses’ experiences with regards to current knowledge, clinical practice and training in the recognition of clinical deterioration in children. It could then be determined whether a formal guideline on the early recognition of clinical deterioration in children would be perceived as being beneficial by the respondents in this study. The research question that guided this study was “what are the perceptions and experiences of registered professional nurses working in paediatric wards with regards to their recognition of unexpected clinical deterioration in children?” An exploratory descriptive study, utilising a qualitative approach was applied. The target population consisted of all registered professional nurses working in paediatric wards in academic hospitals in the Western Cape, South Africa. Ethical approval was obtained. Informed written consent was obtained from the participants. The purposive sampling method was used to select the participants (n=17) who met the criteria. Five focus group interviews were conducted to collect the data, using an interview guide. The planned methodology with its instrumentation and procedures was verified through a pilot study that was conducted on the first focus group interview. The steps of the research process included transcribing the collected data verbatim from the audio recordings and the field notes, and then analysing the data by summarising and packaging the data, identifying themes and trends in the data and verifying and drawing conclusions. The analysis themes identified were based on Donabedian’s conceptual framework, comprising Structure (the environment in which the care takes place), Process (method by which the care takes place), and Quality Assurance (the planned, organised evaluation of the patient care which has been rendered). The findings showed that the increased level of severity of illness of children nursed in paediatric wards, as well as staff shortages, gaps in training on resuscitation and clinical deterioration, limited ICU beds and staff, lack of adequate monitoring and emergency equipment in the wards, and inexperienced staff are all factors that were identified that increase the risk of staff not being able to detect clinical deterioration in children nursed in paediatric wards. Teamwork among nursing staff and other medical professionals, as well as parental involvement in the care of the children, assisted staff in being able to detect clinical deterioration. Most participants were unfamiliar with ‘early warning systems’ and reported that there are no paediatric ‘early warning scores’ (PEWS) in place. They believed such a system would be beneficial; however they had concerns regarding the time it would take to score a patient, the training involved, and the ease of use of such a tool and system. Recommendations for addressing non-recognition of clinical deterioration by nurses in paediatric wards such as appropriate knowledge and skill updating, were put forward in the study.

AFRIKAANSE OPSOMMING: ‘n Kliniese verswakking by kinders wie in pediatriese sale verpleeg word, wat nie betyds waargeneem word nie, kan dit lei tot ‘n amperse of werklike kardio-pulmonale arres. Kardio-pulmonale arres in kinders word dikwels voorafgegaan deur ‘n verandering in die fisiologiese parameters (so vroeg as 24-uur voor die arres). Die voorkoming van saalverwante kardio-pulmonale arres berus op die vermoeë van verpleeg- en mediese personeel om die abnormale fisiologiese tekens so vroeg as moontlik waar te neem en daadwerklik op te tree voordat die arres plaasvind. Die doel van hierdie studie was om die ondervindige van verpleegkundiges te identifiseer met betrekking tot die bestaande protokolle, opleiding en hulpbronne wat beskikbaar is vir die waarneming van die kliniese agteruitgang in kinders. ‘n Bepaling sal gevolglik gemaak kan word of die studie-respondente ‘n amptelike riglyn rakende die vroegtydige waarneming van kliniese agteruitgang in kinders voordelig sou vind al dan nie. Die rigtinggewende navorsingvraag vir die studie was “wat is die sieninge en ondervings van geregistreerde verpleegkundiges in pediatriese sale rakende die herkening van onverwagte kliniese agteruitgang in kinders?” ‘n Verkennende, beskrywende navorsingsmetodologie, met ‘n kwalitatiewe aanslag, is gebruik. Die teikenpopulasie het bestaan uit alle geregistreerde professionale verpleegkundiges, werksaam in die pediatriese sale van die akademiese hospitale in die Wes Kaap, Suid-Afrika. Etiese toestemming, asook ingeligte, skriftelike toestemming is vooraf verkry van elke deelnemer. ‘n Doelbewuste steekproefnemings metode is gebruik om die studie deelnemers, wat aan die navorsingskriteria voldoen het, te kies. Vyf fokusgroep onderhoude is gevoer om data in te samel en ‘n onderhoudsgids is gebruik vir dié onderhoude. Om die navorsingmetodologie, instrumentasie and prosedures te bevestig, is ‘n voortoets tydens die eerste fokusgroep onderhoud gedoen. Die stappe van die navorsingproses is gevolg om die ingesamelde data, bestaande uit klankopnames en veldnotas, woord-vir-woord oor te skryf. Die data is hierna ontleed deur middel van opsomming en samevoeging, terwyl temas en neigings geïdentifiseer is en afleidings geverifieër en gefinaliseer is. Die geïdentifiseerde ontledingstemas is basseer op Donabedian se konsepsuele raamwerk, bestaande uit Struktuur (die versorgingsomgewing), Proses (die versorgingsmetodes) en Kwaliteitsversekering (die doelbewuste en beplande evaluering van gelewerde verpleegsorg). Die navorsingsbevindinge het daarop gedui dat verskeie faktore ‘n rol speel in die risiko-toename wat verband hou met personeel wat nie die kliniese agteruitgang in kinders wat in pediatriese sale verpleeg word, waarneem nie. Die faktore sluit in: die kinders se graad van siekte, personeeltekorte, opleidings tekortkominge ten opsigte van resussitasie- en die identifikasie van kliniese agteruitgang by kinders, tekorte aan genoegsame moniterings- en noodtoerusting in die sale, en onervare personeel. Die waarneming van kliniese agteruitgang is wel bevorder deur spanwerk onder verpleegkundiges en ander mediese personeel, asook ouers wat betrokke was by die versorging van hulle kinders. Die meerderheid van die navorsingdeelnemers was nie vertroud met ‘vroeë waarskuwingsstelsel’ nie, en het aangedui dat geen ‘pediatriese vroeë waarskuwingsstelsels’ beskikbaar is nie. Alhoewel hulle van mening was dat so ‘n stelsel voordelig kon wees, het hulle bedenkinge gehad oor die tyd wat dit in beslag sou neem om die dokumentasie te voltooi, die opleiding wat hulle sou moes ontvang, en wat die moeilikheidsgraad van so ‘n stelsel sou wees. Die voortvloeiende aanbevelings van hierdie studie, wat die nie-herkenning van kliniese agteruitgang deur verpleegkundiges in pediatriese sale aanspreek, sluit in toepaslike kennis- en vaardigheids opdatering.

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