162. Cardio-Pulmonary Resuscitation

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162. Cardio-Pulmonary Resuscitation

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Syllabus

CHAPTER 1
INTRODUCTION AND OVERVIEW OF THE STUDY

1.1 INTRODUCTION ………………………………………………………………………………………… 1
1.1.1 The AACN Synergy Model for Patient Care …………………………………………………….. 4
1.1.2 The global context of cardio-pulmonary resuscitation………………………………………… 5
1.2 BACKGROUND TO THE RESEARCH PROBLEM …………………………………………… 6
1.2.1 Overview of Botswana …………………………………………………………………………………. 7
1.2.2 Statistics for health care personnel in the Southern African region………………………. 8
1.2.3 Health care services in Botswana ………………………………………………………………… 10
1.2.4 The incidence of trauma and emergency cases in Botswana ……………………………. 11
1.2.5 The preparation and roles of nurses in Botswana …………………………………………… 14
1.2.5.1 General training of nurses in Botswana…………………………………………………………. 14
1.2.5.2 The scope of practice of nurses in Botswana …………………………………………………. 18
1.2.5.3 Training in CPR and life-saving procedures …………………………………………………… 18
1.3 STATEMENT OF THE RESEARCH PROBLEM …………………………………………….. 19
1.4 SIGNIFICANCE OF THE RESEARCH………………………………………………………….. 21
1.5 PURPOSE OF THE RESEARCH…………………………………………………………………. 22
1.6 RESEARCH OBJECTIVES…………………………………………………………………………. 22
1.7 PHASES OF THE RESEARCH……………………………………………………………………. 23
1.7.1 Phase 1: Audit phase…………………………………………………………………………………. 23
1.7.2 Phase 2: Evaluation phase………………………………………………………………………….. 23
1.7.3 Phase 3: Discussion phase…………………………………………………………………………. 24
1.7.4 Phase 4: Recommendation phase ……………………………………………………………….. 24
1.8 RESEARCH QUESTIONS ………………………………………………………………………….. 24
1.8.1 Phase 1: Quantitative research design (health care system)…………………………….. 25
1.8.2 Phase 2: Quantitative research design (nurse)……………………………………………….. 25
1.8.3 Phase 3: Qualitative research design (nurse, system and patient) …………………….. 25
1.8.4 Phase 4: Recommendation phase (nurse, system and patient)…………………………. 26
1.9 DEFINITIONS OF KEY TERMS…………………………………………………………………… 26
1.9.1 Conceptual and operational definitions …………………………………………………………. 26
1.10 CONCEPTUAL FRAMEWORK……………………………………………………………………. 31
1.11 ASSUMPTIONS………………………………………………………………………………………… 31
1.11.1 Theoretical (conceptual) assumptions…………………………………………………………… 32

1.11.2 Methodological assumptions ……………………………………………………………………….. 32
1.12 THE RESEARCH DESIGN AND METHODOLOGY………………………………………… 33
1.12.1 The procedure adopted for conducting the research ……………………………………….. 33
1.12.2 Research design……………………………………………………………………………………….. 34
1.12.3 Reliability and validity for phases 1 and 2 of the study …………………………………….. 37
1.12.4 Trustworthiness of the data obtained in phases 3 and 4 of the study …………………. 37
1.13 ETHICAL CONSIDERATIONS…………………………………………………………………….. 37
1.13.1 The scope and limitations of the study ………………………………………………………….. 38
1.13.2 Methodological limitations …………………………………………………………………………… 38
1.13.3 Theoretical limitations ………………………………………………………………………………… 39
1.14 DIVISION OF CHAPTERS………………………………………………………………………….. 39
1.15 CONCLUSION………………………………………………………………………………………….. 40
CHAPTER 2
CONCEPTUAL FRAMEWORK: THE SYNERGY MODEL FOR
PATIENT CARE OF THE AMERCIAN ASSOCIATION OF CRITICAL
CARE NURSES

2.1 INTRODUCTION ………………………………………………………………………………………. 41
2.1.1 The American Association of Critical Care Nurse Certification Synergy

Model for Patient Care ……………………………………………………………………………….. 42
2.2 HISTORICAL BACKGROUND …………………………………………………………………….. 42
2.3 THE AACN SYNERGY MODEL FOR PATIENT CARE……………………………………. 43
2.3.1 The major tenets of the AACN Synergy Model for Patient Care ………………………… 44
2.3.2 Assumptions that guide the AACN Synergy Model for Patient Care…………………… 45
2.3.3 Patient characteristics as described in the AACN Synergy Model for Patient Care . 48
2.3.3.1 Resiliency ………………………………………………………………………………………………… 49
2.3.3.2 Vulnerability ……………………………………………………………………………………………… 50
2.3.3.3 Stability ……………………………………………………………………………………………………. 51
2.3.3.4 Complexity ……………………………………………………………………………………………….. 51
2.3.3.5 Resource availability ………………………………………………………………………………….. 52
2.3.3.6 Participation in care……………………………………………………………………………………. 53
2.3.3.7 Participation in decision making …………………………………………………………………… 54
2.3.3.8 Predictability …………………………………………………………………………………………….. 55

2.3.4 Outcomes derived from the patient ………………………………………………………………. 55
2.3.4.1 Functional and behavioural changes…………………………………………………………….. 55
2.3.4.2 Trust ……………………………………………………………………………………………………….. 56
2.3.4.3 Ratings…………………………………………………………………………………………………….. 56
2.3.4.4 Satisfaction and comfort……………………………………………………………………………… 56
2.3.4.5 Quality of life …………………………………………………………………………………………….. 57
2.3.5 Nurse competencies in the light of the AACN Synergy Model for Patient Care…….. 57
2.3.5.1 Clinical judgement……………………………………………………………………………………… 57
2.3.5.2 Advocacy/moral agency ……………………………………………………………………………… 59
2.3.5.3 Caring practices ………………………………………………………………………………………… 60
2.3.5.4 Collaboration…………………………………………………………………………………………….. 61
2.3.5.5 Systems thinking……………………………………………………………………………………….. 62
2.3.5.6 Response to diversity…………………………………………………………………………………. 64
2.3.5.7 Clinical enquiry………………………………………………………………………………………….. 65
2.3.5.8 Facilitation of learning ………………………………………………………………………………… 66
2.3.5.9 Summary of nurses’ competencies ………………………………………………………………. 67
2.3.6 Outcomes derived from the nurse ………………………………………………………………… 68
2.3.6.1 The management of physiological changes …………………………………………………… 68
2.3.6.2 The management and prevention of the presence and absence of complications… 68
2.3.6.3 Extent of care and treatment objectives attained…………………………………………….. 69
2.3.7 The health care system according to the AACN Synergy Model for Patient Care…. 69
2.3.8 Outcomes derived from the system………………………………………………………………. 70
2.3.8.1 Recidivism ……………………………………………………………………………………………….. 70
2.3.8.2 Cost and resource utilisation……………………………………………………………………….. 70
2.4 APPLICATION OF THE AACN SYNERGY MODEL FOR PATIENT CARE DURING
DURING CARDIO-PULMONARY RESUSCITATION………………………………………. 72
2.4.1 Patients’ characteristics and nurses’ competencies during CPR ……………………….. 72
2.4.2 Patients’ characteristics during CPR …………………………………………………………….. 72
2.4.3 Nurses’ characteristics during CPR………………………………………………………………. 73
2.4.3.1 Clinical judgement……………………………………………………………………………………… 73
2.4.3.2 Advocacy/moral agency ……………………………………………………………………………… 74
2.4.3.3 Caring practices ………………………………………………………………………………………… 75
2.4.3.4 Collaboration…………………………………………………………………………………………….. 76
2.4.3.5 Systems thinking……………………………………………………………………………………….. 76
2.4.3.6 Response to diversity…………………………………………………………………………………. 77

2.4.3.7 Clinical enquiry………………………………………………………………………………………….. 77
2.4.3.8 Facilitation of learning ………………………………………………………………………………… 78
2.5 APPLICATION OF THE AACN SYNERGY MODEL FOR PATIENT CARE IN
VARIOUS SETTINGS………………………………………………………………………………… 78
2.6 CONCLUSION………………………………………………………………………………………….. 80
CHAPTER 3
LITERATURE REVIEW
3.1 INTRODUCTION ………………………………………………………………………………………. 81
3.2 CONCEPTUAL FRAMEWORK……………………………………………………………………. 84
3.3 BRIEF HISTORICAL REVIEW ON CARDIO-PULMONARY RESUSCITATION
(CPR)………………………………………………………………………………………………………. 84
3.3.1 Definition of cardio-pulmonary resuscitation (CPR) …………………………………………. 85
3.4 HAEMODYNAMICS OF, AND PATIENT CHARACTERISTICS DURING CARDIAC
ARREST AND CARDIO-PULMONARY RESUSCITATION (CPR) …………………….. 86
3.4.1 The role of cardio-pulmonary resuscitation (CPR)…………………………………………… 88
3.4.2 General principles of adult, paediatric and neonatal cardio-pulmonary

resuscitation (CPR)……………………………………………………………………………………. 88

3.4.3 Competencies required by registered nurses during cardio-pulmonary

resuscitation (CPR)……………………………………………………………………………………. 89
3.4.3.1 Assessment of the airway …………………………………………………………………………… 89
3.4.3.2 Breathing …………………………………………………………………………………………………. 91
3.4.3.3 Circulation/chest compressions……………………………………………………………………. 93
3.4.3.4 Recommneded administration of CPR for different age groups…………………………. 94
3.4.3.5 Defibrillation ……………………………………………………………………………………………… 94
3.4.3.6 Defibrillator……………………………………………………………………………………………….. 95
3.4.3.6.1 Types of defibrillators…………………………………………………………………………………. 95
3.4.3.6.2 Manual external defibrillators (MEDs) …………………………………………………………… 95
3.4.3.6.3 Automated external defibrillators (AEDs)……………………………………………………….. 96
3.4.3.6.4 Sequence of actions during use of an automated external defibrillator………………. 98
3.5 AED ALGORITHM …………………………………………………………………………………….. 99

3.6 DRUGS ADMINISTERED DURING ACLS…………………………………………………… 100
3.6.1 Routes for administration of drugs………………………………………………………………. 101
3.7 ALGORITHMS ………………………………………………………………………………………… 102
3.7.1 Differences between BLS, Immediate Life Support (ILS) and ACLS…………………. 107
3.7.2 The chain of survival ………………………………………………………………………………… 108
3.8 PROVISION OF EDUCATIONAL TOOLS BY THE HEALTHCARE SYSTEMS –
MANIKINS ……………………………………………………………………………………………… 109
3.8.1 History of manikins…………………………………………………………………………………… 110
3.8.2 Types of manikins ……………………………………………………………………………………. 110
3.8.3 Types of manikins used for CPR………………………………………………………………… 111
3.8.3.1 Little Anne………………………………………………………………………………………………. 111
3.8.3.2 Little Anne Junior (“Little Junior”)………………………………………………………………… 113
3.8.3.3 Resusci Adult Anne Skill Reporter………………………………………………………………. 114
3.9 MILESTONES ON THE WAY TO DEVELOPMENT OF INTERNATIONAL
GUIDELINES 2000 – THE FIRST INTERNATIONAL CONFERENCE ON
GUIDELINES FOR CPR AND ECC ……………………………………………………………. 115

3.10 FACTORS THAT PRECIPITATED MAJOR CHANGES IN THE 2005 AHA

GUIDELINES FOR CPR AND ECC ……………………………………………………………. 117

3.11 ETHICAL PRINCIPLES OBSERVED FURING CARDIO-PULMONARY

RESUSCITATION……………………………………………………………………………………. 119
3.11.1 “Do Not Attempt Resuscitation” (DNAR)………………………………………………………. 121
3.11.1.1 Abandoning resuscitation………………………………………………………………………….. 121
3.11.1.2 Withholding and withdrawing CPR ……………………………………………………………… 122
3.11.2 The nurse’s role in decisions about CPR……………………………………………………… 122
3.12 THE OUTCOMES OF CPR……………………………………………………………………….. 123
3.13 SCOPE OF PRACTICE FOR NURSES ON BLS, ACLS ………………………………… 124
3.13.1 Education and training in CPR …………………………………………………………………… 125
3.13.2 Future trends in CPR ……………………………………………………………………………….. 127
3.13.2.1 The Auto Pulse ……………………………………………………………………………………….. 129
3.13.2.2 The Active Compression-Decompression Device and the Impedance

Threshold Device …………………………………………………………………………………….. 130
3.13.2.3 Simultaneous sterno-thoracic CPR …………………………………………………………….. 132
3.13.2.4 Cardiovent® bellows on sternum resuscitation……………………………………………… 132
3.13.2.5 The LUCASTM chest compression device …………………………………………………… 133

3.13.2.6 CPREzyTM………………………………………………………………………………………………. 134
3.14 THE CHARACTERISTICS OF CPR AND THE ROLE OF NURSES IN THE
PROVISION OF CPR……………………………………………………………………………….. 138
3.15 THE ROLE OF INTERNATIONAL COMMITTEES ………………………………………… 140
3.16 FACTORS THAT INFLUENCE THE PERFORMANCE OF CPR……………………… 140
3.16.1 The eduction and training of nurses in cardio-pulmonary resuscitation …………….. 141
3.16.2 Role of nurse educators ……………………………………………………………………………. 143
3.16.3 Role of nurses in CPR and defibrillation………………………………………………………. 144
3.16.4 Role of policies and protocols on CPR ………………………………………………………… 145
3.17 LITERATURE ON NURSES’ PERCEPTIONS, BARRIERS AND NEEDS IN
PROVIDING CPR ……………………………………………………………………………………. 147
3.18 ROLE OF HEALTHCARE SYSTEM IN THE PERFORMANCE OF CPR…………… 150
3.18.1 Inadequate resources and facilities by the healthcare system and the impact on
the peformance of CPR…………………………………………………………………………….. 150
3.18.2 Outcomes derived from the auditing of CPR (recidivism and cost and resource
utilisation)……………………………………………………………………………………………….. 153
3.18.3 In-service education and its effects on nurses’ competency in the peformance of
CPR ………………………………………………………………………………………………………. 159
3.19 NURSES’ CHARACTERISTICS AS COMPETENCIES………………………………….. 162
3.19.1 Inadequate knowledge and skills and the effects on CPR performance ……………. 162
3.20 NURSES’ PERCEPTIONS OF CPR …………………………………………………………… 182

3.21 BARRIERS THAT HINDER THE EFFICIENT APPLICATION AND PERFOR-
MANCE OF CPR …………………………………………………………………………………….. 185

3.21.1 Stress ……………………………………………………………………………………………………. 185
3.21.2 Perceived barriers and needs ……………………………………………………………………. 189
3.22 HUMAN FACTORS THAT AFFECT THE QUALITY OF CPR …………………………. 191
3.22.1 Teamwork ………………………………………………………………………………………………. 191
3.22.2 Leadership ……………………………………………………………………………………………… 193
3.22.3 Attitudes…………………………………………………………………………………………………. 195
3.22.4 Motivation ………………………………………………………………………………………………. 197
3.22.5 Facilitation of learning as a need in CPR provision ……………………………………….. 197
3.22.6 Innovative teaching methods as a response to diversity and their effects on the
learning of CPR……………………………………………………………………………………….. 198
3.22.7 The role of simulation in the learning of CPR ……………………………………………….. 202
3.22.8 Ethical issues and their effects on the performance of CPR……………………………. 206

3.23 ACQUIRED IMMUNO-DEFICIENCY SYNDROME (AIDS) AND CPR………………. 209
3.24 METHODOLOGIES USED IN THE LITERATURE REVIEWS…………………………. 210
3.25 CONCLUSION………………………………………………………………………………………… 211

CHAPTER 4
RESEARCH METHODOLOGY
4.1 INTRODUCTION …………………………………………………………………………………….. 214
4.2 AIM AND PURPOSE OF THE RESEARCH …………………………………………………. 214
4.2.1 Aim of the study ………………………………………………………………………………………. 214
4.2.2 Research objectives…………………………………………………………………………………. 214
4.3 PHASES OF THE RESEARCH………………………………………………………………….. 215
4.3.1 Phase 1: Audit phase (the system)……………………………………………………………… 216
4.3.2 Phase 2: Evaluation phase (the nurse)……………………………………………………….. 217
4.3.3 Phase 3: Discussion phase (the nurse and the system)………………………………… 218
4.3.4 Phase 4: Recommendations phase (The nurse, the system and the patient)……. 219
4.4 RESEARCH QUESTIONS ………………………………………………………………………… 219
4.5 RESEARCH SETTING (THE SYSTEM)………………………………………………………. 221
4.6 RESEARCH METHODOLOGY………………………………………………………………….. 222
4.6.1 Definitions ………………………………………………………………………………………………. 222
4.6.1.1 Phase 1: Audit phase (system): a quantitative research design ………………………. 222
4.6.1.2 Phase 2: Evaluation phase (nurse): quasi-experimental quantitative research
design ……………………………………………………………………………………………………. 223
4.6.1.3 Phase 3: Qualitative research design (nurse, patient and system) …………………… 223
4.6.1.4 Phase 4: Recommendations phase (nurse, system and patient): a quantitative
research design ………………………………………………………………………………………. 224
4.6.2 Description of the concepts used in the study ………………………………………………. 224
4.6.2.1 Quantitative research……………………………………………………………………………….. 224
4.6.2.2 Qualitative research …………………………………………………………………………………. 225
4.6.2.3 Descriptive research ………………………………………………………………………………… 225
4.6.2.4 Exploratory research………………………………………………………………………………… 225

4.7 RESEARCH METHOD……………………………………………………………………………… 226
4.7.1 Definition of the term “methodology” …………………………………………………………… 226
4.7.2 Population………………………………………………………………………………………………. 226
4.7.3 Sample…………………………………………………………………………………………………… 227
4.7.4 Sampling………………………………………………………………………………………………… 227
4.8 PHASE 1: QUANTITATIVE RESEARCH DESIGN………………………………………… 228
4.8.1 Structured observational audit of the emergency trolley …………………………………. 228
4.8.1.1 Purposes of an audit ………………………………………………………………………………… 229
4.8.1.2 Data collection tools/instruments………………………………………………………………… 229
4.8.1.3 Content of the checklist for the emergency trolley …………………………………………. 230
4.8.1.4 Sample…………………………………………………………………………………………………… 230
4.8.1.5 Sampling technique………………………………………………………………………………….. 230
4.8.2 Observational audit of the hospital policies on CPR ………………………………………. 231
4.8.2.1 Sample…………………………………………………………………………………………………… 231
4.8.2.2 Sampling technique………………………………………………………………………………….. 231
4.8.2.3 Data collection instrument…………………………………………………………………………. 231
4.8.3 Observational audit of the in-service educational records ………………………………. 231
4.8.3.1 Sample…………………………………………………………………………………………………… 232
4.8.3.2 Sampling technique………………………………………………………………………………….. 232
4.8.3.3 Data collection instrument…………………………………………………………………………. 232
4.8.4 Observational audit of the death records……………………………………………………… 232
4.8.4.1 Sample…………………………………………………………………………………………………… 232
4.8.4.2 Sampling technique………………………………………………………………………………….. 233
4.8.4.3 Data collection instrument…………………………………………………………………………. 233
4.8.4.4 Inclusive criteria ………………………………………………………………………………………. 234
4.8.5 Data analysis ………………………………………………………………………………………….. 234
4.9 PHASE 2: QUANTITATIVE RESEARCH DESIGN (NURSE) ………………………….. 234
4.9.1 Investigating the CPR knowledge and skills of registered nurses…………………….. 235
4.9.1.1 Quasi-experimental research interventions ………………………………………………….. 235
4.9.1.2 Research questions …………………………………………………………………………………. 236
4.9.1.3 Study population ……………………………………………………………………………………… 236
4.9.1.4 Sample…………………………………………………………………………………………………… 236
4.9.1.5 Sampling process ……………………………………………………………………………………. 237
4.9.1.6 Selection of the required sample………………………………………………………………… 237
4.9.1.7 Sampling procedure…………………………………………………………………………………. 238

4.9.2 Inclusion and exclusive sampling criteria……………………………………………………… 239
4.9.3 Data collection techniques for phase 2………………………………………………………… 240
4.9.3.1 Data collection tools/instruments………………………………………………………………… 241
4.9.3.2 Contents of the closed-ended questionnaire for phase 2………………………………… 241
4.9.3.3 Pre-testing the instrument …………………………………………………………………………. 242
4.9.3.4 Description of the manikin………………………………………………………………………….. 243
4.9.4 Data collection method……………………………………………………………………………… 244
4.9.4.1 Data collection at hospital A………………………………………………………………………. 245
4.9.4.2 Data collection at hospital B………………………………………………………………………. 246
4.9.5 Scoring system for the performance of CPR ………………………………………………… 246
4.9.6 Data analysis ………………………………………………………………………………………….. 247
4.9.6.1 The chi-square test ………………………………………………………………………………….. 247
4.9.6.2 The McNemar test …………………………………………………………………………………… 247
4.9.6.3 The Mann-Whitney U test………………………………………………………………………….. 248
4.9.6.4 The Wilcoxon matched-pairs signed-ranks test…………………………………………….. 248
4.10 RELIABILITY AND VALIDITY IN QUANTITATIVE RESEARCH………………………. 248
4.10.1 Validity of the research design …………………………………………………………………… 249
4.10.1.1 Internal validity ………………………………………………………………………………………… 249
4.10.1.2 External validity……………………………………………………………………………………….. 249
4.10.2 Validity of the research instrument ……………………………………………………………… 250
4.10.2.1 Face validity……………………………………………………………………………………………. 250
4.10.2.2 Construct validity……………………………………………………………………………………… 250
4.10.2.3 Content validity ……………………………………………………………………………………….. 251

4.11 PHASE 3: QUALITATIVE RESEARCH DESIGN: FOCUS GROUP DISCUS-
SIONS WITH REGISTERED NURSES (SYSTEM, NURSE AND PATIENT) …….. 251

4.11.1 Research method…………………………………………………………………………………….. 251
4.11.2 Focus group discussions…………………………………………………………………………… 251
4.11.2.1 Purpose of the focus group discussions………………………………………………………. 252
4.11.2.2 Advantages and disadvantages of the focus group discussions………………………. 253
4.11.3 The population ………………………………………………………………………………………… 253
4.11.3.1 Inclusion criteria………………………………………………………………………………………. 254
4.11.3.2 Exclusion criteria……………………………………………………………………………………… 254
4.11.4 The sampling process………………………………………………………………………………. 254
4.11.4.1 Sample size ……………………………………………………………………………………………. 255

4.11.5 The setting ……………………………………………………………………………………………… 255
4.11.5.1 Homogenity of the participants…………………………………………………………………… 256
4.11.5.2 Application of the focus group interview ………………………………………………………. 256
4.11.5.3 Planning of the environment………………………………………………………………………. 256
4.11.5.4 Planning of the session…………………………………………………………………………….. 256
4.11.6 Role of the moderator ………………………………………………………………………………. 257
4.11.6.1 Moderator preparations…………………………………………………………………………….. 257
4.11.6.2 Facilitating the session……………………………………………………………………………… 258
4.11.7 Planning of the questions………………………………………………………………………….. 258
4.11.8 Data analysis ………………………………………………………………………………………….. 260
4.12 PHASE 3: QUALITATIVE RESEARCH DESIGN (SYSTEM, NURSE AND

PATIENT) ………………………………………………………………………………………………. 261
4.12.1 Semi-structured interviews with the nurse managers …………………………………….. 261
4.12.2 Sampling procedures ……………………………………………………………………………….. 261
4.12.2.1 Target population …………………………………………………………………………………….. 262
4.12.2.2 Sample size ……………………………………………………………………………………………. 262
4.12.2.3 Inclusion criteria………………………………………………………………………………………. 262
4.12.2.4 Exclusion criteria……………………………………………………………………………………… 263
4.12.3 Data collection technique for phase 3 …………………………………………………………. 263
4.12.3.1 Data collection instrument…………………………………………………………………………. 264
4.12.3.2 Conducting the interviews …………………………………………………………………………. 264
4.12.3.3 Reason for choosing the semi-structured interview method ……………………………. 264
4.12.3.4 Developement of the instrument…………………………………………………………………. 265
4.12.4 Anticipated problems during data collection and measures taken to minimise
these problems ……………………………………………………………………………………….. 266
4.12.4.1 Minimising response set biases …………………………………………………………………. 266
4.12.4.2 Minimising transient personal factors ………………………………………………………….. 267
4.12.4.3 Minimising situational contaminants ……………………………………………………………. 267
4.12.4.4 Minimising researcher’s bias ……………………………………………………………………… 267
4.12.4.5 Pre-testing of the instrument ……………………………………………………………………… 267
4.12.5 Contents of the semi-structured interview schedule for phase 4………………………. 268
4.12.6 Administration of the instrument…………………………………………………………………. 269
4.12.6.1 Familiarisation with the use of the tape recorder …………………………………………… 269
4.12.6.2 Self-introduction of the researcher and explanation of the study’s purpose ……….. 270
4.12.6.3 Timing of the interviews ……………………………………………………………………………. 270

4.12.6.4 The proces of interviewing ………………………………………………………………………… 270
4.12.6.5 The process of recording interview data………………………………………………………. 271
4.12.6.6 Note-taking during the inteviews ………………………………………………………………… 271
4.12.6.7 Tape-recording of the interviews ………………………………………………………………… 271
4.12.7 Data analysis ………………………………………………………………………………………….. 272
4.12.7.1 Transcriptions from the tape-recorded interviews………………………………………….. 272
4.13 ESTABLISHMENT OF RIGOUR IN QUALITTATIVE RESEARCH…………………… 273
4.13.1 Establishmment of trustworthiness……………………………………………………………… 274
4.13.2 Credibility (truth value) ……………………………………………………………………………… 274
4.13.3 Prolonged engagement and persistent observation ………………………………………. 275
4.13.4 Triangulation …………………………………………………………………………………………… 275
4.13.4.1 Investigator triangulation …………………………………………………………………………… 276
4.13.4.2 Data source triangulation ………………………………………………………………………….. 276
4.13.4.3 Method triangulation…………………………………………………………………………………. 277
4.13.5 External checks……………………………………………………………………………………….. 277
4.13.5.1 Peer debriefing………………………………………………………………………………………… 277
4.13.5.2 Member checks……………………………………………………………………………………….. 278
4.13.6 Dependability (consistency) ………………………………………………………………………. 278
4.13.7 Confirmability (neutrality) ………………………………………………………………………….. 278
4.13.8 Establishment of the inquiry audit……………………………………………………………….. 279
4.13.9 Transferability (applicability)………………………………………………………………………. 279
4.14 ETHICAL CONSIDERATIONS…………………………………………………………………… 281
4.14.1 Permission to conduct the study ………………………………………………………………… 281
4.14.2 Securing informed consent………………………………………………………………………… 281
4.14.3 Protection of human rights ………………………………………………………………………… 282
4.14.4 Beneficence ……………………………………………………………………………………………. 282
4.14.5 Respect………………………………………………………………………………………………….. 283
4.14.6 The right to informed consent…………………………………………………………………….. 283
4.14.7 Privacy and confidentiality…………………………………………………………………………. 283
4.14.8 The right to fair treatment………………………………………………………………………….. 284
4.14.9 Benefits………………………………………………………………………………………………….. 284
4.15 CONCLUSION………………………………………………………………………………………… 285

CHAPTER 5
DATA ANALYSIS AND DISCUSSION: THE AUDIT PHASE
5.1 INTRODUCTION …………………………………………………………………………………….. 286
5.1.1 Statement of the problem………………………………………………………………………….. 286
5.2 RESEARCH OBJECTIVES……………………………………………………………………….. 286
5.2.1 Phase 1 (Audit phase – the system)……………………………………………………………. 287
5.2.2 Phase 2 (Evaluation phase – the nurse) ……………………………………………………… 287
5.2.3 Phase 3 (Discussion phase – patient, nurse and system) ………………………………. 288
5.2.4 Phase 4 (Recommendation phase – the patient, nurse and system)………………… 288
5.3 DATA ANALYSIS…………………………………………………………………………………….. 288
5.3.1 Analysis of the data. Phase 1: Auditing of the emergency trolleys, the records,
hospital policies and procedure manuals……………………………………………………… 289
5.3.1.1 Description of the emergency trolley …………………………………………………………… 289
5.3.1.2 Auditing of the emergency trolley ……………………………………………………………….. 289
5.3.1.3 Comparison of the equipment in the emergency trolley of the ten wards in the
two referral hospitals………………………………………………………………………………… 291
5.3.1.4 Distribution of equipment for airway and breathing maintenance……………………… 293
5.3.1.5 Distribution of equipment for fluid and circulation ………………………………………….. 294
5.3.1.6 Availability of electrical and hardware equipment ………………………………………….. 296
5.3.1.7 Availability of emergency drugs………………………………………………………………….. 297
5.3.1.8 Frequency of checking the emergency trolleys……………………………………………… 298
5.3.1.9 Guidelines followed in the wards………………………………………………………………… 300
5.4 AUDITING OF IN-PATIENT DEATH RECORDS…………………………………………… 300
5.4.1 Demographic data of 508 patients who died during the years 2005 and 2006 in
the two referral hospitals …………………………………………………………………………… 301
5.4.1.1 Discussion of the findings revealed by the auditing of the death records…………… 301
5.4.1.2 Causes of death………………………………………………………………………………………. 302
5.4.1.3 Deaths recorded by shifts …………………………………………………………………………. 303
5.4.1.4 Incidences of death during weekends …………………………………………………………. 304
5.4.1.5 Cardiac compressions and defibrillations …………………………………………………….. 305
5.4.1.6 Resuscitations by a nurse, by a nurse and a doctor, and by a nurse and an
anaesthetist ……………………………………………………………………………………………. 306
5.4.1.7 Administration of drugs …………………………………………………………………………….. 307

5.5 AUDITING OF THE PROCEDURE MANUAL……………………………………………….. 308
5.6 AUDITING OF IN-SERVICE EDUCATION ON CPR IN THE WARDS ……………… 309
5.7 AUDITING OF IN-SERVICE EDUCATION RECORDS IN THE TWO

REFERRAL HOSPITALS………………………………………………………………………….. 310
5.8 APPLICATION OF THE FINDINGS OF THE AUDIT PHASE TO THE AACN
SYNERGY MODEL FOR PATIENT CARE…………………………………………………… 310
5.9 CONCLUSION………………………………………………………………………………………… 311

CHAPTER 6
DATA ANALYSIS AND DISCUSSION: PHASE 2
EVALUATION OF REGISTERED NURSES’ CPR KNOWLEDGE
AND SKILLS
6.1 INTRODUCTION …………………………………………………………………………………….. 313
6.1.1 Purpose of the study ………………………………………………………………………………… 313
6.2 DATA ANALYSIS…………………………………………………………………………………….. 314
6.2.1 Analysis of data: phase 2 (evaluation phase): quasi-experimental research
conducted with registered nurses in the two referral hospitals…………………………. 314
6.2.1.1 Demographic information about the registered nurses …………………………………… 315
6.2.1.2 Gender…………………………………………………………………………………………………… 315
6.2.1.3 Age ……………………………………………………………………………………………………….. 316
6.2.1.4 Academic qualifications…………………………………………………………………………….. 317
6.2.1.5 Experience……………………………………………………………………………………………… 318
6.2.1.6 Area of assignment ………………………………………………………………………………….. 319
6.2.1.7 Formal training in CPR……………………………………………………………………………… 320
6.2.1.8 Additional training in CPR …………………………………………………………………………. 321
6.2.1.9 Frequency of CPRs performed…………………………………………………………………… 322
6.2.1.10 Outcomes of CPRs performed by registered nurses ……………………………………… 323
6.3 DATA ANALYSIS…………………………………………………………………………………….. 324
6.4 PRESENTATION OF THE FINDINGS ………………………………………………………… 324
6.4.1 Assessment of knowledge on CPR among the registered nurses in the two
referral hospitals ……………………………………………………………………………………… 325
6.4.2 Presentation of the pre-test, post-test and re-test scores ……………………………….. 325

6.4.3 Comparison of the scores of pre-test, post-test and re-test assessments of

CPR knowledge ………………………………………………………………………………………. 326
6.4.4 Scores on test of knowledge before training (pre-test) …………………………………… 330
6.4.5 Scores on test of knowledge administered after the training session (post-test)…. 331
6.4.6 Scores on test of knowledge administered three months after the training

session (re-test) ………………………………………………………………………………………. 332

6.4.7 Graphical displays: presentation of responses to individual questions on

knowledge about CPR ……………………………………………………………………………… 332
6.4.8 Statistical significance of CPR cognitive knowledge tests ………………………………. 342
6.4.8.1 Comparison of the respondents’ knowledge scores from the two referral

hospitals…………………………………………………………………………………………………. 343
6.4.8.2 A comparison of knowledge scores in terms of the respondents’ gender ………….. 344
6.4.8.3 A comparison of scores on knowledge in terms of respondents’ ages………………. 345
6.4.8.4 A comparison of knowledge in terms of the respondents’ years of experience…… 346
6.4.9 The significance of differences when comparing the respondents’ CPR

knowledge scores in terms of age, gender and experience …………………………… 347
6.5 THE SKILLS TEST…………………………………………………………………………………… 347
6.5.1 Assessment of the CPR skills of registered nurses ……………………………………….. 347
6.5.2 Statistical significance of assessment of tests on CPR skills …………………………… 351
6.5.2.1 Statistical significance of results for the 70 participants who completed all three
tests ………………………………………………………………………………………………………. 352
6.5.2.2 Penalty scores obtained in the test on CPR skills before training (pre-test)……….. 353
6.5.2.3 Penalty scores obtained in the test on CPR skills after training (post-test) ………… 355
6.5.2.4 Penalty scores obtained in the test on CPR skills three months after training
(re-test) ………………………………………………………………………………………………….. 356
6.5.3 Graphical displays: presentation of scores obtained for various CPR skills in the
pre-test, post-test and re-test …………………………………………………………………….. 357
6.6 DISCUSSION OF THE FINDINGS……………………………………………………………… 369
6.6.1 Acquisition and retention of cognitive knowledge of CPR……………………………….. 369
6.6.2 Acquisition and retention of CPR psychomotor skills……………………………………… 370
6.6.3 A comparison of CPR skill scores obtained by the participants from the two
referral hospitals ……………………………………………………………………………………… 371
6.6.3.1 A comparison of CPR skill scores in terms of gender…………………………………….. 372
6.6.3.2 A comparison of CPR skill scores in terms respondents’ ages ………………………… 373
6.6.3.3 A comparison of CPR skill in terms of respondents’ years of experience ………….. 374

6.7 SUMMARY OF THE DATA ANALYSIS OF THE QUASI-EXPERIMENTAL
RESEARCH CONDUCTED AMONG REGISTERED NURSES IN THE
TWO REFERRAL HOSPITALS………………………………………………………………….. 375
6.7.1 Demographic characteristics of the respondents…………………………………………… 375
6.7.2 Knowledge about CPR……………………………………………………………………………… 375
6.7.3 CPR skills ………………………………………………………………………………………………. 376
6.7.4 Statistical interpretation of the CPR knowledge and skills of the respondents ……. 376
6.8 APPLICATION OF THE FINDINGS OF THE EVALUATION PHASE TO THE
AACN SYNERGY MODEL FOR PATIENT CARE…………………………………………. 377
6.9 CONCLUSION………………………………………………………………………………………… 378

CHAPTER 7
ANALYSIS AND DISCUSSION OF QUALITATIVE DATA: FOCUS
GROUP DISCUSSIONS (A) AND SEMI-STRUCTURED INTERVIEWS (B)
7.A.1 INTRODUCTION …………………………………………………………………………………….. 380
7.A.2 THE PURPOSE OF PHASE 3-A OF THE STUDY………………………………………… 380
7.A.3 THE PROFILE OF THE PARTICIPANTS…………………………………………………….. 381
7.A.3.1 Demographic characteristics of the participants ……………………………………………. 382
7.A.4 PRESENTATION OF THE QUESTIONS …………………………………………………….. 382
7.A.5 DATA ANALYSIS FOR PHASE 3-A OF THE STUDY ……………………………………. 384
7.A.5.1 Organising and cleaning the data……………………………………………………………….. 384
7.A.5.2 Data analysis ………………………………………………………………………………………….. 385
7.A.6 PRESENTATION OF THEMES, CATEGORIES AND CODING SYSTEM ………… 386
7.A.6.1 The lack of organisational and systemic support, and of the resources in the
healthcare system……………………………………………………………………………………. 386
7.A.6.1.1 Verbatim evidence from the focus group discussions – 1……………………………….. 387
7.A.6.2 Perceived lack of competence and readiness to perform CPR………………………… 390
7.A.6.2.1 Verbatim evidence from the focus group discussions – 2……………………………….. 390
7.A.6.3 The stress and ethical dilemmas generated by CPR associated with the

end-of-life experiences as a feature of the performance of CPR ……………………… 394
7.A.6.3.1 Verbatim evidence from the focus group discussions – 3a……………………………… 395
7.A.6.4 Perceived need for training, and the influence of education and professional
development on the performance of CPR ……………………………………………………. 401

7.A.6.4.1 Verbatim evidence from the focus group discussions – 3b……………………………… 401
7.A.7 DISCUSSION OF THE RESULTS OF FOCUS GROUP DISCUSSIONS

(PHASE 3-A)…………………………………………………………………………………………… 403
7.A.8 APPLICATION OF THE FINDINGS OF THE FOCUS GROUP DISCUSSION TO
THE AACN SYNERGY MODEL FOR PATIENT CARE………………………………….. 404
7.A.9 SUMMARY OF THE FINDINGS OF PHASE 3-A ………………………………………….. 405
7.B DISCUSSION PHASE – PHASE 3-B ………………………………………………………….. 406
7.B.1 Discussion of data analysis of the semi-structured qualitative interviews

conducted with nurse managers from the two referral hospitals ………………………. 406
7.B.2 PURPOSE OF PHASE 3-B OF THE STUDY……………………………………………….. 406
7.B.2.1 Demographic information about the participants ………………………………………….. 407
7.B.2.2 Information about the CPR perceptions, barriers and needs among registered
nurses from the nurse managers’ perspectives…………………………………………….. 407
7.B.2.3 Sample size ……………………………………………………………………………………………. 408
7.B.3 DATA ANALYSIS FOR PHASE 3-B OF THE STUDY ……………………………………. 408
7.B.3.1 Quantitative data analysis for phase 3-B……………………………………………………… 408
7.B.3.2 Demographic data of the participants………………………………………………………….. 408
7.B.3.3 Structure of the questionnaire ……………………………………………………………………. 411
7.B.3.4 Qualitative data analysis for phase 3-B……………………………………………………….. 418
7.B.4 DATA STRUCTURE: THEMES AND CATEGORIES …………………………………….. 418
7.B.5 THEME 1: ORGANISATIONAL FACTORS THAT INFLUENCE THE
PERFORMANCE OF REGISTERED NURSES AND NURSE MANAGERS
WHEN THEY PERFORM CPRs…………………………………………………………………. 419
7.B.5.1 Category 1.1: Human resources…………………………………………………………………. 420
7.B.5.2 Category 1.2: Absence of in-service education …………………………………………….. 422
7.B.5.3 Category 1.3: The lack of a resuscitation team……………………………………………… 424
7.B.5.4 Category 1.4: Policies and standards………………………………………………………….. 425
7.B.5.5 Category 1.5: Lack of mandatory CPR training …………………………………………….. 428
7.B.5.6 Category 1.6: Lack of policy on “Do Not Attempt Resuscitation” (DNAR) ………….. 429
7.B.5.7 Category 1.7: Ethical conflicts (different opinions about resuscitating

HIV/AIDS patients)…………………………………………………………………………………… 431
7.B.6 THEME 2: FACTORS LIMITING THE PERFORMANCE OF REGISTERED
NURSES AND NURSE MANAGERS DURING THE PROVISION OF CPR
SERVICES……………………………………………………………………………………………… 432

7.B.6.1 Category 2.1: Lack of CPR knowledge and skills among nurses, nurse managers
and doctors …………………………………………………………………………………………….. 433
7.B.6.2 Category 2.2: Lack of available equipment and drugs……………………………………. 434
7.B.6.3 Category 2.3: Inconsistent practices …………………………………………………………… 436
7.B.6.4 Category 2.4: Lack of confidence/feelings of inadequacy……………………………….. 437
7.B.6.5 Category 2.5: Stress caused by overwhelming workloads………………………………. 439
7.B.6.6 Category 2.6: Lack of incentives ………………………………………………………………… 440
7.B.6.7 Category 2.7: Lack of guidelines ………………………………………………………………… 441
7.B.6.8 Category 2.8: Attitude of the doctors …………………………………………………………… 442
7.B.6.9 Category 2.9: Communication barriers………………………………………………………… 443
7.B.6.10 Category 2.10: Lack of adequate space in hospital wards………………………………. 444
7.B.7 THEME 3: TRAINING AND DEVELOPMENT NEEDS OF THE REGISTERED
NURSES AND THE NURSE MANAGERS…………………………………………………… 445
7.B.7.1 Category 3.1: The role of Botswana’s Nursing and Midwifery Council………………. 445
7.B.7.2 Category 3.2: Annual mandatory CPR certification ……………………………………….. 447
7.B.7.3 Category 3.3: Continuous professional development …………………………………….. 448
7.B.7.4 Category 3.4: Debriefing after participation in CPR ……………………………………….. 450
7.B.7.5 Category 3.5: Computer-based learning………………………………………………………. 452
7.B.7.6 Category 3.6: Simulation…………………………………………………………………………… 453
7.A.8 SUMMARY OF THE FINDINGS OF PHASE 3-B ………………………………………….. 455
7.B.9 APPLICATION OF THE FINDINGS OF THE SEMI-STRUCTURED INTERVIEW
TO THE AACN SYNERGY MODEL FOR PATIENT CARE…………………………….. 458
7.B.10 CONCLUSION………………………………………………………………………………………… 459

CHAPTER 8
CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS OF THE
STUDY ACCORDING TO THE SYNERGY MODEL FOR PATIENT CARE
8.1 INTRODUCTION …………………………………………………………………………………….. 460
8.2 CONCLUSIONS AND RECOMMENDATIONS FOR AUDIT PHASE

(PHASE 1: SYSTEM)………………………………………………………………………………. 460
8.2.1 The objectives of the audit phase (phase 1) of the study (system) …………………… 461
8.2.2 Auditing of the emergency trolleys ……………………………………………………………… 462
8.2.3 Auditing of the death records …………………………………………………………………….. 464

8.2.4 Auditing of the procedure manual……………………………………………………………….. 466
8.2.4.1 Proposed procedure manual for CPR …………………………………………………………. 466
8.2.5 Auditing the in-service records …………………………………………………………………… 467
8.3 CONCLUSIONS AND RECOMMENDATIONS FOR DISCUSSIONS PHASE
(PHASE 3: SYSTEM)……………………………………………………………………………….. 468
8.3.1 The objectives of phase 3 of the study (system) …………………………………………… 468
8.4 THEME 1: ORGANISATIONAL FACTORS THAT INFLUENCE THE
PERFORMANCE OF REGISTERED NURSES AND NURSE MANAGERS IN
THE PROVISION OF CPR………………………………………………………………………… 468
8.4.1 Category 1.1: Human resources…………………………………………………………………. 468
8.4.2 Category 1.2: An absence of in-service education ………………………………………… 469
8.4.3 Category 1.3: The absence of a resuscitation team……………………………………….. 470
8.4.4 Category 1.4: Policies and standards………………………………………………………….. 471
8.4.5 Category 1.5: Lack of mandatory training…………………………………………………….. 472
8.4.6 Category 1.6: The absence of a “Do Not Attempt resuscitation” policy……………… 473
8.4.7 Category 1.7: Ethical conflicts (different opinions about resuscitating HIV/AIDS
clients) …………………………………………………………………………………………………… 474
8.5 THEME 2: FACTORS THAT LIMIT THE PERFORMANCE OF REGISTERED
NURSES AND NURSE MANAGERS DURING THE PROVISION OF CPR
SERVICES……………………………………………………………………………………………… 475
8.5.1 Category 2.1: Lack of knowledge and skills among nurses, nurse managers
and doctors …………………………………………………………………………………………….. 475
8.5.2 Category 2.2: Lack of availability of equipment and drugs………………………………. 475
8.5.3 Category 2.3: Inconsistent practice …………………………………………………………….. 476
8.5.4 Category 2.4: Lack of confidence/feelings of inadequacy……………………………….. 477
8.5.5 Category 2.5: Stress caused by overwhelming workloads………………………………. 477
8.5.6 Category 2.6: Lack of incentives ………………………………………………………………… 478
8.5.7 Category 2.7: Lack of guidelines ………………………………………………………………… 479
8.5.8 Category 2.8: Attitude of the doctors …………………………………………………………… 479
8.5.9 Category 2.9: Communication barriers………………………………………………………… 480
8.5.10 Category 2.10: Lack of adequate space in hospital wards………………………………. 481
8.6 THEME 3: TRAINING AND DEVELOPMENT NEEDS OF THE REGISTERED
NURSES AND THE NURSE MANAGERS…………………………………………………… 482
8.6.1 Category 3.1: Role of the nursing council…………………………………………………….. 482
8.6.2 Category 3.2: Annual mandatory certification……………………………………………….. 482

8.6.3 Category 3.3: Continuous professional development …………………………………….. 483
8.6.4 Category 3.4: Debriefing …………………………………………………………………………… 484
8.6.5 Category 3.5: Computer learning ……………………………………………………………….. 485
8.6.6 Category 3.6: Simulation…………………………………………………………………………… 485
8.7 CONCLUSIONS AND RECOMMENDATIONS FOR THE EVALUATION PHASE
AND THE DISCUSSION PHASE (THE NURSE) ………………………………………….. 486
8.7.1 The objectives of the evaluation phase of the study (phase 2: nurse) ………………. 486
8.7.2 Background information about the participants……………………………………………… 487
8.7.3 Findings, conclusions and recommendations for evaluation phase (phase 2:
the nurse)……………………………………………………………………………………………….. 487
8.8 CONCLUSIONS AND RECOMMENDATIONS FOR THE DISCUSSION PHASE
(PHASE 3: THE NURSE)………………………………………………………………………….. 490
8.8.1 The objectives of the discussion phase (phase 3: the nurse) ………………………….. 491
8.8.2 Background information of the participants ………………………………………………….. 491
8.8.3 Findings, conclusions and recommendations for discussion phase (phase 3:
the nurse)……………………………………………………………………………………………….. 491
8.9 RECOMMENDATIONS TO IMPROVE LEVELS OF PATIENT CARE BEFORE,
DURING AND AFTER CPR ………………………………………………………………………. 494
8.9.1 Cardio-pulmonary arrest prevention ……………………………………………………………. 494
8.10 LIMITATIONS OF THE RESEARCH…………………………………………………………… 496
8.11 RECOMMENDATIONS FOR FURTHER RESEARCH …………………………………… 497
8.12 FINAL CONCLUSIONS…………………………………………………………………………….. 497

BIBLIOGRAPHY……………………………………………………………………………………………………… 501

……………………………………………………………………………………………………………………………………………………………………………………………………………………

 

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