THE INTERDEPENDENCE BETWEEN DONABEDIAN’S MODEL AND THE MANAGEMENT PROCESS

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The staffing models of an intensive care unit

Lee (2002:1-2) indicates that some hospitals may devote separate units to the care of patients with specific critical care needs based on disciplines such as those mentioned by Monahan et al (2007:192), namely, cardiothoracic, pulmonary, general and surgical ICUs. Evidently, this is the case in both public and private hospitals in Gauteng Province, South Africa. Notably, some hospitals have a single critical care unit which is said to be multidisciplinary or general in terms of the different patients they admit. Lee (2002:2) further explains that the characteristics of the intensive care units vary in organisation and structure; however, three commonly used staffing models are the following:

  • Open model: is used mainly in the United States, and it is where any physician with privileges to admit patients into a specific hospital oversees the care of his or her patients in the ICU (also used in some private hospitals in Gauteng Province, South Africa). Different doctors have consulting rooms in a specific hospital or around the hospital. They consult with their patients and if need be, admit them to the specific hospital. Each of the doctors who admit a patient to the intensive care unit is responsible for the care and treatment of that patient until the patient is discharged from the unit or is referred to another doctor. Significantly, the advantage is that the patient is seen by one doctor and as such there is only one line of authority to deal with the patient. However, the disadvantage is that one unit has to deal with a number of different doctors for different patients. As such, there will be many different protocols of care for the patients in one unit (Lee 2002:2).
  • Closed model: patients requiring intensive care are transferred to the care of a critical care specialist (intensivist) or a team of intensivists who assume full responsibility for the patient while she or he is in ICU (used in public hospitals and also some private hospitals in South Africa, Gauteng Province). There are doctors who are called intensivist, because they specialise in intensive care. These doctors work mainly in the critical care units and oversee the care of the patients admitted in the critical care unit for the rest of the patient’s stay. The advantage is that there is always a doctor available to attend to the patients’ problems; however, the same doctor may not be able to prescribe specialised treatments. It is pivotal that there should always be consultation with the primary doctor who admitted the patient in the unit for other specialised forms of treatment. Nevertheless, this may prolong a patient’s stay in the unit whilst waiting for the primary doctor. The intensivist is also not given full authority to decide when the patient can be transferred out of the unit, but has to wait for the doctor in charge of the patient (Lee 2002:2).
  • Semi closed model: this model is similar to the closed model except that the admitting physician maintains close contact with the patient in the ICU even though the onsite intensivist manages the patient’s care (used in some of the public and private hospitals in Gauteng Province, South Africa). In this case, the intensive care unit has got a resident doctor (onsite intensivist) who is consulted before admission of the patient. The resident doctor oversees the patient during his or her stay in the unit, and the referring doctor simultaneously comes to see the patient and directs the care and treatment together with the resident doctor until the patient is discharged from the unit. This model also has its own advantages and disadvantages which may cause some of the problems in the management of larger ICUs. The problems will be explored from the participants’ point of view (Lee 2002:2).

The BACCN (2010) indicates that the staffing and the nursing team in a critical care unit typically comprise of registered nurses, advanced critical care practitioners, critical care outreach nurses, and practice development nurses, who are supported by assistant critical care practitioners and health care assistants.

Human resources: categories of nurses and the management team

Nurses are the key players in critical care units. The level of care needs required by each patient should equate to the skills and knowledge of the registered nurse delivering and/or supervising that care (BACCN 2010:4). In South Africa, different categories of nurses, namely, registered nurses, ICU trained as well as those without an ICU qualification but experienced in ICU care, plus enrolled nurses take care of the patients.
However, the enrolled nurses fulfil their function under the supervision of the registered nurses. More often, registered nurses without critical care experience and enrolled nurses would also work in these areas. This situation is brought about mainly by the shortage of staff as the registered nurses without an ICU qualification and the enrolled nurses are not specially trained to work in the specialised units such as ICUs (researcher’s observation). In addition, there is a tendency to also add auxiliary nurses and care workers in ICUs. As a result, the experiences, attitudes and commitment of these nurses contribute to the challenges in the effective and efficient management of the unit.
The management team in the ICU consists of physicians, surgeons, ICU nursing manager and critical care nurses, and also the collaborative multidisciplinary health team. The multidisciplinary health team includes representatives from pharmacy, physiotherapy, nutrition, radiology, infection control, social and support services. According to the BACCN (2010:4), a supernumerary clinical co-coordinator, who is a senior critical care qualified nurse, will be required for larger and geographically diverse units of more than 6 beds. The clinical co-coordinator’s role is to ensure that effective, safe and appropriate care is delivered during each shift, by managing and supporting staff and patients, and acting as a communicator and liaison person between the rest of the multidisciplinary team.

Equipment and supplies

Equipment and supplies should be readily available for each bed including cardiac and respiratory monitoring systems. The types of equipment and supplies required will be dependent on each patient’s condition.

Large intensive care units

McKee and Healy (2002:19) indicate that the 15 countries of the former Soviet Union have by far the most hospitals with some very large and others with small units. In contrast, in Central and Eastern Europe countries, they have fewer but very large hospitals with a bed capacity of about 1000 beds. With the challenges related to the provision of hospital beds, Western Europe has experienced a decline (steady but gradual) in the number of acute beds (McKee & Healy 2002:19) which is referred to as downsising. In the United States hospitals have undergone structural changes due to mergers between hospitals that occurred in the 1990s (Furnholmen & Magnussen 2000:29).

CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM.
1.4 PURPOSE OF THE STUDY.
1.5 SIGNIFICANCE OF THE STUDY.
1.6 DEFINITION OF KEY CONCEPTS
1.7 THEORETICAL FRAMEWORK
1.8 INTRODUCTION TO METHODOLOGY
1.9 ETHICAL CONSIDERATIONS
1.10 STRUCTURE OF THE THESIS
CHAPTER 2 CONTEXTUALISING THE STUDY THEME
2.1 INTRODUCTION
2.2 THEORETICAL FRAMEWORK
2.3 THE INTERDEPENDENCE BETWEEN DONABEDIAN’S MODEL AND THE MANAGEMENT
PROCESS
2.4 CRITICAL (INTENSIVE) CARE UNITS CONCLUSION.
CHAPTER 3 RESEARCH METHODOLOGY
3.1 INTRODUCTION
3.2 RESEARCH PERSPECTIVE
3.3 RESEARCH DESIGN
3.4 RESEARCH METHODS FOR THE DIFFERENT PHASES.
3.5 PHASE
3.6 PHASE CONCLUSION.
CHAPTER 4 DESCRIPTIVE DATA ANALYSIS
4.1 INTRODUCTION
4.2 PHASE
4.3 DATA PRESENTATION
4.4 DATA ANALYSIS
4.5 DESCRIPTION AND INTERPRETATION OF DATA..
4.6 CONCLUSION.
CHAPTER 5 DISCUSSION OF DATA AND DEVELOPMENT OF THE STRATEGIES

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STRATEGIES TO OVERCOME THE CHALLENGES IN THE MANAGEMENT OF LARGER CRITICAL CARE UNITS

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