To answer the third research question, the list of job independence levels is identified by 129 nursing activities. The scale that is used to measure the job independence levels has a range from the completely dependent to the completely independent level and we divide this range into 5 levels of Likert scale.
Generally, 73 nursing activities are identified to be completely independent and they are listed in the first rows in Table 4.1 e.g., blood pressure check, pulse check, respiratory sound measurement, naso-oral suction, tracheal suction, nursing procedure r/t T-cannula exchange, nursing procedure r/t intubation, nasal prong, O2 mask apply, observation &
maintenance of respirator, body weight measurement, body height measurement, blood sugar level measurement, I/O measurement, total feeding assistance, nursing procedure r/t nasogastric tube inserting, tube feeding, tube feeding & observation via gastrostomy, cleansing enema, retention enema, gas enema, simple catheterization, bladder irrigation, diaper change & skin care, urine specific gravity measurement, thoracic drainage maintenance, bililary drainage maintenance, gastric drainage maintenance, position change using Stryker, assistance on prosthesis use, assistance on crutch use, transfer of patient using
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wheelchair, transfer of patient using stretcher, body temperature measurement, hot & cold pack apply, application of hot & cold regulator, nursing procedure r/t diversion & relaxation, walk accompany, bed bathing and physiotherapy et.al.
Besides their complete independence, a nursing activity still contributes to somewhat dependence by consulting the patient, which was recorded by a nurse.
According to the different job independence levels, the 4th level of the Likert scale is somewhat independent. There are few responses by nurses on 40 nursing activities e.g., respiratory rate measurement, respiratory pattern measurement, postural drainage, humidifies apply, partial feeding assistance, blood sampling, glycerin enema, encourage skin care, stool sampling, bladder training, assistance of bed span use urine sampling, hemo-vac & drainage maintenance, sputum sampling, 24 hour time sampling, simple position change, position change circle bed, exercise & position change, simple assistance on exercise, passive ROM exercise, assistance of mobility disturbance patient, encourage sleep, encourage rest, accomplish encourage, recreation instruction, total change of sheet, partial change of sheet, clothes change, complex dressing, nursing procedure r/t partial restraint, consciousness check, monitoring, family support of terminal patient, intramuscular injection, transfusion, coordination & consulting, assisting (radiographer, endoscopy), documentation of patient care, documentation of ward management and order checking.
There are 15 nursing activities identified as of level 3 of the job independence scale and this level is neutral independent. The nursing activities under 3rd level are CVP measurement, personal education, nursing procedure r/t TPN infusion, nursing procedure r/t indwelling catheterization, nursing procedure r/t indwelling catheterization, nursing procedure for prevention contracture, nursing procedure r/t skin traction, nursing procedure r/t skeletal traction, humidity regulation, simple dressing, admission interview, personal education, oral medication, general intravenous infusion, assisting doctors on a ward round, assisting doctors with technical procedures, handing over to nurses on next shift and medication management.
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Table 9The Identification the Job Independence Level of Each Nursing Activity
Nursing activity Minimum Maximum
Blood pressure check 5 5
Pulse check 5 5
Respiratory sound measurement 5 5
Physiotherapy 5 5
Naso-oral suction 5 5
Tracheal suction 5 5
Nursing procedure r/t T-cannula exchange 5 5
Nursing procedure r/t intubation 5 5
Nasal prong, O2 mask apply 5 5
Observation & maintenance of respirator 5 5
Body weight measurement 5 5
Body height measurement 5 5
Blood sugar level measurement 5 5
I/O measurement 5 5
Total feeding assistance 5 5
Nursing procedure r/t nasogastric tube inserting 5 5
Tube feeding 5 5
Tube feeding & observation via gastrostomy 5 5
Cleansing enema 5 5
Retention enema 5 5
Gas enema 5 5
Simple catheterization 5 5
Bladder irrigation 5 5
Diaper change & skin care 5 5
Urine specific gravity measurement 5 5
Thoracic drainage maintenance 5 5
Bililary drainage maintenance 5 5
Gastric drainage maintenance 5 5
Drainage fluid sampling 5 5
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Position change using Stryker 5 5
Assistance on prosthesis use 5 5
Assistance on crutch use 5 5
Transfer of patient using wheelchair 5 5
Transfer of patient using stretcher 5 5
Body temperature measurement 5 5
Hot & cold pack apply 5 5
Application of hot & cold regulator 5 5
Nursing procedure r/t diversion & relaxation 5 5
Walk accompany 5 5
Bed bathing 5 5
Shaving 5 5
Nail cavity cleansing 5 5
Perinea nursing 5 5
Sits bath 5 5
Complete isolation for infection prevention 5 5
Partial isolation for infection prevention 5 5
Skin massage for bed sore prevention 5 5
Opiod & poison check 5 5
Close observation for suicide prevention 5 5
Nursing procedure for fall down prevention 5 5
Isolation & close observation 5 5
Observation & check for fire prevention 5 5
CVP check 5 5
Sputum sampling 4 5
24 hour time sampling 4 5
Simple position change 4 5
Position change circle bed 4 5
Exercise & position change 4 5
Simple assistance on exercise 4 5
Passive ROM exercise 4 5
Assistance of mobility disturbance patient 4 5
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Encourage sleep 4 5
Encourage rest 4 5
Accomplish encourage 4 5
Recreation instruction 4 5
Total change of sheet 4 5
Partial change of sheet 4 5
Clothes change 4 5
Complex dressing 4 5
Nursing procedure r/t partial restraint 4 5
Consciousness check 4 5
Monitoring 4 5
Family support of terminal patient 4 5
Intramuscular injection 4 5
Transfusion 4 5
Coordination & consulting 4 5
Assisting (radiographer, endoscopy,) 4 5
Documentation of patient care 4 5
Documentation of ward management 4 5
Order checking 4 5
CVP measurement 3 5
Nursing procedure r/t TPN infusion 3 5
NA r/t indwelling catheterization 3 5
Nursing procedure for prevention contracture 3 5
Nursing procedure r/t skin traction 3 5
Nursing procedure r/t skeletal traction 3 5
Humidity regulation 3 5
Simple dressing 3 5
Admission interview 3 5
Personal education 3 5
Oral medication 3 5
General intravenous infusion 3 5
Assisting doctors on a ward round 3 5
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Assisting doctors with technical procedures 3 5
Handing over to nurses on next shift 3 5
Medication management 3 5
Counseling 2 5
Note: 5, completely independent; 4, somewhat independent; 3, neural independent; 2, somewhat dependent; 1, completely dependent
In summary, the above scales of both medical and surgical nursing units show that there are 73 nursing activities that are identified to be completely independent, the 40 nursing activities are measured as level 4 are somewhat independent, the 15 nursing activities of level 3 are neutral independent and 1 nursing activity of level 2 is somewhat dependent.
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Chapter 5Discussion and Conclusion
This chapter contains the summary of findings and discussion of the study, including the limitations of the study. It also examines the implications for practice by Vietnamese nurses.
Summary of Findings and Discussion
The study found in the first research question showed that the Vietnamese nurses performed 129 nursing activities for the patient care which were categorized into 11 direct nursing domains and 3 indirect nursing domains. Similarly, the Park and Song (2000) identified 135 nursing activities at general medical and surgical nursing unit which were categorized into 10 direct nursing domains and 2 indirect nursing domains. In this study, communication nursing domain is described for direct nursing activities, whereas Park and Song (2000) study, communication nursing domain was described for indirect nursing activities.
The surgical nurses perform 9 among 123 nursing activities that are different from the 6 among 120 nursing activities that were performed by medical nurses. For example, those 9 nursing activities perform by the surgical nurses are cleansing enema, glycerin enema, thoracic drainage maintenance, bililary drainage maintenance and hemo-vas and drainage maintenance, whereas those 6 nursing activities perform by the medical nurses are T-cannula exchange, tube feeding via gastrostomy and partial restraint. This difference in the nursing activities between the two units is due to the small sample and a short time of two weeks to conduct this study. Therefore, this result cannot be generalized for medical and surgical nursing units in Vietnam.
The findings from the second research question are described according to the time and frequency for the each nursing activity at medical and surgical nursing units. Then, this data is analyzed for both direct and indirect nursing areas.
Generally, the nursing activities that are performed at the both units with high frequency are respiration management, blood pressure check, pulse check, monitoring and documentation of patient records. These results are similar to those of Barry-walker,
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Bulechek and MeCloskey (1994), who found that the high ratio of the time of medical-surgical nursing was spend in oxygen therapy and vital signs monitoring.
In my study, the nursing time of each nursing activity shows the difference in nursing time between Vietnamese nurses and Korean nurses. This difference in nursing time is explained by Bloom (1997) study where he argues that the nursing time of each activity varies from nurse to nurse and depends mostly on the practitioner’s skill, knowledge and clinical experience. For example, the nursing activities performed by Vietnamese nurses and Korean nurses are almost 119 and 72 respectively that take less than 10 minutes, 9 and 51 respectively that take from 10 to 21 minutes and 1 and 13 respectively that take more than 21 minutes.
The spiritual support nursing activity consists of admission interview, counseling, personal education, group education and religious support. The above study highlights the fact that the time of spiritual support nursing activity is very less in Vietnam. The Vietnamese nurses spend just 2 to 5 minutes for admission interview and 3 to 8 minutes for counseling whereas; the Korean nurses take more time like 16 to 18 minutes for admission interview and 16 to 18 minutes for counseling. The reason why Korean nursing spends more time on spiritual support is because they have developed Advanced Nursing Practice (APN).
Moreover, much of management and document recording nursing activities are computerized, thus providing much free time to a Korean nurse to focus on direct nursing activities.
In Vietnam, the new nursing license is going to be issued in January 2011 in which the patient counseling and education nursing activity is of much importance. Therefore, the hospitals in Vietnam should focus on training the nurses and do time management in order to perform patient counseling and education nursing activity.
Vietnamese nurses having more educational preparation can save more time to do the above mentioned activities. The more educated and the more experienced nurses perform psychosocial activities more often, while less educated and less experienced nurses perform physiological activities more often (Young, 1995).
The challenge for the leaders at the two Vietnamese hospitals is how to improve the quality of caring and motivate the nurses to perform psychosocial activities when almost
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80% of the nurses are diploma holders and around 80% of the nurses have less than 10 years of experience.
The solution based on this evidence based research is to build a training program which should focus more on psychosocial interventions to the nurses where the nurses should be persuaded to go for higher studies so that they can give better spiritual support and they can obtain a license of professional nursing.
Also, the findings from the third research question show that the percentage of communication, which involves coordination and consulting between medical personal and coordination & consulting between units, is very low with just 3.45% at medical and 2.72%
at surgical nursing units for the day shift. While, Williams at el. (2009) reported 11.1% for direct communication by England nurses at Neuro-rehabilitation unit. The Bagian et al.
(2010) reported the better communication improves teamwork and lack of communication can lead to mistakes.
My study also shows that the direct nursing time is higher than the indirect nursing time at medical and surgical nursing units. Almost 68.61% and 70.82% of the time spend for direct nursing care in the day shift and night shift respectively at the medical nursing unit.
Moreover, 31.39% and 29.19% of the time spend for indirect nursing care in the day shift and night shift respectively at the medical nursing unit.
Similarly, McCloskey et al. (1996) findings show that 55% of the time is spend for direct nursing activities while 45% of the time is spend for direct nursing activities.
However, Hendrickson et al. (1990) in a work sampling study also found that nurses on average time spend only 31% of the time for direct nursing care, and 45% of the time for indirect nursing care, remaining time of nurses is spend for non-clinical purposes.
The study results showed that the nursing time for direct care is higher at medical nursing unit than surgical nursing unit for both day shift and night shift. However, the indirect nursing time at surgical nursing unit is higher than medical nursing unit for both day shift and night shift.
The reason why the indirect time for surgical nursing is higher than the medical nursing is because the time spend for recording by surgical nurses is twice as much as time spends for recording by the medical nurse. For example, the nurses at both of the units take care of different number of patients e.g., 10 to 15 patients per nurse at the surgical unit and
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usually 5 to 9 patients per nurse at the medical unit. With the greater number of patients, the nurses need to spend more time for recording documents. Also, the length of the stay of patients at the surgical unit is from 1 to 7 days, whereas it is about 2 to 15 days in medical unit. The patient for surgical unit stays in for surgical preparation and after surgery they stay till the stability of their health condition. So, the number of the discharged patients at surgical unit is always higher than medical unit. After the patient is discharged, the nurse who took care of this discharged patient must spend at least 30 minutes to complete and transfer the document records of the patient. Therefore, the surgical nursing spends a lot of time on recording documents as number of discharged patients is high. This results in an increase of indirect time for surgical nursing.
The Harless (2003) showed that direct nursing activities are used to build the cost for nursing service. In some of the developed countries, where the nursing is considered as a profession, their research showed that medical nursing unit spends more of their time for direct care rather than the surgical nursing unit. This is the reason why the medical nursing cost is higher than surgical nursing unit (Park and Song, 1989).
On the other hand, the Vietnamese nurses at the medical nursing unit have lower nursing cost than surgical nursing unit. This is the opposite of the ideal case where the medical nursing has high nursing cost because of high direct time (reason already mentioned above). But in Vietnam, the nursing cost of the medical nursing unit is not relevant with their nursing services and it needs to be controlled by the leaders.
We can see the difference of the total nursing time during a shift is significant among day shift and night shift; acuity levels and units. According to Park and Song (2002) showed that the nursing time at operating room is different depending upon the acuity levels e.g., 4.02 hours is the nursing time needed to take for acuity I; 7.32 nursing hours is the nursing time needed to take for acuity II.
Another study on nursing time was conducted by Song (1990) which reported that 3.9 hours and 5.4 hours of nursing time are spend for acuity I and acuity II respectively, which were performed by Korean nurses at general medical nursing units. Almost 3.2 hours and 4.5 hours of nursing time are spend for acuity I and acuity II respectively, which were performed by Korean nurses at general surgical nursing units.
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In Vietnam, Thuan (2001) showed 1.5 hours for direct nursing activities and 0.5 hour for indirect nursing activities at the surgical nursing unit for acuity I in Cho Ray hospital.
However, my study gives a better understanding of nursing time for acuity I and II calculated by each nursing activity at general medical and surgical nursing units. Moreover, the nursing activities that were used for this research could well identify the nursing cost as done by Song (2000). But in Thuan (2001) reported there are nursing activities were removed because the study was not clear enough to classify nursing activities in order to build the nursing cost. Our study also used a sufficiently large sample.
For countries with less developed economy, lack of the high-technology environment e.g., modern equipment to monitor and support to nurses is a matter of increasing pressure and demands more nursing working hours. The above results reflect the current status of nurses in Vietnam, where the work of nursing is not completely independent. The Vietnamese nurses mostly utilize their time to fulfill the orders of medical doctors, so they don’t have the time to update their knowledge and consult the patients.
According to the fourth research question, counseling is somewhat dependent. In Vietnam, the nurse who performs counseling is mostly a new nurse with 3 months of experience after she receives her diploma. In reality, the nurse who has less education and clinical experience will have low independence level. Those nurses are not confident enough to perform patient counseling and education. The Williams (2009) has shown that the job independence level depends on the education levels, year of the clinical experience and the nurses themselves.
In 2011, the nursing license is going to enforce and demand the nurses to take more care of the patients; otherwise the patient has the right to sue the hospital. So, the nursing should be improved and update their knowledge by themselves regularly to correspond to the patient needs.
Limitations of the Study
A convenient sample from two hospitals was used for the research and almost all the subjects were collected from the day shift (90.5%) and (9.5%) for the night shift. The sample of night shift in this study is not the current representation for the night shift at medical and
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surgical nursing units in Vietnam. This is because the Vietnamese nurses work four times more during the day shift than the night shift. Moreover, for countries with less developed economy, lack of the high-technology is a matter of increasing pressure and demands that the nurses should work more during the day shift. The nursing activities like medicine nursing and administrative management nursing during the day shift were excluded due to their non-involvement in patient care. In short, this study has one drawback related to the number of surveys where the ratio of the day and night shift is not balanced.
Language barriers for translation from English to Vietnamese were carefully addressed. The Vietnamese nurses encountered few difficulties answering the questionnaires because the original question was in English.
In addition, the method of this research is self-reported. The participants have to memorize the time of each nursing activity which they performed during a shift. So, the participant could not recall the exact time of their activities.
Conclusion
With the continued emphasis on studying costs of nursing services, quality of care, and knowledge development, it is apparent that the identification of nursing interventions is an initial step. This study has identified the nursing activities used by nurses in Vietnam. The findings are numerous, interesting, and valuable. The study analyzed the nursing current situation in Vietnam; where much time is spend for recording nursing activities and it needs to be controlled. The study also shows that the total time for direct nursing is higher in medical nursing unit than surgical nursing unit. However, the medical nursing received less nursing costs as compared to surgical nursing, which are not relevant with their nursing services and needs to be controlled by the leaders. Also, the study highlights the fact that the percentage of spiritual support activity is very less, where it is one of the main nursing functionality and it will be reformed in January 2011 to make new issue on nursing. In short, this nursing domain needs to be improved through proper nursing education.