REPORT : EXPERIENCE OF BLACK PATIENTS IN A CRITICAL CARE UNIT IN A HOSPITAL IN PIETERMARITZBURG .

The conceptual framework was based on Henderson’s (1966) Model for Nursing; the mode of nursing intervention is that of assisting the patient in performing activities that he would perform unaided if he had the necessary strength, will or knowledge. Such framework reinforces the fact that the critically ill patient in the CCU , req u ir in g so p h is tic a te d , technological support has been, until hospital admission, a whole, complete and independent being.


MOTIVATION FOR STUDY
At the time of this study, the researcher was working as the matron in charge of the Critical Care Units (CCU) of a large hospital in Edendale, Pietermaritzburg. She was aware of an abundance of literature on the C.C.U. environment and its effect on both staff and patients in o v e rse a s w ork b u t fo u n d n o th in g documenting reactions of South African black patients to their C.C.U. experience.
There are 8 critical care units in the hospital each of which cater for separate specialised fields such as surgical, medical, obstetric, paediatric etc.
At the time of study, Edendale was the centre of marked violence and social unrest, the hospital had to cope with escalating numbers of seriously injured people and only patients gravely ill were admitted to the CCUs.
Analysis of the CCU m ale surgical patient population for the month of March 1990 showed a total of 25 men admitted whose mean age was 38 years (range 16-70 years). The mean length of stay was 6,8 days and 20,8% of the patients died. Of the 25 patients, 12 were in CCU as a result of either gunshot or stab wounds.
The 33 female patients admitted to the medical CCU during the same month had a mean age of 35,6 years (range 12-70), a mean length of stay of 3 days and 24% of the women died.

OBJECTIVE
The objective of the study specifically was to gain knowledge and understanding of patients' experience of admission to a C.C.U. in the hospital. The researcher believes that such understanding should help the nurse give patient care to aid recovery as soon as possible.
The conceptual framework was based on Henderson's (1966) Model for Nursing; the mode of nursing intervention is that of assisting the patient in performing activities that he would perform unaided if he had the necessary strength, will or knowledge. Such framework reinforces the fact that the critically ill patient in the C C U , r e q u irin g s o p h is tic a te d , technological support has been, until hospital admission, a whole, complete and independent being.
The research design was a descriptive e x p lo ra to ry survey u sin g a semi-structured interview schedule. All interviews were carried out by the researcher. Data gathered were mainly of a qualitative nature.
The sample was one of convenience composed of 19 well-oriented adults and two 12-year old c h ild re n .
A ll respondents had been nursed in either the surgical or medical CCU for more than 24 hours. All p a tie n ts w ere Zulu-speaking, as is the researcher and Zulu was the m edium used for all interview s. Some interview s w ere carried out within the CCU and others conducted in the ward shortly after transfer from the CCU. This sample was not representative of the total population of CCU patients. A random sample stratified for important variables such as age, sex, educational level etc would allow g en eralisatio n but w ould be im p o ssib le to a ch iev e w ith in th e researcher's constraints. It is beUeved, nevertheless, that this small convenience sa m p le d o e s h e lp th e n u r s e s ' understanding of the black patients' perceptions of his stay in CCU.
Eleven women, 8 men and two 12-year boys w ere in te rv ie w e d .
F o u r interviewees were registered nurses. Sixteen resp o n d en ts had had little schooling and 4 with no schooling were illiterate. The nurses were the only group which could be thought of as professional but only two patien ts (b o th young women) were unemployed. The age range was 12-70 years with a median of 40 years.
Individual interviews took 2-4 hours to complete. Specific demographic details and the patients' previous experience of hospitalisation were covered. Patients were then asked to expand on their perceptions of com m unication with nurses, doctors and physiotherapists, opinion on noise in the unit, visitors, theufeelings about specific nursing and physiotherapy treatm ents and their general impressions in the CCU.
The basis of the study rests in qualitative data and it is important to realise that qualitative standards of reUability and validity are inappropriate in qualitative work; the research instrument was the re se a rc h e r herself and dep en d ab le fin d in g s rely on h e r a b ility as an in te rv ie w e r and on h er individual reference frame for nursing. Leininger (1985) argues that validity in qualitative research refers to gaining knowledge and understanding of the nature, meaning and characteristics of the phenomenon under study.
As a result of this study, the researcher has found careful, detailed interviews with patients about their experiences as CCU patients helpful in 'opening her eyes' to the patients' worlds. These interviews have been so enlightening for her that she recommends that all CCU nurses, especially nursing students of the discipline, engage in at least some similar interviews. Such interviews which focus solely on the personal viewpoint of the patient are quite different from the nursing care studies ordinarily carried out by students.

FINDINGS
The researcher was impressed by the sensitivity and understanding of the patients who mostly made a point of m entioning to her the hard work of n u rs e s . I n d e e d , so m e p a tie n ts consciously tried not to add to the nurses' burden by withholding information. The two 12-year old boys were critical of the nurses, but yet showed great tolerance and understanding of nurses' work and their responsibility for patients perceived as more critically ill than they were themselves.
All patients showed acceptance of their situation and appreciation of care given to them.
Patients took for granted that disturbing factors such as noises, telephone rings and bright lights were beyond the control of the nurses and w ithheld adverse comment, although they had mostly been disturbed and worried by them.
The ventilators caused most irritation and only one patient did not mention these m a c h in e s as a s o u rc e of disturbance. Six patients specifically mentioned the different rhythms at which ventilators were set and the following comments illustrate this point:-"it had an irritating effect because there were 3 ventilators and they all did not keep the same rhythm and pace and they sounded like frogs"; "the ventilators were used by patients on both sides o f me and the breathingrate was set differently.... they did not give the same sound and I could not adapt myself to their rhythm"-, "the noise was beyond the nurses' control..

. I, myself could not tolerate the noise made by the ventilators as I had this tendency o f controlling my breathing according to the rate o f the ventilator and I could not keep the same pace -it was too fast or too slow".
Others commented that the similarity of the noise of the ventilators to either snoring men or frogs (of which some patients were afraid) was very disturbing.
Patients showed awareness of different types of interaction between individual patients and individual nurses. In patients' term s, a 'good nurse' gives individual attention and a 'bad nurse' does not respond readily to patients' needs.
Awareness of rank differences within the nursing hierarchy was shown; patients knew which registered nurses functioned well within the unit and some mentioned that they were pleased if senior nurses disciplined junior nurses as this was viewed as efficient.
The patients' expectations of the doctors and of the nurses are quite different. Doctors were held in great respect and were never criticised; the nature of their training was well known and patients did n o t expect d o c to rs to u n d e rsta n d traditional beliefs and practices.
Nurses, however, were greatly criticised for not engaging patients in "intimate conversation".
Nurses had concentrated on the physical and medical aspects of the patient, and they did not spend enough time talking with their patients to discuss patients personal issues.
Patients wanted the nurses to spend more time on their social, psychological and s p ir itu a l a s p e c ts . M ost p a tie n ts verbalised that the nurses had not spent enough time communicating with them but added that nurses had been busy attending to critically ill patients.
Patients appeared to be de-personalised to some extent; Mrs K said "they only talked about health education". Mr G had wanted the nurses to show interest in his social situation. His cattle and sheep gave him status within his community and he felt that he had "done quite well even though he was a pensioner". Mr T was happy when he thought that 'social chat' had taken place. In Zulu society it is the woman who as the 'public relations person' should engage in personal social in te r c o u r s e .
T he r e s e a r c h e r 's impression was that patients saw nurses as wom en not quite fulfilling their expected social role.
In spite of such relatively minor fault finding by patients, on the whole, nurses were regarded positively. E n v iro n m e n ta l c irc u m stan c e s are d iffic u lt a t th e h o s p ita l and th e researcher as a senior staff member, was aware of this. The South African Society of Anaesthetists (1990) has produced guidelines for the provision of 'ideal' conditions for the care of critically ill p a tie n ts . It is re a lis e d th ese are guidelines only and not a binding code of p r a c tic e b u t th e re sh o u ld be th e registered nurse for each patient at all times, as well as secretarial and clerical service.
Guidelines are suggested, too, in regard to number of beds per unit of space, equipment (including C.C.U beds with s p e c ia lis e d b e d -h e a d layout) and recommended training for C.C.U. staff. F u lfilm e n t of su ch id e a l re c o m m e n d a tio n s a re beyond the financial means of hospital services of Natal and kwaZuIu but the researcher suggests th at with a p p ro p riate and sensitive modes of nurse education, CCU nurses will continue to work towards the goal formulated by the AACN in 1980:-"The goal o f critical care nursing is to ensure effective interaction to effect competent nursing practice and optimal patient outcomes within an environment supportive o f both". (Holloway, 1988,5).