In this unit you will cover nursing as a profession, characteristics of a professional nurse, professional organisations, the Nursing Council of Kenya and the legal aspects of nursing in Kenya. You will also cover disciplines of nursing and professional practice and conclude with a study of trends in nursing practice and the nursing process. It will build on what you have already learnt and it will also serve as revision.

This unit is composed of two sections:

Section One: Professionalism and Trends in Nursing.

Section Two: The Nursing Process.

SECTION ONE: PROFESSIONALISM AND TRENDS IN NURSING

Unit Objectives

By the end of this unit you will be able to:

∙Perform professional duties in conformity with the ICN code of ethics

∙Demonstrate an understanding of the legal aspects of nursing practice in Kenya

∙Display the characteristics of a professional nurse

∙Apply the nursing process to provide quality care

Introduction

Welcome to section one of this unit on professionalism and trends in nursing that directly relates to clinical practice.

Objectives

By the end of this section you will be able to:

∙Describe trends in nursing

∙Describe professionalism

∙List the national, regional and international

professional organisations	and	their
relationships

∙Describe the Nursing Council of Kenya

∙List the legal aspects of nursing in Kenya

∙Describe the disciplines of nursing in Kenya

∙Describe professional practice

Profession

You are already working in the nursing profession, and now you are being trained to become a Kenya Registered Community Health Nurse. On completion of this

programme, you will be expected to be proficient in providing general nursing, reproductive health and community health services.

This section of unit one, aims at moulding you to become a professional nurse. You will at all times, whether on or off duty, be expected to

display certain professional characteristics. You will begin by defining a profession, a professional nurse and professional nursing practice.

Bailliere's Nurses dictionary defines a profession as a 'calling, vocation requiring specialised knowledge, methods and skills, as well as preparation in an institution of higher learning in the scholarly, scientific and historical principles underlying such methods and skills'. The dictionary further states that members of a profession are committed to continuing study, to enlarging their body of knowledge, to placing service above personal gain and to providing practical services, vital to human society and social welfare. It adds that a profession functions autonomously and is committed to higher standards of achievement and conduct (Baillieres').

You may be familiar with reputable professions such as engineering, law and medicine. All these professions have similar characteristics.

The nursing profession is distinguished by its philosophy of care, full time commitment to human well being, particular blend of knowledge and skills, valuable service to the community and the regulation of its practice.

What are the characteristics of a profession?

Make a note of some of your thoughts on a notepad and then click the link below to check your answer.

Did you think of the following?

A profession:

∙Has a theoretical body of knowledge and skills

∙Encourages full time commitment to service, establishing standards of practice which are maintained by all members

∙Exercises self-discipline

∙Protects the public

∙Is responsible for the advancement of the profession

∙Develops its ethics to accommodate new

demands and circumstances of the profession

Professional Nurse

A professional nurse is an individual who has successfully undergone a prescribed nursing training programme, has passed a licensing examination and is registered by the national nursing regulatory body, in our context the Nursing Council of Kenya (NCK).

Characteristics of a Professional Nurse A professional nurse:

∙Displays high standards of performance and integrity in nursing practice

∙Seeks constantly to improve her/his technical and interpersonal skills through continuing education and research

∙Uses sound judgement and discretion in dealing with patients/clients and their relatives

∙Provides holistic care to patients, family and community

∙Deals competently with crisis situations

∙Puts what is good for professional services to patients ahead of self-interest

∙Coordinates and evaluates nursing services in cooperation with members of other health services (collaboration and networking)

∙Is not overly concerned with the materialistic aspects of nursing

∙Expects to find satisfaction and spiritual values in their work

∙Feels responsible for the status of nursing and tries to advance and never to retard it

∙Has inner resources to which she/he can turn to, for renewal of faith and courage when weary and discouraged

∙Is proud of her/his profession and considers it to be at par with other professions like medicine or law or any other vocation practised for compensation, which at the same time contributes in its own unique way to the welfare of humanity

Personal Attributes

Personal attributes that help a nurse to display professionalism include:

∙Good personal appearance with a voice that does not scare patients

∙A ready smile, gentle hand, orderly in thought and action

∙Emotionally mature, compassionate, dignified, tolerant, friendly, sympathetic and interested in other people

All characteristics are advantageous to the creation of a friendly and conducive environment for the patient's recovery. As a

nurse, you must at all times have serenity of mind and self-control to be able to handle a variety of situations and patients.

Remember: A professional nurse at all times displays integrity, commitment and ethical behaviour. They display intelligence, good judgement and handle emergencies well.

A professional nurse is also responsible in professional and social situations.

Personal Grooming

Personal grooming is very important to nurses. Remember, every patient has a mental picture or image of how their nurse should be. The nurse's appearance provides security and hope to a patient.

A nurse's uniform should not be tight or very loose to hinder free movement during an emergency. It must be very clean to prevent cross infection and is to be well pressed. The dress or skirt should be below the knee cap to give allowance for bending. The material should not be 'see-through'.

Female nurses should avoid bright inner wear especially if their uniform is white. The uniform should be well maintained, that is, fallen buttons or torn zippers should be replaced, rips and tears mended and stains removed.

As you are aware, hair is a source of micro- organisms. Female nurses should tie back long hair neatly. Male nurses should have their beards and moustaches neatly shaven. The nurse's cap should be worn neatly and securely.

Shoes should be low-heeled and soft to avoid making excessive noise, which may disturb patients. The nurse should maintain daily care of shoes, socks or stockings in order to prevent cross infection. Nails should be trimmed and coloured nail polish avoided. The freedom to wear jewellery, watches, pens, scissors or handkerchiefs will depend on individual hospital regulations

Remember: The patients have a right to identify the nurse who is providing their care. It is advisable therefore to wear an identification tag at all times showing full names and qualifications.

Nursing Ethics

You are being prepared to practise professional nursing which involves adherence to the code of ethics.

Collin's dictionary defines ethics as:

∙Moral principles

∙Code of behaviour

∙Study of morals

We can further define ethics as morals and philosophical principles that define actions as being either right or wrong. The ethical concepts touch on your practice as you interact with other people, the society, co-workers and the profession.

Remember: The patient is to be at the centre of your practice. Patients have the right to contribute to their own care and as you provide care, always remember to respect the beliefs, values and customs of the patient.

As a professional nurse you are expected to uphold and abide by the code of ethics.

Guidelines

∙You should always hold personal information in confidence and use your discretion in sharing this information.

∙You should always remember that it is your responsibility to keep abreast with current trends in the nursing profession so as to maintain competence in nursing practice through continuing education.

∙Always maintain the highest standards of nursing care possible within the given reality of a specific situation.

∙When accepting any responsibilities delegated to you, ensure that you are competent to carry out the assignment.

∙Maintain professional standards of personal conduct that reflect credit upon the profession at all times.

∙Share with other citizens the responsibility for initiating and supporting action to meet the health and social needs of the public during your practice.

∙Sustain a co-operating relationship with co-workers in nursing and other fields.

∙Take appropriate action to safeguard the individual when a co-worker or any other person endangers their care.

∙You have a major role in determining and implementing desirable standards of nursing practice and nursing education.

∙Be active in developing a core of professional knowledge.

∙Acting through a professional organisation, you are to participate in establishing and maintaining equitable social and economic working conditions in nursing. This, therefore, means that you are to be a member of your professional association.

Have you heard of the International Council of Nurses Code of Ethics?

The International Council of Nurses (ICN) Code of Ethics was adopted in Mexico City in

1973. It states that the fundamental responsibility of the nurse is to promote health, prevent illness, restore health and alleviate suffering. Moreover, the need for nursing is universal. Inherent in nursing is respect for life, dignity and the rights of man.

Nurses are to provide care to individuals regardless of nationality, race, creed, colour, age, sex, politics or social status. As a nurse you will be providing health care to the individual, family and the community. You will be operating in teams, such as a nursing team which is within a health team.

CODE OF ETHICS (INTERNATIONAL COUNCIL OF NURSES)

Ethical Concepts Applied to Nursing

The fundamental responsibility of the nurse is fourfold; to promote health, to prevent illness, to restore health and to alleviate suffering.

The need for nursing is universal. Inherent in nursing is respect for life, dignity and rights of man. It is unrestricted by considerations of nationality, race, creed, colour, age, sex, politics or social status.

Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups.

Nurses and people

The nurse’s primary responsibility is to those people who require nursing care.

The nurse, in providing care, promotes an environment in which the values, customs and spiritual beliefs of the individual are respected. The nurse holds in confidence personal information and uses judgement in sharing this information.

Nurses and practice

The nurse carries personal responsibility for nurse practice and for maintaining competence by continual learning.

The nurse maintains the highest standards of nursing care possible within the reality of a specific situation.

The nurse uses judgement in relation to individual competence when accepting and delegating responsibilities.

The nurse when acting in professional capacity should at all times maintain standards of personal conduct which reflect credit upon the profession.

Nurse and Co-workers

The nurse sustains a cooperative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard the individual when their care is endangered by a co-worker or any other person.

Nurses and the profession

The nurse plays the major role in determining and implementing desirable standards of nursing practice and nursing education.

The nurse is active in developing a core of professional knowledge.

The nurse, acting through the professional organisation, participates in establishing and maintaining equitable social and economic working conditions in nursing.

Code of Ethics as applied to Nursing

Nurses minister to the sick, assume responsibility for creating a physical, social and spiritual environment which will be conducive to recovery and stress the prevention of illness and promotion of health by teaching and example. They render health service to the individual, the family and the community and co-ordinate their services with members of other health professions.

Service to mankind is the primary function of nurses and the reason for the existence of the nursing profession. The need for a nursing service is universal. Professional nursing service is based on human need and is therefore unrestricted by considerations of nationality, race, creed, colour, politics or social status.

Inherent in the code is the fundamental concept that the nurse believes in the essential freedoms of mankind and in the preservation of human life. It is important that all nurses be aware of the Red Cross Principles and of their rights and obligations.

The profession recognises that an international code cannot cover in detail all the activities and relationships of nurses, some of which are conditioned by personal philosophies and beliefs.

1.The fundamental responsibility of the nurse is threefold; to conserve life, to alleviate suffering and to promote health.

2.The nurse shall maintain at all times the highest standards of nursing care and of professional conduct.

3.The nurse must not only be well prepared to practice but shall maintain knowledge and skill at a consistently high level.

4.The religious beliefs of a patient shall be respected.

5.Nurses hold in confidence all personal information entrusted to them.

6.Nurses recognise not only the responsibilities but the limitations of their professional functions, do not recommend or give medical treatment without medical orders except in emergencies, and report such action to a physician as soon as possible.

7.The nurse is under an obligation to carry out the physician’s orders intelligently and loyally and to refuse to participate in unethical procedures.

8.The nurse sustains confidence in the physician and other members of the health team; incompetence or unethical conduct of associates should be exposed but only to the proper authority.

9.The nurse is entitled to just remuneration and accepts only such compensation as the contract, actual or implied, provides.

10.Nurses do not permit their names to be used in connection with the advertisement of products or with any other forms of self advertisement.

11.The nurse co-operates with and maintains harmonious relationships with members of other professions and with nursing colleagues.

12.The nurse adheres to standards of personal ethics which reflect credit upon the profession.

13.In personal conduct, nurses should not knowingly disregard the accepted pattern of behaviour of the community in which they live and work.

14.The nurse participates and shares responsibilities with other citizens and other health professions in promoting efforts to meet the health needs of the public – local, state, national and international.

The professional nurse also has to be knowledgeable of what they are practising at the health facility and should acquire the technical skills that will assist in and improve the work performance.

You may be asking yourself, "How does the Code of Nurses affect me during my daily practice?"

The 'Code' incorporates general statements of principle applicable to all circumstances, upon infringement of which a nurse practitioner is liable to disciplinary action or penalty or both. The Code of Ethics embodies the standards by which each nurse practitioner forms a conscience, a capacity for moral reasoning and governs the practice of nursing.

You should also get yourself a copy of the Procedure Manual from the Nursing Council of Kenya, (at a fee) if you do not have one. It will assist you both in your daily work and in the study of this course.

Professional Organisations

Now we are going to discuss some professional nursing organisations which include:

∙National Nurses Association of Kenya (NNAK)

∙East Central Southern Africa College of Nursing (ECSACON)

∙International Council of Nurses (ICN) Nurses in Kenya, just like any other countries in the world, are members of professional organisations at national, regional and global levels.

In Kenya the professional nursing organisation that has both regional and international recognition is the National Nurses Association of Kenya (NNAK).

The National Nurses Association of Kenya The National Nurses Association of Kenya (NNAK) is a professional association for nurses, which is registered by the Registrar of Societies as a welfare association.

Membership

Membership of NNAK is open to all nurses who are either registered or enrolled by the Nursing Council of Kenya. Student nurses can join as associate members.

There are two types of membership:

∙Life membership

∙Ordinary membership

The Association has branches in all provinces. Members in each branch elect a Branch Chairman, Secretary and Treasurer. In turn, these elect national office bearers every two years who comprisethe National Chairman, Vice Chairman, Secretary, Treasurer, Organising Secretary and their respective Vices.

The Association has an Executive Committee which comprises of national office bearers and branch chairmen. Various nursing disciplines are represented as chapters, for example, midwives, operating theatre nurses, mental health and psychiatric nurses, educationists, intensive care nurses and private practice nurses. The headquarters of NNAK is in Nairobi.

NNAK is a member of a regional body known as the East Central Southern Africa College of Nursing (ECSACON) whose offices are situated in Arusha, Tanzania, the Association of Professional Societies of East Africa (APSEA) and the International Council of Nurses (ICN) situated in Geneva.

Additionally, NNAK collaborates with other professional bodies such as the Royal College of Nurses, Royal College of Midwives, the Canadian Nurses Association, American

Nurses Association, Kenya Medical Association (KMA), the Association of Kenya Obstetricians/Gynaecologists (KOGS) and other health organisations.

Functions of the National Nurses Association of Kenya

The functions of the National Nurses Association of Kenya are:

∙Promoting nursing and maintaining the honour, interest and practice of all aspects of the profession as a whole

∙Promoting and maintaining high standards of nursing education

∙Stimulating and encouraging nursing research

∙Promoting co-operation between this body and other national and international professional bodies

∙Promoting good understanding between the Association, central and local governments and all communities

∙Acting as a local representative body of the nursing profession

∙Supporting a high standard of nursing ethics, conduct and practice which is organised and functions unrestricted by consideration of nationality, race, creed, politics, sex or social status

∙Assisting whenever possible members who by reason of adversity or ill health are in need of help

∙Arranging and holding periodic meetings of

the Association for professional, educational and social purposes

∙Circulating such information as may be thought necessary by means of a journal, bulletin or any other method

∙Accepting or refusing any gift endowed or bequest made to or acquired by the Association or for the purposes of any specific object connected with the science, art of nursing and executing any charitable or other trusts which may be considered expedient or desirable in the interests of the Association

∙Maintaining an up to date list of all members in Section 4 a (i), (ii) and (iv) of the NNAK constitution

∙Performing all such other lawful things as may from time to time be conducive to the attainment of furtherance of the above functions. (NNAK Constitution, section 3 1987)

Chapters

The chapters of NNAK include:

∙Midwives

∙Education

∙Theatre Nurses

∙Mental Health and Psychiatric Nurses

∙General Nurses

∙Private Nurse Practitioners

∙Paediatric Nurses

National Executive Committee

This is a very large committee comprising the national executives who run the office at the headquarters (the National Chairman, two Vice Chairmen, an Honorary Secretary and the Vice Treasurer, Organising Secretary and the Editor).

Other members are the Branch Chairmen, Chairmen of Chapters, Division of Nursing (MOH) and the Nursing Council of Kenya. Other committees in the NNAK are the Education, Editorial and Finance Committees.

The Division of Nursing, on behalf of the Ministry of Health, deals with employment issues for nurses and sponsorship for higher education. Furthermore, it provides working facilities for nurses, technical know how and supervision. On the other hand, the Nursing Council of Kenya deals with training of nurses, maintenance of standards of nursing education and nursing practice and, additionally, the regulation of nurses' conduct. Finally, NNAK serves as an advocate for the nurses and the community.

The NNAK's activities, as you will note, are geared towards promoting excellence in nursing. There are national activities such as the Florence Nightingale week, Annual General Meetings, branch activities and chapter activities which aim to improve the quality of nursing and reproductive health care.

Finally, there are those activities channelled by ICN/ECSACON through the Ministry of Health. Apart from the discussed activities, there are several meetings conducted at the NNAK, such as quarterly Executive Committee meetings and monthly meetings for the chapters.

The following are just some brief highlights of what you will acquire from the NNAK:

∙Updates in knowledge, attitude and skills in nursing and midwifery practice to improve your performance for quality care to patients/clients

∙Interactions and the opportunity to share experiences with other nurses

∙The formation of links with other organisations

∙Advocacy on welfare issues such as better education as well as better remuneration and improved conditions of service

So far we have been discussing your professional body, which is a member of a regional body known as ECSACON. Let us now highlight a few points about this body.

The East Central Southern Africa College of Nursing (ECSACON)

ECSACON is a professional agency of the Commonwealth Regional Health Community (CRHC). Its main objective is to promote and reinforce professional excellence through the development of programmes. It is expected that this will, in turn, strengthen nursing and midwifery practice, education, research, leadership and management to improve service delivery and uplift the quality of health of the communities in the East Central Southern Africa (ECSA) region.

ECSACON is a corporate body of nurses and midwives of member states comprising Botswana, Lesotho, Kenya, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe and any other states that will accede to membership of CRHC for the ECSA region.

The membership of the college consists of individual nurses/midwifes and Professional organisations such as:

∙ NationalNurse/Midwifery Association (NNAS/NMAS)

∙National Nursing Councils (NNCS)

An individual can become a member once registered by the Nurses Regulatory Body as a nurse/midwife in any of the member states.

Benefits of Membership to ECSACON

The first benefit is knowledge. This knowledge is obtained through the many activities ECSACON conducts, such as quadrennial conferences where nurses from member countries meet and share research finding on topics of national interests in health. They exchange information on various topical issues on nursing, midwifery and health, mapping the

way forward for excellence in nursing/midwifery, education and practice. Interacting with nurses from the region is a benefit on its own. Apart from this, ECSACON has conducted many projects, for example, on research, leadership and management, advocacy and so on.

Members are also provided with reading materials through the CNR or Nursing Council.

Members also have rights and privileges . ECSACON - Membership Rights and Privileges

The membership rights and privileges of ECSACON are:

∙Voting and speaking at the ECSACON meetings

∙Nominating candidates for ECSACON elections and Standing Committees

∙Participating in ECSACON conferences,

workshops, seminars and other professional activities as appropriately promoted by ECSACON

∙Nominating candidates for ECSACON fellowships and awards

∙Receiving professional guidance and assistance from ECSACON

∙Receiving from or through ECSACON documents and periodic information about activities and news about nursing worldwide

∙Having their professional articles of regional and international interest published in ECSACON newsletter/journal/ magazines

∙Enjoying benefits established by

ECSACON

International Council of Nurses (ICN)

The International Council of Nurses is a federation of nurses’ associations (NNAS) in 122 countries. It was founded in 1899. ICN was the first health professionals’ organisations to be formed and remains the largest among international organisations relating to the provision of health care. It is operated by nurses for nurses.

The Secretariat of the ICN is based in Geneva and consists of a president, a chief executive and members. ICN works to ensure quality nursing and sound health policies for all. It strives for the advancement of nursing knowledge and the presence of a worldwide respected nursing profession and a competent, satisfied nursing workforce.

The ICN has goals and core values that guide its activities..

Goals

The goals of ICN are to influence health and nursing globally and strengthen national nurses associations.

Values

The values of ICN are to encourage visionary leadership, inclusiveness, flexibility and partnership among all member states and the achievement of excellence in nursing/midwifery education and practice.

Vision

The ICN states that its vision is to unite all nurses within the ICN to speak with one voice as advocates of all that ICN serves; to acknowledge that a human being has the right to preventive and curative care; to spearhead the health care progress and shape health policy around the world through enhancing nurses' expertise, strength, their numbers, alignment of their efforts and collaboration with the public and other health professionals. The ICN mission statement is derived from this vision.

Mission

The ICN's mission is to lead societies to better health and to promote healthy lifestyles, workplaces and communities; to support strategies which alleviate poverty, pollution and other causes of illness, while incorporating science and advanced technology in the provision of compassionate and ethical caring; to shape nursing education in accordance with values, policies, standards and conditions that free nurses to practise to the full extent of their education and abilities within multi-disciplinary health teams.

Philosophy

The ICN philosophy entails commitment to caring, advocating on behalf of patients, and helping people help themselves. ICN ensures that the nursing profession is highly valued, appropriately utilised, recognised, rewarded and represented throughout the healthcare system.

You have now gone through the ICN vision, mission and philosophy. You should have identified some crucial themes such as the role of the nurse as:

∙Provider of nursing care and health services

∙Policy maker

∙Collaborator with the public and other health professionals

Health is a universal right of every human being regardless of the social status. You have to encompass teamwork within multi- disciplinary teams.

Finally, you have to keep abreast by incorporating science and technology into the health delivery services in nursing practice. You will now study trends in nursing.

Historical Background

Historically the nursing practice in Kenya, just like anywhere else in the world, was performed on a tradition that sick people received care from female family members in their own homes. Therefore, it can be said that the family is the oldest and the most used health care delivery service in the world. Currently this approach to care provision is known as 'family nursing'.

Florence Nightingale (1869) stated: "…it has been said and written scores of times that every woman makes a good nurse, but I believe, on the contrary, that the elements of nursing are all but unknown...". She further stated: "It is well known that nursing exists to serve the society."

As social conditions and health care needs change, the nurses' roles and nursing practices continue to alter in response to these changes. Florence Nightingale is the founder of professional nursing. She initiated formal nursing training using a curriculum replacing apprenticeship.

Western medicine in Kenya was introduced with the arrival of missionaries in 1895. Doctors and nurses were brought from Britain and Europe. They trained dressers and assistants on the job. Later on they began to conduct basic training in missionary hospitals.

In 1949, a nurses, midwives and health visitors council was formed by an ordinance. In 1950, formal nursing training at enrolled and registered levels was started. The practice of nursing followed a medical model. The patient was nursed as fragments of diseased body parts using task allocation.

Task Allocation/Job Assignment

This method of dividing duties was based on the industrial concept of division of labour. The patient was fragmented into a series of jobs assigned to different nurses of different grades. Thus a hierarchy of tasks and staff was created for patients. This resulted in a fragmentation and lack of continuity of care, with patients subordinated to the system rather than being central to it.

You may recall a practice in the wards whereby the most junior nurse was assigned sluice rooms, others observations, wound dressings, drug administration, specimen collection, theatre cases, doctors round and so on.

In the 1950s, nurse leaders in North America began to recognise that the development of nursing knowledge and practice must run simultaneously with research. Florence Nightingale in 1859 wrote that nursing was more than the administration of medicine and application of poultices. This shows that Florence Nightingale had recognised that nursing needed a combination of both intellectual and practical skills.

In the 1960s to 1980s, many developments and changes in nursing took place stemming from the professional desire for innovation and change in practice. The nurses' leaders felt that the patient was alienated from their own care, and that there was a need for improvements in nursing. Nurse leaders began trying to demonstrate that nursing was a profession with its own unique body of knowledge.

Virginia Henderson (1966) delineates the unique functions of the nurse as follows:

"…to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, knowledge. And to do this in such a way as to help him gain independence as rapidlyas possible."

In the search for a unique body of knowledge, nurse theorists were using scientific methods to describe, explain and predict nursing practice and its outcomes. You must be wondering how these developments were reflected on nursing in Kenya?

In the 1960s and 1970s task allocation was exclusively practised in the context of hospital nursing. Task assignment is still practised when there is shortage of staff. During the said period, however, lots of changes took place in the health delivery system in Kenya.

Politically, independence was attained in 1963. The KANU manifesto declared its intention to fight what it saw as the three greatest enemies of development: poverty, illiteracy and disease. Within this context, health care had to be made available to the community. This led to the introduction of community health nursing training (KECHN) in 1966 at MTC Kisumu.

Midwifery training had already been introduced in the 1950's at enrolled level, and at registered level in 1965. At the same time, expatriate nurses who were administrators of nursing services, and nursing educators were leaving the country at independence. In anticipation of gaps in training and skills, a Diploma in Advanced Nursing was started in 1968 at the University of Nairobi to prepare Nurse Educators and administrators.

The shift to community health nursing was to provide preventive and promotive health care service delivery.

Florence Nightingale (1867), states in her private notes, "my vision …is that the ultimate destination of all nursing is the care of the sick in their own homes …I look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2000."

Do you think this was a prediction of the global Primary Health Care Concept of 'Health for all by the year 2000'?

What is Health?

Many people think that health is the absence of illness but the World Health Organisation (WHO) in 1946 defined health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity. The health delivery services in the 1970's laid great emphasis on community- based health care in the implementation of Primary Health care concept (WHO, 1978).

Nurse leaders worldwide became dissatisfied with the task allocation method of organising patient care as it alienated the patient from the nursing care.

Nurses felt that there should be accountability of the care being given with a view to improving the quality of care.

Therefore, in the 1980's nurses started moving away from 'tasks' to individualised nursing care. This move away from a pre-occupation with tasks to a focus on patients led to the introduction of a nursing process that provided a systematic method for individualised nursing. The progression of these systems started with patient allocation to team nursing and then primary nursing

The Nursing Process

The nursing process was introduced in the 1970s in North America and 1980s in Britain. In 1977, the United Kingdom Central Council (UKCC) recognised the nursing process and decreed that the care of patients should be studied and practised in the sequence of the nursing process. (Dickinson,1982).

The British nurses viewed this type of introduction with suspicion, since it was done in haste, adopting a top-down approach and coercive change strategy that led to misunderstandings and difficulties. The same trend was visible in Kenya in the late 1970s, bringing confusion to the nurses in the clinical practices who, up to now, assumed that the nursing process is an assessment tool for nursing students and not a guideline for patient care

The argument most nurses present is that good nurses have always used the nursing process even though they did not analyse what they were doing in terms of a process or steps and did not document the information in an orderly and comprehensive manner.

Thus, the nursing process is wholly feasible in the context of practice, which is organised on the basis of patient allocation, team nursing or primary nursing. Assessing, planning, implementing and evaluating are embedded in everyday nursing practice.

Patient Centred Systems of Organising

Nursing Care

Patient Allocation

Each nurse is allocated a small number of patients (up to six) to look after during a whole work shift.

Team Nursing

As you probably know, the nursing staff in a ward is divided into teams, each team taking responsibility for the total care of a subgroup of the patients.

Primary Nursing

This is a patient-centred nursing system. One nurse

(the primary nurse) assumes individual responsibility for a particular patient. Theoretically this responsibility extends over the entire period the patient requires nursing although in practice there has to be delegation to other nurses (the associate nurses) during periods of absence from the ward. The potential benefits of primary nursing for patients are continuity of care and cover.

The concept of primary nursing responds to

thedirective of putting patients first and it embodies the ideals of individualised nursing. Therefore, if nurses are to accomplish the goals of nursing as defined by the nursing leader, nursing must have a body of theoretical knowledge on which to base its practice. This will be achieved through conducting nursing researches at the clinical sites.

Nursing Models

A nursing model as defined by Riehl & Roy (1980) is a systematically constructed, scientifically based and logically related set of concepts of nursing practice together with the theoretical bases of these concepts and the values required for their use by the practitioner. Models are developed carefully and methodically, usually as a result of prolonged research and may involve many months or years of observing nursing practice and thinking about why nursing is carried out.

Fawcett (1984) quoted Reilly (1975) who said: "We all have a private image (concept) of nursing practice. In turn this private image influences our interpretations of data, our decisions and our actions. But can a discipline continue to develop when its members hold so

many differing private images? The proponents of conceptual models of practice are seeking to make us aware of private images so that we can begin to identify commodities in our perception of the nature of practice…"

Conceptual models for nursing are, therefore, the formal presentation of private images of nursing. They consist of many concepts, which identify the essential components of the disciplines. They show relationships between the concepts and may introduce already established theories from other disciplines,

which are applicable for nursing.

The Values of Nursing Models

A model can be useful for nursing practice, education, management and research. In nursing practice, a model provides a framework for what a nurse does and how they do it.

In nursing education, a model provides a framework, which organises the curriculum, the knowledge, skills and approaches, which are necessary for learning and practice.

In management, a model can outline the common goals to be achieved. In research, a model provides guidance about what should be studied in order to extend nursing knowledge and thus improve knowledge.

Various models have already been developed. They include Orem's self-care model (Orem 1971), which model depicts nursing as assisting individuals to their optimal level of self-care.

Roy (1970) centred her model on the concept of adaptation. Rogers (1970) focused on the concept of environment and the nursing of a client (patient) interacting with the environment.

The various models have the following in common:

∙Person

∙Health

∙Nursing activities/process

∙Environment

Theories of Nursing

What is a Theory?

A theory is a generalised explanation of a phenomenon. Nursing theories have been developed from other disciplines such as psychology, sociology, education and biological sciences. You may wish to understand the importance of a theory. Theory underpins research. It also provides a way of explaining the meaning of research findings, or a language for the communication of nursing knowledge.

Nursing practice can, therefore, be explored and explained through the use of common concepts, for example, pain, grief, stress, quality of care.

Patients and practitioners have to share the findings of research for the knowledge base to

grow and to be utilised. From these discussion concepts, models and nursing theories are interlinked and they form the basis of professional nursing practice.

The Nursing Council of Kenya

The Nursing Council of Kenya was established by the Nurses Act, Chapter 257 of the laws of Kenya. The Council is a corporate body having perpetual succession and a common seal with power to sue and be sued and to purchase, hold, manage and dispose of land and other property and to enter into such contracts, as it may consider necessary or expedient.

On the other hand, the Nurses Act, Chapter 257 of the laws of Kenya was enacted as an Act of Parliament to make provision for the training, registration, enrolment and licensing of nurses, to regulate their conduct and to ensure their maximum participation in the health care of the community and for connected purposes (Nurses Act 1985).

Two

persons...

Four

persons...

Eleven elected members...

...representing nursing associations (one from NNAK and one from KEPNA (Kenya Progressive Nurses Association).

...nominated by the outgoing council to represent: General Nursing, Midwifery and Community Health Nursing.

...who may be involved in clinical practice, nursing education and administration. They must be registered nurses as follows: Three registered nurses, three midwives, three community health nurses and two psychiatric nurses.

The functions of the Nursing Council are carried out through committees, that is, the Full Council and six standing committees

Functions of the Nursing Council

The functions of the Nursing Council are:

∙Establishing and improving of all branches of the nursing profession in all their aspects and to safeguard the interest of all nurses

∙Establishing and improving the standards of professional nursing and of health care within the community

∙Prescribing and regulating syllabuses of instruction and courses of training for

persons seeking registration or enrolment under the Act

∙Recommending to the Minister institutions to be approved for the training of persons seeking registration or enrolment under the Act

∙Prescribing and conducting examinations for persons seeking registration or enrolment under the Act.

∙Prescribing badges, insignia or uniforms to be worn by persons registered, licensed or enrolled under the Act

∙Regarding the conduct of person registered, licensed or enrolled under the act, and to take such disciplinary measures as may be necessary to

maintain a proper standard of conduct among such persons

∙Regarding the standards for nursing care, qualified staff, facilities, conditions and environment of health institutions

∙Directing and supervising the compilation and maintenance of registers, rolls and records required to be kept under sections 12, 14 and 16

∙Advising the Minister on matters concerning all aspects of nursing

The Full Council

This is composed of the 22 members of the council. The main functions of the full council is to make decisions and to ratify the decisions of the six standing committees. The council meets every three months.

The Standing Committees

The Standing Committees meet every three months except the Registration and Education Standing Committees which meet monthly. They meet to discuss issues under their mandate. You shall now look at the roles of the various committees.

.

The Education Standing Committee

The committee deals with all issues that relate to nursing education such as:

∙Designing nursing programmes, syllabus and national curriculum according to the health needs of the community

∙Scrutiny of institutional curriculum to see whether they meet the minimum standards for producing a safe practitioner

∙Formulating training materials like education policies, guidelines and procedures and log books for recording clinical practice learning

∙Monitoring students during training for example discontinuations, readmissions and discipline cases.

∙Dealing with examinations. This includes setting examinations, packaging and dispatch of examinations to training institutions, administration of examinations and receipt of examination scripts in liaison with the training institutions. It also involves the marking of examination scripts, moderation of examination results and presenting the results to various committees and Full Council. The Council

ratifies the examination results. Examination results are then released to the individual candidates, training institutions and provincial nursing officers.

∙Approving training institutions and monitoring the institutions to ensure that standards of nursing education are

maintained. Areas being monitored include:

- Facilities in the school of nursing and

clinical			area
- Approved	teacher/student	ratio	of 1:10
- Adequate	clinical	area	staff

- Adequate bed occupancy at a minimum

of

60%

-Facilitating continuing education for nurses

-Guiding nurses and their supervisors on what the nurses must know to be able to

offerupdated quality care to patients and clients

The Standards and Ethics Committee

This committee deals with:

∙Initiation and maintenance of standards of nursing education and nursing practice

∙Coordinates council visits to health institutions for the purposes of monitoring the quality of nursing education or quality of care being offered to patients and clients respectively

∙Coordinates research sub-committee meetings which facilitate research and surveys related to nursing practice and nursing education

Registration and Licensing Standing Committee

The Registration and Licensing Standing Committee meets every month. It deals with the registration, enrolment and licensing of nurses for nursing practice. This is applicable to those trained in Kenya and those trained outside Kenya.

Kenyan law states that nurses are not allowed to practise nursing prior to registration, enrolment or licensing by the Nursing Council. This Committee also licenses nurses for private practice and processes licensing for practice and retention of nurses in the registers, rolls and records.

Investigations Standing Committee

This committee investigates all cases of

professional misconduct, negligence, malpractice and impropriety. This is to establish whether the alleged crime has been committed and whether the nurse has a case to answer or not. A recommendation is then made to the Full Council which in turn institutes disciplinary proceedings.

Finance Standing Committee

This committee deals with all financial issues of the Council in relation to income and expenditure.

Disciplinary Committee

This is a Standing Committee which deals with disciplinary cases recommended by the investigations standing committee. It is independent of the Full Council.

Members are drawn from experienced nurses practising general nursing, midwifery, community health nursing, mental health and psychiatric nursing, the legal advisor and a representative of the Chief Nursing Officer. The registrar is the secretary.

The Nursing Council Secretariat

All activities of the Nursing Council are coordinated by the Secretariat. The Nursing Council Secretariat conducts the day to day activities of the Council.

The Secretariat is composed of council officers and council staff.

The council officers who are the registrar, education officers, examination officers, registration officers and standards and ethics officers are currently employees of the Ministry of Health deployed to work at the council.

They coordinate various Standing Committees and Subcommittees as discussed earlier. As a practising nurse you may be familiar with the offences under the 257 Act.

The council staff includes the accountant, accounts assistant, secretaries, copy typists, records clerk, driver and supportive staff who are employees of the Council.

Nursing Council Elections

The Nursing Council of Kenya conducts elections of council members every three years. All registered nurses are eligible to vie for representation of various disciplines for example general nurses, midwives, community health nurses and mental health and psychiatric nurses.

The nurses may be practising either in clinical practice, nursing education or leadership and management. The procedures to be followed are at the back pages of the Nurses Act. For more information you can always contact the Registrars' office.

Legal Aspects of Nursing in Kenya

As a nurse you are liable to the national laws as well as professional ethics related to your practice. You have already studied the functions of the Nursing Council and the Disciplinary Committee.

Examples of Offences

NEGLIGENCE

You will be charged with this offence if you do not provide the expected care to a patient or client in the field you were trained in.

MISCONDUCT

Misconduct includes stealing drugs or hospital property, forgery or fraud, coming on duty while drunk, fighting while on duty or use of abusive language.

MALPRACTICE

Remember you are a trained nurse. If you provide substandard care to patients you will be charged of malpractice. In addition, if you also perform procedures that are out of your scope of practice you may be charged with malpractice.

IMPROPRIIETY

As a nurse the profession binds you to conduct yourself professionally while on duty or off duty.

If you fight in a bar or anywhere or conduct yourself unprofessionally you will have discredited or shamed the nursing profession and will, therefore, be liable to be charged with impropriety.

Other Laws Related to Nursing Practice The following are some of the laws that are relevant to nursing practitioner

The Public Health Act (cap 242)

This Act is commonly referred to as the mother Act among the Acts of Health Professionals.

It describes the health delivery services in the country.

The Public Health Act (cap 242)

This Act is commonly referred to as the mother Act among the Acts of Health Professionals.

It describes the health delivery services in the country.

Pharmacy and Poisons Act (Cap 244)

You should be familiar with this law because of drug prescription and administration.

Medical Practitioners and Dentists Act Cap (253)

In your community health nursing practice or private nurse practice you will be expected to diagnose and treat minor ailments, this encroaches on this law.

Narcotic Drugs and Psychotropic Substances (Control) Act 1994

While dealing with the dangerous drugs, you will be required to be familiar with this law. This also applies to dealing with drug misuse and abuse.

Mental Health Act Cap (248)

You have been exposed to mental health and psychiatric nursing.

You will interact with such patients in your practice as a general nurse, midwife and community health nurse.

Other Laws Related to Nursing Practice Medical Laboratory Technicians and Technologists Act (1999)

You will be taking body specimens from

patientsandclients. You should therefore be familiar with this law.

Clinical Medicine Act

This law is related to the medical Practitioners and Dentists Act because of diagnosing and treating minor ailments.

Food, Drugs and Chemicals Act

You will be dealing with the nutritional status of the patient. In addition, you are one of the food handlers in the hospital. Familiarise yourself with the law.

Children and Young Persons Act

In your practice you will be interacting with babies, children, adolescents and teenagers. This may be in wards, departments, clinics, maternity, school health and the community. Remember children have rights which you must recognise.

You may be the provider of the health services, advocate or advisor of other health professionals in your multidisciplinary teams. You may have heard of the African Charter on the Rights and Welfare of the Child which was adapted by the 26th ordinary session of the Assembly of Heads of State and Government of the OAU, Addis Ababa, Ethiopia - July 1990.

African Charter on the Rights and Welfare of the Child

∙Any custom, tradition, cultural or religious practice that is inconsistent with the rights, duties and obligations should be discouraged.

∙Enjoyment of rights and freedoms is recognised and guaranteed irrespective of race, ethnic group, colour, sex, language, relation, political or other opinion, national and social origin of the child's parents or

legal guardians. This includes fortune, birth or status.

∙Best interests of the child should be the primary consideration.

∙The right to life is inherent and should be protected by law. Death sentence should not be pronounced for crimes committed by the child.

∙Right from birth to a name. The child should be registered immediately after birth, and has a right to acquire a nationality.

∙Freedom of expression.

∙Freedom of association.

∙Freedom of thought, conscience and religion.

∙Protection of privacy.

∙Right to education.

∙Right to rest and leisure, to engage in play and recreation and cultural activities appropriate to the age of the child and to participate freely in cultural life and the arts.

∙A mentally or physically disabled child has the right to special measures of protection in keeping with his physical and moral needs under conditions which ensure his dignity, promote his self reliance and active participation in the community.

∙Right to enjoy the best attainable state of physical, mental and spiritual health.

∙Protection from all forms of economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child's physical, mental, spiritual, moral or social development.

∙Protection from all forms of torture, inhuman or degrading treatment, especially physical or mental injury or abuse, neglect or maltreatment including sexual abuse while in the care of a parent, legal guardian, or school authority or any other person who has the care of the child.

As a nurse you are expected to:

∙Provide necessary support for the child and for those who care for the child.

∙Identify children suffering from abuse and torture.

∙Report or refer for investigation, treatment and follow up of cases of child abuse and neglect.

Get yourself a copy of the Children and Young Persons Act from the Government printers.

Workman's Compensation Act

You should familiarise yourself with this law. It outlines what you should do in cases of accidents during practice, with specific focus on how to go about applying for compensation of the damages caused as a result of the accident. This will assist you to advise others

Bill of Rights

In the process of the provision of health care, both the patients and the nurse have a Bill of Rights. You will study them separately.

The Patient's Bill of Rights

Earlier in the unit we discussed that health care is a right to every individual in this country. You should always remember that as you provide care to the patient, they have a right to:

∙Considerate and respectful care.

∙Obtain complete information concerning their treatment, progress and prognosis of the disease/condition. In certain situations the patients may not be in a reasonable condition to understand or it may be medically inadvisable to give particular information. Therefore, an appropriate person should be given the information on their behalf.

∙Know by name the person caring for them.

∙Receive information necessary for them to give informed consent prior to the commencement of any procedure and/or treatment except for emergencies. The information given should include specific procedures and/or treatment, the medical risks involved, probable duration of incapacitation, where alternative significant medical care or treatment exist, or when the patient requests for information concerning medical alternatives, they have the right to such information. The patients also have the right to know the name of the person providing the treatment.

∙Refuse treatment to the extent permitted by law but must be informed of the medical consequences of their action.

∙Privacy concerning their care. Those persons not directly involved in the care must get permission from the patient in order to be present.

∙Confidentiality with regard to all communication and records pertaining to their care.

∙Expect that a hospital within its capacity can make reasonable response to the patient's request for service. The hospital must provide evaluation service and/or referral as determined by the urgency of condition. When medically permissible,

patients may be transferred to another health facility only after they have received adequate information and explanation concerning the need for and alternatives to such a transfer. The receiving health institution must first have accepted the transfer for the patients.

∙Obtain information as to any relationship of their hospital to other healthcare facilities and education institution in so far as their care is concerned.

∙Obtain information regarding the existence of any professional relationship among individuals by name who are treating them.

∙Be advised if the hospital proposes to engage in or perform human experimentation affecting their care or treatment. Patients have the right to refuse to participate in such research.

∙Expect reasonable continuity of care and have the right to know in advance appointment times and doctors availability.

∙Question and receive an explanation of their bill regardless of source of payment (Note - some medical practitioners may unnecessarily inflate the bill if the patient is insured).

∙Know what hospital rules and regulations apply to his/her conduct as a patient.

Remember that all these must be followed with an overriding concern for the patient and above all the recognition of his/her dignity as a human being. Success in achieving this recognition assures success in the defence of the rights of the patient.

Nurses Bill of Rights

You as a nurse have many rights. You are entitled to human rights, and the rights of a worker.

As a worker you have the right to a safe environment, adequate working tools and supplies, right to risk allowance, right to professional autonomy and the right to opportunities for further education, promotion and career development.

Code of Regulations

As an employee you must acquaint yourself with the code of regulations of the organisation you have joined. If you are employed by the government of Kenya, then it is worthy to familiarise yourself with the government code of regulations which contains:

∙ Organisation of government and procedures or conduct of government business

∙The Public Service Commission

∙Correspondence; Publication and Printing

∙Terms and conditions of employment

∙Annual staff appraisal reports

∙Rules of conduct

∙Salaries, increments and seniority

∙Advances, allowances, transport, housing, medical privileges, leave, examinations and courses of training etc

You are now aware that the Nursing Council of Kenya is responsible for the provision of quality care to patients and clients. This is why it is a requirement by the Council that all nurses in the country update their knowledge and skills through continuing education and professional development.

You are now able to differentiate between the National Nurses Association of Kenya and the Nursing Council of Kenya

Disciplines of Nursing in Kenya

You have studied the legal aspects of nursing and the Nursing Council of Kenya. You will now look at professional nursing which will start with the disciplines of nursing in Kenya.

The disciplines of nursing include:

∙General Nursing

∙Midwifery

∙Community Health Nursing

∙Mental Health and Psychiatric Nursing

∙Nurse Anaesthetist

∙Ophthalmic Nursing

∙Paediatric Nursing

Professional Nursing Practice

You may have come across many people who think and consider nursing to be a series of practical tasks carried out by nurses and who believe that anybody can become a nurse. This interpretation does not take into account the thinking processes involved in the complex

activities of assessing, planning, implementation and evaluation of the care given, nor does it acknowledge the knowledge and attitudes which must be acquired for implementing individualised nursing in various circumstances and for patients/clients from different age groups and backgrounds.

Despite Nightingale's early recognition of the need for a combination of intellectual and practical skills, nursing has concentrated for a very long time on the practical level rather than developing simultaneously a theoretical perspective on which to base its practice.

Clinical Practice

A professional nurse in clinical practice provides clinical nursing in general nursing,

midwifery and community health nursing practice. You are familiar with various definitions of nursing.

For the purposes of this section, the operational definition is:

Nursing is an art and science which aims at professional excellence in the provision of holistic care that is compassionate, culturally and socially sensitive to patients and clients.

Clinical nursing practice has three major roles: Provider, Advocate and Researcher.

Provider Role in Clinical Practice

The provider role entails all those actions you will accomplish when meeting the nursing and healthcare needs of individuals, families and significant others using the nursing process. You are also expected to collaborate with other members of the nursing team and multidisciplinary teams in your practice. As you are executing the provider role you will also be playing the leadership role, which at various levels involves behavioural components such as deciding, relating, influencing and facilitating.

Each of these components is directed toward change, using the process of effective communication. As a leader, you will be expected to utilise interpersonal relations to effect change in the behaviour of those you relate with. You will be in leadership positions in a variety of circumstances such as assisting an individual patient or family to make change in their health related behaviours. It also involves assisting groups or communities to alter their health practices, or groups of nurses or other health professionals to effect the actions of patients or communities in achieving desirable health behaviours.

Another role in clinical practice is advocacy...

Advocacy Role in Clinical Practice

In clinical practice you are expected to play the role of a patients' advocate. This role involves: anticipating and meeting the requirements of a patient who is unable to meet their own needs. You are to be aware of the patients' needs and to communicate them to other health professionals involved in the care.

You will be expected to coordinate the activities of all persons involved in the provision of health care. As a provider of care and a patient's advocate you should aim at providing quality care to your patients and clients. This can be enhanced through getting involved in nursing research

Research Role in Clinical Practice

There are various definitions of research. The core issues are emphasised in relation to generating knowledge in a systematic and scientific way. Developing nursing knowledge was initially more recognised by nurse educators than clinical practice nurses.

Meley (1991) in her account of the development of theoretical nursing describes how North American nurses in the 1950's recognised that without ongoing research, nursing would remain stagnant, and nursing research would not develop with the advantage of theoretical understanding. Research activities and theory development began to grow in the 1950's initially in North America but gradually spread to other parts of the world.

You should note that you have valuable contributions to make towards operational research at your clinical site. It is, therefore, your responsibility to make those contributions.

Characteristics of a Professional Nurse A professional nurse:

∙Displays high standards of performance and integrity in nursing practice

∙Seeks constantly to improve her/his technical and interpersonal skills through continuing education and research

∙Uses sound judgement and discretion in dealing with patients/clients and their relatives

∙Provides holistic care to patients, family and community

∙Deals competently with crisis situations

∙Puts what is good for professional services to patients ahead of self-interest

∙Coordinates and evaluates nursing services in cooperation with members of other health services (collaboration and networking)

∙Is not overly concerned with the materialistic aspects of nursing

∙Expects to find satisfaction and spiritual values in their work

∙Feels responsible for the status of nursing and tries to advance and never to retard it

∙Has inner resources to which she/he can turn to, for renewal of faith and courage when weary and discouraged

∙Is proud of her/his profession and considers it to be at par with other professions like medicine or law or any other vocation practised for compensation, which at the same time contributes in its own unique way to the welfare of humanity

How can you make those contributions? You must constantly be on the alert of nursing problems and important questions about your nursing practice. This can serve as the basis of articulating research problem areas. Since you are directly involved in providing care, you are often in the best position to identify such questions and problems.

You have a responsibility to become actively involved in research studies.

How can you be involved in research?

You are already in one way or another involved in research through the massive data you collect from day to day. Your shortcoming is that you do not know how to utilise the data. In this course you will learn about data collection and interpretation of the data to other health care professionals or to patients and their families. The details will be covered in module four.

What you need to remember now is that you must be continually aware of studies that are directly related to your areas of clinical practice. You must share the findings with your colleagues and utilise them in an attempt to improve patients' care.

Remember, when research studies are not made available to other nurses, the impact of the findings on nursing practice is diminished. You should be aware that the future of nursing science depends on active involvement of nurses in the implementation and utilisation of nursing research.

Nurses must develop curiosity about nursing practice. Their belief in the worth of nursing practice is emphasised by the acceptance of the research role and responsibility.

Nursing Education

There are several aspects of nursing education. In Kenya there are nursing programmes regulated by the Nursing Council of Kenya and continuing nursing education conducted at areas of practice. We will start by looking at the basic programmes.

Basic Programmes

There are three levels of nursing programmes.

Degree Programmes

The five universities offering bachelor in nursing for school leavers are:

∙University of Eastern Africa, Baraton which started in 1988

∙University of Nairobi which started in March 1992

∙Moi University which started in September 1998

∙KENYATTA University

∙Kenya Methodist University (KRCHN - BScN upgrading)

Other programmes offering first degrees in nursing for registered nurses are conducted at KMTC Nairobi in collaboration with the University of Dundee, Scotland; the Aga Khan University Kenya Campus and the American World University.

Egerton University, Tropical Institute of Community Health in Kisumu has also shown an interest in offering such courses.

Diploma Programmes

There are two basic programmes in Kenya: the Kenya Registered Nursing (KRN) and Kenya Registered Community Health Nursing (KRCHN).

KRN is being conducted at the Nairobi Hospital and Mater hospital in Nairobi. KRCHN is being conducted by many schools of nursing sponsored by the government, mission and private organisations.

Certificate Programmes

The only certificate nursing programme that is currently in place is the Kenya Enrolled Community Health Nursing which is being conducted by the government, mission and private institutions.

Basic Programmes

All these programmes are tailored in such a way that there is an integration of general nursing, midwifery, community health nursing, mental health and psychiatric nursing.

Apart from the basic programmes there are post-basic programmes at diploma and

certificate levels covering midwifery, community health nursing and mental health and psychiatric nursing, nurse anaesthetist, ophthalmic nursing and paediatric nursing.

Institutions offering higher education at master's level for nurses are:

∙University of Nairobi offering Masters in Nursing

∙Kenyatta University offering Masters in Public Health and Epidemiology

∙KMTC offering Masters in Medical Education and Masters in Nursing in collaboration with University of Dundee

Other places which also admit nurses for a master's degree are Moi University and University of Nairobi. All the tutors or lecturers

teaching in these programmes are practising in nursing education.

The Nursing Council of Kenya is advocating that all nurses update their knowledge and skills through continuing education conducted in workshops, seminars and case presentations or on the job training. The main aim is the provision of quality care to patients and to keep abreast with scientific and technological developments.

You read earlier that nursing research can be conducted in the clinical area. You can now add to that. that research is also conducted in nursing education to improve its quality.

SECTION 2: THE NURSING PROCESS

Introduction

This second section will introduce you to professionalism and the nursing process. It will build on what you have already learnt and it will also serve as revision.

Objectives

By the end of this section you will be able to:

∙Define the nursing process

∙Describe the rationale of using the nursing process

∙List the steps of the nursing process

Definition of the Nursing Process

The nursing process is a technique which scientifically attempts to solve problems created by the patient's illness and to meet the health care and nursing needs of patients.

Rationale for Using the Nursing Process The nursing process introduces a concept of

objective measurement into nursing management at the bed side. It compels you as the nurse to look more closely at the problems as the patient sees them rather than as you assume the problems to be. Furthermore, it defines what the nursing role is all about and creates a boundary within which you can safely practise clinical skills.

The nursing process establishes nurse-patient relationship on a firm basis because it is objective and is a total care technique. The care plan, being related to one individual, gives you as a nurse greater professional job satisfaction. The nursing process, apart from being practical, is also a research tool since you can collect data that is retrospective, current and prospective.

With regards to patients problems, how do you define a problem?

A problem is any condition or situation which requires nursing intervention for the patient to regain a state of health or towards a peaceful death.

In learning the art of applying the nursing process, you are applying science which is the skilled art of making the well and the sick more comfortable and to feel well cared for.

You may have already used the nursing process. As a reminder, however, the steps are:

1.Assessment

2.Planning

3.Implementation

4.Evaluation

Assessment

Assessment starts with your very first

encounter with the patient. It involves a systematic collection of data conducted on a patient, done to determine their health status and to identify any actual or potential health problems in order to formulate a nursing diagnosis, this becomes the basis of the nursing care plan. A sensitive and continuous nursing assessment by means of nursing history and health assessment is essential in maintaining awareness of the nursing care that a patient receives.

The nursing history is taken for the purposes of determining the patient's state of illness. It also provides you as a nurse with the opportunity to collect the data and to convey interest, support and understanding to the patient.

The skill used in obtaining history is interviewing. An interview is a dialogue between patients and you as their nurse, which

is a very personal experience.

Interviewing is a process that requires wisdom, judgement, tact and experience. It involves a sensitive direction of a conversation with patients in order to obtain information about them.

Your approach to the patient will largely determine the amount and quality of information that you will receive.

Achieving a relationship of mutual trust and respect will require the ability to communicate a sincere interest in the patient.

You must make the patient as comfortable as possible and offer privacy for the interview. The skills involved in interviewing a patient include:

∙Listening and questioning

∙Observing and interpreting

∙Synthesising

∙Incorporating what is learnt into a plan of care

The Process of Interviewing

The process of interviewing involves:

∙Talking and listening to the patient

∙Allowing the patient to tell their story in their own way

∙Looking for the main area of concern

∙Giving the patient time, without interruption, to tell you why they are seeking help

∙Being attentive not only to the patient's verbal expression but also to their non- verbal behaviour which may be displayed in the form of gestures, postures and facial expressions

∙Anticipating the patients' anxieties and trying to relieve them

∙Making relevant enquiries

∙Ensuring that the client feels that they are being understood

The Process of Interviewing

Health facilities have developed their own interview guides but what is important is to conduct a thorough assessment of the patient with regard to their basic human needs and their state of wellness or illness.

A variety of models can serve as the framework for the assessment of basic needs. These include Functional Health

Patterns (Gordon:1982), Maslow's Hierarchy of Needs and Eriksson's Eight Stages of Human Development.

Assessment of the total needs of the patient

includes their physical, psychological, emotional, intellectual, developmental, social, cultural and spiritual needs.

Health Assessment

How would you conduct a health assessment?

The health assessment of the patient may be carried out prior to, during or following the nursing history, depending on the patient's physical and emotional state, their response to their illness and hospitalisation, and the immediate priorities of their illness situation.

What is the purpose of health assessment?

The purpose of the health assessment is to identify the parameters of physical, psychological and emotional function that include a nursing need that exists. The

techniques and skills that are utilised in conducting the health assessment include:

∙Use of the senses of sight, touch, hearing and smell

∙Use of appropriate interview skills and techniques

∙Physical examination

∙Techniques and strategies for assessing behaviours and role changes

The Physical Examination

You have been performing physical examinations on patients in various situations. A physical examination is designed to determine the patient's assets which may serve to compensate for their limitations. Therefore, to accomplish the purposes of the physical examination, you must be skilled in the techniques of inspection, palpation, percussion and auscultation.

You must also have a sound basic knowledge of anatomy and physiology and of the symptomatology of the disease process with which the patient presents.

You must learn to observe with the 'seeing' eyes, hear with the 'hearing' ears, feel with 'feeling' hands and interpret the findings of the examination

At the completion of the nursing history and health assessment, you should inform the patient how the data will be used, the conclusions that will be drawn, and the fact that they and their family or significant others will be involved in developing the plan for care. By the termination of the assessment they should know who you are as their nurse and how they can communicate with you.

You are familiar with performing a physical examination which is usually carried out following the health history. In order to facilitate the data collection process, the assessment is performed in well lit, warm area. The patient is undressed and draped appropriately so that only the area to be examined is exposed.

The physical and psychological comfort of the patient is considered at all times. If a particular manoeuvre may cause discomfort, an explanation of what to expect precedes that part of examination. Fingernails are kept short to avoid injuring the patient. The examination is to be performed in an organised and systematic manner. This encourages cooperation and trust on the part of the patient.

The patient's health history provides you with a complete health profile that guides all aspects of the physical assessment. In addition, it helps you to focus on body organs and systems that are of particular concern to the patient.

The basic tools of the physical examination are the human senses of vision, hearing, touch and smell. These human tools may be augmented by special man-made appliances,

for example, stethoscope and ophthalmoscope.

The first fundamental process in physical examination is inspection, and the power to

observe must be cultivated.

A general inspection is carried out at the first contact with the patient

While creating rapport by introducing yourself to the patient, shaking their hand and talking to them, many impressions register in this

exchange, and numerous valuable observations can be made.

For example, age can be assessed, the general appearance whether thin or fat, anxious or depressed, body structure normal or deformed, posture and stature, body movements, nutritional status, speech pattern and body temperature. The physical examination requires a systematic approach of a head to toe and is accompanied by:

∙Taking vital signs such as temperature, pulse, respiration and blood pressure

∙Measuring height, weight, fluid intake and output

∙Auscultating for body sounds of the lungs,

the	navel	and	other	organs
using stethoscope

∙Palpating soft areas of the body to check for solid masses, abnormal rigidity or

tenderness

You will review physical examination again when you study the clinical diagnosis.

Nursing Diagnosis

After the completion of the nursing history and the health assessment, you should analyse, synthesise and summarise the data collected and determine the patient's need for nursing care. You should also identify the actual or potential health problems responsive to resolution by nursing actions as nursing diagnosis.

When developing the nursing diagnosis for a particular patient, you must first identify the commonalities among the assessment data you have collected. These common features lead to the categorisation of related data that reveals the problem that needs nursing intervention. Therefore, the patient's nursing problem is defined as the nursing diagnosis.

Remember that nursing diagnosis is not medical diagnosis or medical treatment or diagnostic studies. Nursing diagnoses are the patient's actual or potential problems that are

enumerable to resolution by nursing actions. Nursing diagnoses that are succinctly stated in terms of the specific problems of the patient will guide you to develop a nursing care plan.

Recording the Nursing Diagnosis

You should record the patient's nursing diagnosis in the nursing care plan as well as in the patient problem list.

A problem is defined as anything that concerns the patient, endangers their health, requires management and concerns any member of the health care team.

You have already gone through the assessment steps of the nursing process by looking at the data collection methods, that is, interview, observation, physical examination and taking vital observations.

Remember you will be required to utilise communication, interpersonal and client- provider skills in conducting the assessment, collecting and analysing data using subjective and making objective observations and performing the necessary physical examination. This is followed by formulating a nursing or medical diagnosis to clarify client's needs.

Then comes arranging the client's needs accordingly in order of priority, and forming partnership with clients in assessing their care needs and determining appropriate intervention strategies to address them.

Planning

Once you identify the nursing diagnosis, the next step is to develop the planning components of the nursing process. This phase involves:

∙Setting priorities to the nursing diagnoses specifying immediate, intermediate and long term goals of nursing action

∙Identifying specific nursing interventions, appropriate for attaining goals.

∙Identifying interdependent interventions

∙Documenting the nursing diagnosis, goals, nursing interventions and expected outcomes on the nursing care plan

During this phase of the nursing process, it is your responsibility to communicate with the appropriate persons any assessment data indicative of health needs that can be met by other members of the health care team.

Setting Priorities

Setting priorities for the nursing diagnoses should be a process of collaboration between you and the patient or their family members.

Consideration must be given to the urgency of the problem, with the most crucial problems receiving the highest priority.

Maslow's hierarchy of needs provides a useful framework for the determination of priority problems. The use of this hierarchy requires that high priorities be given to physical needs. After the priorities of the physical needs are met, subsequent priorities are reassigned according to the urgency of needs at other levels of the hierarchy.

Establishing Goals for Nursing Action

After establishing the priorities of the nursing diagnosis, identify the immediate, intermediate and long-term goals and the nursing actions appropriate for the attainment of your goals. You should include the patients and the family in the establishment of the goals for the nursing actions.

∙ Immediate Goals Immediate goals address existing problems.

∙Intermediate Goals Intermediate goals address the potential problems likely to occur in the near future.

∙Long Term Goals Long term goals require longer periods of time for their accomplishment. This usually involves prevention of complications and further health problems, health education and rehabilitation.

You should involve the patient and the family in

decision-making about the nursing interventions to meet the goals. Involvement of the patient and the family in the planning of

nursing interventions promotes their cooperation in the implementation of the nursing care.

The identification of appropriate nursing interventions and their related goals depends on your recognition of the strengths and potential of the patient and the family; his understanding of the patho-physiological alterations that he experiences and his sensitivity to his emotional, psychological and intellectual response to his state of illness.

In addition, your knowledge of nursing, your clinical experience and awareness of available supporting resources influence the validity of the nursing interventions that you identify as appropriate in resolving the patient's nursing diagnosis.

Establishing Expected Outcomes

You should state the expected outcomes of the nursing interactions.

These outcomes should be stated in terms of the patient's behaviour. They should be realistic and measurable.

What you should realise is that:

∙The outcomes that define the expected behaviour of the patient will serve as the basis for evaluation of the

effectiveness of the nursing interventions.

∙The critical time periods provide a time frame for determining effectiveness of the nursing interventions and existence of a need for additional or altered nursing care.

Formulating the Nursing Care Plan

The nursing care plan serves to communicate the following information to all members of the nursing team:

∙The nursing diagnosis and priorities

∙The goals of the nursing intervention

∙The nursing interventions which are expressed in the form of nursing orders

∙The expected outcomes which identify the expected behavioural responses of the patient

∙The critical time periods within which each outcome must be met

You must write down the precise behaviour expected in the nursing care plan. It should be written in a systematic manner that facilitates its use by all nursing personnel. You should provide space in the care plan for the documentation of the patient's response in the nursing interventions and the outcomes.

The nursing care plan is subject to change as the patients problems change or as the priorities of the problem and resolution of the problems shift and as additional information about the patient's state of health is collected.

As you implement nursing interventions, the patient's responses are evaluated and documented and the care plan changed

accordingly. A well-developed and continuously updated nursing care plan is the greatest assistance to the patient, since their nursing diagnosis will be resolved and their needs will be met.

many members of the nursing team and health care team are involved in the patient's care. Continuous updating of the care plan is of paramount importance in ensuring coordination and continuity of care.

Recording Outcomes

The implementation phase of the nursing process is concluded when the nursing interventions have been completed and the patient's responses to them have been recorded. You should concisely and objectively make the recordings.

The recordings should:

∙Relate to the nursing diagnosis

∙Describe the nursing interventions and the patient's response to the interventions

∙Include any additional pertinent data

You can make good evaluation after accurate recording. Documentation of information therefore provides the basis for the measurement of the patient's behavioural response to the nursing intervention.

Evaluation

Evaluation is the final component to the nursing process. It is directed towards determining the patient's response to the nursing intervention and the extent to which the goals have been achieved.

The nursing care plan, therefore, provides the basis for evaluating the nursing diagnosis, goals, and nursing interventions. Expected outcomes provide the specific guidelines that dictate the focus of evaluation.

What is the rationale for using the Nursing Process

Did you think of the following?

∙Introduces a concept of objective measurement into nursing management at the bed side.

∙Compels the nurse to look more closely at the problems as the patient sees them, rather that assuming them.

∙Defines what the nursing role is all about and creates a boundary within which to safely practice clinical skills.

∙Establishes nurse patient relationship on a firm basis because it is objective and is a total technique.

∙Is a research tool for collecting retrospective, current and prospective data

This second unit of the first module lays down principles, concepts and basic procedures to be applied in clinical practice. Most of the content is based on what you have already learnt during your Kenya Enrolled Community Health Nursing course.

This unit is composed of four sections: Section One: Concept of Infection Prevention and Control.

Section Two: Basic Nursing Procedures.

Section Three: Diagnosis and Treatment of Minor Illnesses.

Section Four: The Principles of Safe Drug Use.

Unit Objectives

By the end of this unit you will be able to:

∙Describe the concept of infection prevention and control

∙Describe basic nursing procedures

∙Diagnose and treat minor illnesses

∙Describe the principles of safe drug use

SECTION 1: INFECTION PREVENTION AND CONTROL

In this first section you will cover the concept of Infection Prevention and Control.

The focus of infection prevention is to minimise the risk of transmitting infections to patients, service providers, supportive staff, house keeping personnel and members of the community.

The goal of infection prevention is to minimise post procedure infections in patients and prevent transmission of life threatening infections to patients, service providers, auxiliary staff and members of the community (AVSC 1999).

Objectives

By the end of this section you will be able to:

∙State an overview of infectious diseases

∙Describe the disease transmission cycle and those at risk of infection

∙List some standard precautions

∙List common antiseptics, disinfectants and aseptic techniques

∙Describe the use and disposal of needles and

other sharps

∙Describe the processing of instruments and

other items

∙Describe decontamination and sterilisation

∙Describe the storage of sterile equipment

∙ Describe housekeeping and waste disposal

The Concept of Infectious Diseases

Over the past few decades Kenya has experienced a drastic change in the pattern of infectiousdiseases. Some of those that had been eradicated are re-emerging, and new ones are being identified. There have also been sporadic outbreaks of diseases such as cholera, measles, the plague, and yellow fever. New viruses such as the Hepatitis B and C have become increasingly common. The situation has been made worse by the fact that some micro-organisms are rapidly developing resistance to common antibiotics. Hospital acquired infections are on the increase. This drug resistance, combined with the high HIV/AIDS prevalence, makes infection prevention and control extremely important The World Health Organisation WHO (1996) observes that millions of people all over the world suffer and even die of hospital acquired infections which have become known as nosocomial infections.

These hospital acquired diseases range from trivial to life threatening conditions such as septicaemia. It is thought that this spread may be due to the advance in medicine that exposes patients to more surgical and medical invasive procedures which increase the risk of infection. It is important to note that shortage of resources may have contributed to some nosocomial infections.

Globally the most frequent infections are: surgical wounds infection, lower respiratory tract and urinary tract infections. The emergence of highly infectious diseases such as the Viral Haemorrhagic Fevers (VHF) also increases the risk of hospital acquired infection.

Health care facilities are ideal settings for the transmission of infections because the invasive procedures routinely performed on patients have the potential of introducing micro- organisms into the body.

Who is at Risk of Infection?

The service providers in health care facilities are at high risk because they constantly perform procedures that expose them to infections. They can easily spread an infection they have contracted at the health facility to their families because of poor infection prevention practices.

The community is also at risk of infections if they come into contact with medical waste such as contaminated sharps, dressings, tissue and chemical waste that have been inappropriately disposed

Everyone who works at a health care facility is potentially at risk of infections.

The Disease Transmission Cycle

Infectious agents survive, grow or multiply in a reservoir and then leave the reservoir through a place of exit by a modeof transmission.

The infectious agents then enter the susceptible host through a place of entry. Micro-organisms are normally present on people’s skin, respiratory, intestinal and genital tracts. These micro-organisms are called normal flora. Micro-organisms not normally found on or in the human body are associated

with disease and are known as pathogens.

All micro-organisms can cause infection or disease.

This happens when:

∙The normal flora are introduced into an area of the body in which they are not normally found

∙Pathogens are introduced into the body

∙Micro-organisms are introduced into the

body of a person who is immuno- compromised and thus susceptible to infections

The mode of transmission is the easiest point at which to break the disease transmission cycle. In a health care facility, this can be accomplished by following appropriate infection prevention practices, such as washing the hands before and after procedures, practising aseptic technique and correctly processing instruments

Transmission of Infection in the Health Care Setting

In the health care setting infection can be transmitted:

∙When the health care worker’s skin is pierced or cut by contaminated needles or other sharp instruments

∙When the health care worker’s broken skin (cuts, scratches, rashes, chapped skin, fungal infections) comes into contact with the patient's blood or other body fluids

∙When the patient's blood or other body fluids are splashed on the healthcare worker’s mucous membranes (eyes,

nose, mouth)

All cases of transmission of Hepatitis B and HIV from patients to health care workers have

occurred through accidents such as needle stick injuries.

Furthermore, as a health worker you can spread infections from one patient to another and from patients to yourself, your family and the community.

Infectious diseases could be minimised or eliminated by adhering to medical principles and practices that reduce cross infection in healthcare settings. The spread of most infections can be controlled by observing basic infection prevention control guidelines and proper and adequate treatment of primary cases.

The WHO’s guidelines demand that you should treat all patients as potentially infectious. Furthermore, WHO stipulates proper precaution and use of correct and appropriate protective gear when dealing with or handling blood and blood products, body fluids or contaminated equipment.

According to WHO guidelines, you should:

∙Observe and maintain good personal hygiene and wear appropriate attire.

∙Be vaccinated against vaccine preventable conditions, especially if you are working in high risk areas.

∙If you work in vulnerable areas, for example areas where you handle cooked food, you should be periodically screened for certain diseases, such as typhoid.

∙If you are suffering from infectious conditions and you are working with

susceptible patients, for example, in an operating room, special care baby unit, or the ICU burns unit, you should be re- deployed until you are cleared of the infection.

Having looked at the overview of infection prevention and control, you will now look at it in some more detail.

How can you spread infections from one patient to another or to your family and community?

∙If you do not wash your hands before and after contact with patients, or when you do not wash your hands before leaving the health facility and then touch members of your family or household items

∙When you use surgical instruments, such as needles, syringes and other equipment that have not been processed properly

∙When medical waste is not disposed of properly, members of the community may come into contact with that waste

∙When you contaminate your clothing or hair in the course of rendering care to patients

∙When you contract infections and spread them to some members of your family, they will in turn spread them to other members of the family, who in turn will spread them to others in the community

Definition

The focus of infection prevention is to the utilisation of procedures and techniques in the surveillance investigation and compilation of statistical data in order to minimise the spread of infection.

Goal

The goal of infection prevention is to minimise post procedure infections in patients and prevent transmission of life threatening infections to patients, service providers, auxiliary staff and members of the community (AVSC 1999).

Infection Prevention Practices

Adherence to appropriate infection prevention practices breaks the cycle of spreading infections at the mode of transmission stage.

This will:

∙Prevent post procedure infections

∙Result in high quality, safe services

∙Prevent infections in service providers and supportive staff

∙Protect the community from infections that originate in health care facilities

∙Prevent the spread of micro-organisms that are resistant to antibiotics

∙Lower the cost of health care services

Standard Precautions

Standard precautions are a set of clinical practice recommendations designed to help minimise the risk of exposure to infectious materials, such as blood and other body fluids by both patients and staff. They help break the disease transmission cycle at the mode of transmission step.

A standard procedure is a procedure that should be followed routinely at all times. It should apply to every patient regardless of their presumed infection status. This is because you will not be able to tell who is infected with viruses such as HIV or hepatitis. Even the infected persons themselves may not know that they are infected. You should therefore follow the standard precautions when dealing with every patient.

You will now cover these precautions in more detail.

Hand Washing

Washing your hands before and after contact with each patient is the single most effective method of preventing/decreasing transfer of micro-organisms between you and the patients within a health facility. This method is easy to follow and is an inexpensive procedure. The purpose of hand washing is to remove soil, organic material and transient micro-organisms from the skin.

Think of five appropriate times for washing your hands whilst at work.

∙Immediately after arriving at work

∙Before examining each patient

∙After examining each patient

∙After touching accidentally any instrument

or object that might be contaminated with blood or other body fluids

∙After touching mucous membranes, e.g. eyes, nose, mouth

∙After un-gloving since hands can be contaminated if gloves contain invisible holes or tears

∙After using the toilet or latrine

∙Before eating

∙Before leaving work at the end of the day

The three elements that are essential for effective hand washing are:

∙Soap

∙Running water

∙Friction

Four types of hand washing

Routine hand washing using plain soap and running water

Routine hand washing removes transient

micro-organismsandsoil, blood or other organic material from the hands. This method is appropriate in most situations and the hands should be washed as frequently as possible

Hand washing with antiseptic and running water

In this method, transient micro-organisms and soil are removed.

It kills or inhibits the growth of resident micro-

organisms.Moreover, it may reduce the risk of infections in high risk situations, such as:

∙ When there is heavy microbial contamination

∙Before performing invasive procedures such as vein punctures and other aseptic procedures

∙Before contact with patients who have immune defects, for example, patients with burns, leukaemia etc.

Alcohol hand rub

Alcohol hand rub kills or inhibits the growth of most transient and resident micro-organisms but does not remove all micro-organisms or soil. It can be used when hand washing with soap and running water is not possible as long as hands are not visibly soiled with dirt, blood or other organic material.

Surgical hand scrub

Scrubbing with antiseptic before beginning surgical procedures will help prevent the growth of micro-organisms for a period of time.

It will also reduce the risk of infections to the patient if the gloves are damaged.

Policy Statement

1.Patients and family members shall be instructed in proper hand washing.

2.The patient’s hands shall be washed before eating, after toileting and when soiled.

3.The health care facility approved soap shall be used for routine hand washing.

4.Repeat hand washing shall not be done in the same container of water.

5.Hands shall be washed under running water.

6.Hands shall not be dried on personal

clothes, wet and soiled towels. Air blow

driersare not recommended.

7.Hands shall be washed immediately on arrival at work.

8.Whenever there is a chance of contamination.

9.Before putting on gloves for performing

clinical procedures such as insertion of

IUDor invasive procedures.

10.Before putting on gloves for performing invasive procedures.

11.Between certain procedures on the same patient where soiling of hands is likely, to avoid

cross-contamination of body sites.

12.After contact with items known or considered likely to be contaminated with

blood,body fluids, secretions or excretions (e.g. bedpans, urinals, wound dressing), whether or not gloves are worn.

13.After touching blood, body fluids, secretions excretions, exudates from wounds.

14.Before and after gloves are removed.

15.Before medication preparation.

16.Before preparing, handling, serving or eating food and before feeding a patient.

17.After diapering or toileting children.

18.When hands are visibly soiled.

19.After personal body functions such as using the toilet, wiping or blowing one’s nose.

20.Before leaving work.

You should wash your hands with antimicrobial soap or an antiseptic solution which should then be followed by good rinsing under running water. This is a more effective method of removing and killing transient micro-organisms.

Vigorously rub soaped hands for 15-30 seconds and then rinse under running water.

Plain water removes 50% of transient micro-organisms, while soap removes 80-

90%of micro-organisms.

After washing your hands you should dry them with a clean towel or air dry them.

Be aware that shared towels can become contaminated quickly.

Personal Protective Equipment

These are physical barriers used to prevent transmission of infection to the patient or from the patient to the persons attending them, for example, gloves, gowns, surgical masks and protective eye wear

Gloves

Gloves provide a barrier against potentially infectious micro-organisms in blood, other body fluids, and medical waste, thus lowering the risk of transmitting infections to both health care workers and patients. Gloves also protect against hazardous chemical waste. You should wear gloves whenever you may come into contact with patient's blood and other body fluids, for example, while:

∙Providing clinical services

∙Handling or cleaning used instruments and other items

∙Performing housekeeping activities

∙Use a new pair of gloves for each patient! Disposable gloves are used once and then thrown away

∙Disposable gloves are preferable to renewable gloves because it is difficult to properly process gloves. Disposable gloves should never be processed or reused

TYPES OF GLOVES

Sterile Surgical Gloves or High Level Disinfected Surgical Gloves

These should be worn during all procedures in which your main aim is to avoid introduction of pathogens into the patient, for example during:

∙Surgical procedures

∙Insertion of Norplant implants

∙Pelvic examination of women in labour Disposable surgical gloves are recommended for use.

Single use examination gloves

Single use means discard gloves after use. These should be worn for all procedures in which you will be in contact with intact mucous membranes, such as:

∙IUCD insertion

∙Manual vacuum aspiration

∙Pelvic examination

Also where the primary purpose of wearing gloves is to reduce the risk of you being exposed to blood or other body fluids for example:

∙When drawing blood

∙When working in the laboratory

Gowns and Aprons

These should be made of waterproof material

and worn full size to give maximum protection. They should be

used when splashing of blood or other body fluids or when any other

potentiallyinfectious materials are anticipated, for example during:

∙Surgical operations

∙While conducting deliveries

∙During intubations and sanctioning procedures

∙Any other procedure/activities where splashing is anticipated

Masks and Eye Shields

These provide some protection against

airborne pathogens and shield against splashes. They should be worn during

dentalsurgery,when conducting deliveries and endoscopies or in

anyothersituations where splashing or spattering is anticipated.

Headgear and Boots

Caps are worn full length to cover the head.

Boots and shoe covers should be waterproof and should be cleaned

frequently.	These	should
be used in operative procedures.
Appropriate and	Adequate	Instruments

Processing

While tackling this topic we will deal with the following aspects:

∙Antiseptics and disinfectants

∙Aseptic technique

∙Use and disposal of needles and other sharp objects

∙Decontamination and preparation of chlorine solutions

∙Cleaning instruments and other items

∙Sterilisation and storage

∙High level disinfection and storage

∙Waste disposal

Move on to look at these one by one.

Antiseptics and Disinfectants

An antiseptic is a chemical agent used on the skin and mucous membrane to remove or kill micro-organisms without causing damage or irritation to the skin and mucous membranes. An antiseptic may also prevent the growth and development of micro-organisms.

Antiseptics are not meant to be used on inanimate objects, such as instruments and surfaces (AVSC, 1999). You can use antiseptics for surgical hand scrub, skin preparation as well as cervical and vaginal preparation before a clinical procedure.

Disinfectants are chemical agents used to kill micro-organisms on inanimate objects, such as instruments and surfaces. Disinfectants are not

meant to be used on the skin or mucous membranes (AVSC, 1999).

There are two types of disinfectants: high level and low level.

High Level Disinfectants

High level disinfectants kill bacteria, viruses, fungi and some bacterial endospores. Some high level disinfectants can be used to sterilise equipment and if given sufficient time to act, they are able to destroy bacterial endospores that cause diseases such as tetanus and gas gangrene. Bacterial endospores are difficult to kill because of their protective casing or coating.

High level disinfectants are also used for processing instruments and other items.

Do not soak or store cheatle forceps, scissors, scalpel blades and suture needles in a disinfectant solution for a very long time.

Should you need to sterilise them using high level disinfectant solution, soak them only for a specified time, remove, rinse and store dry.

What you should also note is that micro- organisms can live and multiply in disinfectant solutions which can in turn contaminate the instruments and other items, leading to infections. This topic will be covered in more detail later.

Low Level Disinfectants

Low level disinfectants kill most bacteria and

some viruses and fungi but do not kill tuberculosis causing micro-

organismsandbacterial endospores. They are used for cleaning

surfaces	such	as	floors	and
countertops.	They should		not be	used for
processing			instruments

and other items.

Common Antiseptics and Disinfectants

You are by now aware that the use of antiseptics and disinfectants may vary from hospital to hospital.

Antimicrobial Spectrum

Advantages

Disadvantages

Comments

Antimicrobial Spectrum

Advantages

Disadvantages

Comments

Common Low Level Disinfectants

Examples of low level disinfectants (LLDs) are phenols (carbolic acid such as phenol, lysol) and quaternary ammonium compounds (berzal conium chloride – zephiron). They are commonly used to disinfect walls, floors and furnishings.

Instruments and items such as cheatle forceps, scissors, scalpel blades and suture needles should not be left soaking indefinitely or stored in a disinfectant solution.

Aseptic Technique

During your nursing practice you have probably been performing several sterile procedures such as:

∙Wound dressing

∙Administration of an injection

∙Removing stitches, staples and clips

∙Shortening or removing drains

∙Urinary catheterisation

∙Surgical asepsis in an operating room

Aseptic can be defined as "free from sepsis or germ free".

A technique is a method or skill used for a particular task or technical proficiency. Other definitions of technique are: art, artistry, craft, proficiency, skill, touch.

Weller, (1996) defines aseptic technique as:

“A method of carrying out sterile procedures so that there is the minimum of risk of introducing infection.”

This is achieved by the sterility of equipment and a non touch technique. Brunner and Sudarth (1988) state some basic rules with regards to surgical asepsis as follows:

“Only sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile. In contrast, un-sterile contact at any point renders a sterile area contaminated. If there is any doubt about the sterility of an article or area, it is considered un-sterile.”

Also note whatever is sterile for one patient can only be used for that patient. Unused sterile supplies must be discarded or re- sterilised if they are to be used again.

You must pour sterile fluids from a point high enough to prevent accidental touching of the receptacle, but this should not be so high as to produce splashing which causes the fluid to touch an unsterile surface then flow back into the receptacle causing contamination.

The aseptic technique is applied when performing sterile procedures whether in general nursing, midwifery or community health nursing.

The practices performed just before or during a clinical procedure include hand washing, surgical hand scrub, using barriers such as gloves and surgical attire, proper preparation of a patient for clinical procedures, maintaining a sterile field, using good surgical technique and maintaining a safer environment in the surgical/procedure area.

You will now look at some of the components that have not been covered, beginning with proper preparation of a patient

fora clinical procedure.

Preparing a Patient for Clinical Procedures You have already been preparing patients for a variety of clinical procedures. You must have used some of the antiseptic solutions that were covered earlier.

why you use antiseptic solution on the patient's skin, vagina or cervix

Destroy or prevent the growth of micro- organisms.” You will realise that it is very important to pay proper attention to the preparation of a patient before a procedure because most surgical site infections result from contamination during surgery. To reduce

the risk of infections if you must shave the surgical/procedure site, use antimicrobial soap and water or shave dry. On the other hand, you could shave immediately before the operation, in the operation room or procedure room

Preparing the Skin

Clean the site with soap and water. Wipe the skin in a circular motion, beginning in the centre of the site then moving outwards. Use sterile cotton balls or cotton wool sponges held on sponge forceps. You could use any of the following antiseptics as listed in the preferred order:

∙An iodophor (Betadine); then wait for two minutes and wipe off the excess with sterile dry cotton or gauze

∙4% Chlorhexidine (HIbiclens) wipe off excess with sterile, dry cotton or gauze

∙1-3 % iodine, followed by 60-90% alcohol (ethyl or isopropyl) then allow to air dry

∙Chlorhexidine with cetrimide (Savlon) wipe off the excess with sterile, dry cotton or gauze

Preparing the vagina and cervix Apply an appropriate antiseptic (iodophor) to the vagina and cervix before passing instruments into the uterus such as IUD insertion, uterine evacuation. Alcohol based antiseptics should not be used on the vagina, cervix or other mucous membranes because they are damaging to these tissues.

Maintaining a Sterile Field

Think about how you can maintain a sterile field.

You can maintain a sterile field by placing sterile towels and/or surgical drapes around the surgical/procedures site. Other measures include:

∙Placing only sterile items within the sterile field

∙Opening, dispensing or transferring sterile items without contaminating them

∙Considering items located below the level of the draped client to be unsterile

∙Not allowing sterile personnel to reach across unsterile areas and touch unsterile items

∙Not allowing unsterile personnel to reach across the sterile field or to touch sterile items

Think about how you can maintain a safe environment in the surgical/procedure area. You are aware that specific rooms have been designed for performing surgical/clinical

procedures and processing instruments and

otheritems. You often hear of dressing room or treatment room, autoclaving room and so on. In these rooms traffic is controlled. Other activities are minimised or prohibited. This is because the number of people and amount of activity in them influences the number of micro- organisms and the risk of infections. You must therefore:

∙Limit the entry of unauthorised individuals to surgical/procedure areas

∙Close doors and curtains during all procedures

∙Require that personnel in the surgical area wear clean clothes, a mask, a cap and sturdy footwear

∙Enclose surgical procedure area to minimise dust and eliminate insects

∙Air-condition the room if feasible

∙Disinfect and clean examination/operating tables, instrument trolleys, light handles and any other surfaces that may have been contaminated with blood or other body fluids during a procedure before bringing in a new patient into the room

Use and Disposal of Sharps

You are aware that careless disposal of contaminated sharps can cause infections in the health care facility and the community. Make hypodermic needles and other sharps unusable by incinerating them.

Alternatively the risk of infections can be reduced by decontaminating sharps before disposal, and burying them in a pit to make it difficult for others to scavenge them.

Decontamination is performed by soaking instruments and other items immediately after use, in 0.5% Chlorine solution for ten minutes. Decontamination is done in order to kill viruses (such as Hepatitis B, other hepatitis viruses and HIV) and many other micro-organisms, making instruments and other items easier to clean by preventing blood, other body fluids and tissue from drying on them

Disposing of Sharps

Sharps such as needles, scalpels and so on, are to be handled with extreme caution to avoid injuries during use, disposal or reprocessing. Used needles should not be

recappedbyhand. If necessary use the single hand “scoop” method. With one hand, hold the syringe and use the needle to “scoop up” the cap. Used needles should not be bent or broken after use.

Do not remove the needle from the syringe by hand. Dispose of the needle and attached syringe in a puncture-resistant sharps disposal container

A sharps disposal container may be a heavy cardboard box or an empty plastic or metal container. At all times obey the following rules:

Section

1:

Infection Prevention and Control

∙Dispose of “sharps disposal containers”

when they are three quarters full to reduce the chance of injury when disposing of sharps

∙Dispose of used sharps immediately after use in designated puncture resistant containers labelled with a biohazard symbol and placed in the area where the items were used, for transport to the incinerator/pit for disposal

∙These containers should not be located in areas open to the public

∙Discard used syringes and needles as a unit in the designated puncture resistant container

∙Hold reusable syringes, needles or sharps in a puncture resistant leak proof container labelled with a biohazard sign for transport to the re-processing area

∙Do not pick up a handful of sharp instruments simultaneously

∙Exercise caution when rotating instruments in use

∙Position sharp end of instruments away from yourself and others

∙Do not break, recap or manipulate by hand used needles

∙Wear heavy duty/strong utility gloves during decontamination, cleaning and disinfecting instruments

∙Contact the supervisor immediately if you are injured by sharps

A sharps disposal container may be a heavy cardboard box or an empty plastic or metal container. At all times obey the following rules:

∙Dispose of “sharps disposal containers” when they are three quarters full to reduce

the chance of injury when disposing of sharps

∙Dispose of used sharps immediately after use in designated puncture resistant containers labelled with a biohazard symbol and placed in the area where the items were used, for transport to the incinerator/pit for disposal

∙These containers should not be located in areas open to the public

∙Discard used syringes and needles as a unit in the designated puncture resistant container

∙Hold reusable syringes, needles or sharps in a puncture resistant leak proof container labelled with a biohazard sign for transport to the re-processing area

∙Do not pick up a handful of sharp instruments simultaneously

∙Exercise caution when rotating instruments in use

∙Position sharp end of instruments away from yourself and others

∙Do not break, recap or manipulate by hand used needles

∙Wear heavy duty/strong utility gloves during decontamination, cleaning and disinfecting instruments

∙Contact the supervisor immediately if you are injured by sharps

Steps for Decontaminating Reusable Hypodermic Needles and Syringes

Take the following steps to decontaminate reusable hypodermic needles and syringes:

1.Drop the needle and syringe into a container of 0.5% chlorine solution, and let them soak for ten minutes.

2.Remove the needle and syringe from the solution, using cheatle forceps or by hand,

if	hands	are	protected	by
utility gloves.

3.Rinse by flushing with clean water, or clean immediately.

Management of Injuries from Needles and Other Sharps

∙Wash needle stick cuts with soap and water.

∙Flush the nose, mouth or skin with water if splashed with blood or body fluid.

∙Irrigate the eyes with water or saline if splashed with body fluid.

Post-exposure Prophylaxis Post-exposure prophylaxis with drugs can reduce the risk of transmission of some blood borne pathogens. Following exposure to blood or other body fluids, a number of factors have to be considered. These include:

∙The infection status of the source patient (the patient whose blood or other body fluids are involved)

∙The type of exposure for example: a splash to the skin, or a deep puncture wound by a very bloody needle

∙Whether or not the exposed person has been vaccinated against Hepatitis B, how

much time has passed since the exposure, the availability of the required drugs or other therapy

The prophylaxis will include:

∙For Hepatitis B: Hepatitis immune globulin and Hepatitis B vaccine can reduce the risk of infection after exposure to blood and other body fluids containing the Hepatitis B virus

∙For HIV: Several antiretroviral drugs are used either alone or in combination. These include: Zidovudine (AZT, Retrovir), Lamivudine (3TC, Epivir) and Nelfinavir (viracept)

∙For Hepatitis C: There is no post exposure prophylaxis available for Hepatitis C

Giving Injections

In order to reduce the risk of transmitting infections between patients, you should always adhere to the following:

∙Every time you give an injection, use a new or correctly processed hypodermic needle and syringe.

∙Do not change the needle without changing the syringe between patients.

∙Reusing the same syringe to give injections to many clients is not a safe practice

While administering intravenous fluids you have the responsibility to avoid the transmission of infections.

You must therefore do the following:

∙Unhook the needle or catheter from the IV

lineand dispose of it in a sharps disposal container

∙Throw away any remaining fluid

∙Do not use the same IV line and fluid bag/bottle with multiple clients

Use of Multi Dose Vials

Before you fill a syringe from a multiple dose vial:

∙Check the vial to be sure there are no leaks or cracks.

∙Check the solution to be sure it is not cloudy and that there is no particulate matter in the vial.

∙Wipe the top of the vial with a fresh cotton swab soaked with 60-70% alcohol.

∙Allow to dry.

To reduce the risk of transmitting infections between patients:

∙Always use a sterile needle and syringe every time medication is withdrawn from a

multipledosevial. Reusing the same syringe to give injections to multiple patients, even if the needle is changed is not a safe practice.

∙Do not leave a needle inserted in the vial cap for purpose of withdrawing drugs from a multiple dose vial. This provides a direct route for micro-organisms to enter the vial.

Processing of Instruments and Items

You are now going to cover the processing of instruments in more detail. It is important to bear in mind that when you are involved in the processing of instruments and other items, you are at high risk of infection. You therefore need to take appropriate steps to reduce this risk.

You are at risk of exposure to blood or other body fluids when processing instruments and other items.

You are at a risk of exposure if:

∙You have open cuts on the hands or forearms

∙You have chapped or cracked hands

∙You get injuries from needle sticks or other sharp instruments such as scalpels

∙There is splashing of blood or other body fluids contained on the instruments or other items onto mucous membranes such

as the eyes

The measures you should take to protect yourself when handling instruments and other items focus on:

∙Destroying as many micro-organisms as

possible	early	in
the process

∙Preventing blood and other body fluids from coming in to contact with the skin or membranes

Always wear gloves when handling potentially contaminated instruments and other items

Steps of Processing Instruments and Other Items

Processing instruments and other items involves steps that reduce the risk of transmitting infections from used instruments and other items, to you, other health workers and patients.

These steps are decontamination, cleaning and either sterilisation or high level disinfection.

Decontamination

Decontamination is the first step in processing instruments and other items for re-use. Decontamination kills viruses and many micro- organisms, making the instruments and other items safe to handle by the staff who clean

them. Decontamination also makes instruments and other items easier to clean by preventing blood, other body fluids and tissue from drying on them. Decontamination is done by soaking instruments and other items immediately after use, in a 0.5% chlorine solution for 10 minutes immediately after use (AVSC, 1999). A container of this solution should be kept in every operating room and procedure room so that used items can be placed directly into the bucke

Prepare a new chlorine solution at the beginning of each day or when the solution looks as though it needs to be changed, such as when it becomes heavily contaminated with blood or other body fluids or becomes cloudy.

Preparing a Chlorine Solution

A chlorine solution can be made from household liquid bleach (sodium hypochlorite), commonly known as JIK, or chlorine compounds available in powder form (calcium hypochlorite, chloramines, or chlorinated lime) or tablet (sodium dichloroisocyanurate) form. This is because of their low cost and wide availability. Chlorine solutions prepared from liquid or powdered bleach are recommended for decontamination.

Why is chlorine the most widely used product for preventing infections in health care settings

∙It is a proven and powerful killer of micro- organisms

∙It deodorises

∙It is economical to use

∙It leaves no poisonous residue and is not poisonous to people in the concentrations it is used

Preparing a Chlorine Solution

% Chlorine in liquid bleach -1=total parts of

water for each bleach % Chlorine desired

Example

To make a 0.5% Chlorine Solution from 3.5% bleach:

3.5% -1=7-1= 6 parts of water in each part of bleach

0.5%

Therefore, you must add one part bleach to six parts water to make 0.5% chlorine solutions.

'Parts' can be used for any unit of measure, for example, an ounce, a litre, or a gallon or any container used for measuring such as a pint.

Preparing a Dilute Chlorine Solution Using Bleach Powder

If using bleach powder, calculate the ratio of bleach to water by using the following formula:

% chlorinedesired

Number of grams of % chlorine in bleach powder powder for each litre of water

Example

If you need to make a 0.5% chlorine solution from calcium hypochlorite powder containing 35% active chlorine.

Try to calculate how many grams of powder for each litre of water using the formula above. 0.5% x 1000 = 0.0143 x 1000 = 14.3 grams

35%

Therefore, you must dissolve 14.3 grams of calcium hypochlorite powder in each litre of water used to make 0.5% chlorine solution. When bleach powder is used, the resulting chlorine solution is likely to be cloudy (milky).

Cleaning

This is the second step when processing instruments. It starts by scrubbing with a brush, detergent and water before instruments and other items are sterilised or high level disinfected to remove blood, other body fluids, organic material, tissue, and dirt.

Cleaning greatly reduces the number of micro- organisms including bacteria endospores on instruments and other items.

This is a crucial step in processing instruments

andotheritems. If cleaning has not been done, sterilisation and high level disinfection (HLD) may not be effective because:

∙Micro-organisms trapped in organic material may be protected and survive the sterilisation or HLD process

∙Organic material and dirt can make the chemicals used in chemical sterilisation and HLD less effective

Steps of cleaning:

∙Wear utility gloves, goggles, a mask and protective eyewear when cleaning instruments and other items.

∙Using a soft brush, detergent and water and scrub instrument and other items vigorously to completely remove all blood,

other body fluids, tissue and other foreign matter.

∙Hold instruments and other items under the surface of the water while scrubbing and cleaning to avoid splashing.

∙Disassemble instruments and other items with multiple parts, and be sure to brush in the grooves, teeth and joints of instruments and other items, where organic material can collect and stick.

∙Rinse instruments and other items thoroughly with clean running water to remove all detergents.

∙Allow instruments and other items to air dry, or dry with a clean towel. Instruments and other items should be dry before chemical high level disinfection to avoid diluting the chemicals, which may decrease their effectiveness. Instruments and other items to be high level disinfected by boiling or steaming do not need to be dried first

Thorough rinsing after cleaning is important, particularly with chemical sterilisation or high level disinfection (HLD), because detergents can reduce the effectiveness of these chemicals.

It is important to dry instruments and other items after cleaning them. The water from instruments and other items dilutes the chemicals used for chemical sterilisation or HLD, making that process ineffective. If instruments and other items will be high level disinfected by boiling or steaming, drying is not necessary.

Use of Detergents

Detergents are important for effective cleaning. Water alone does not remove proteins, oils or grease. When the detergent is dissolved in water it breaks and suspends oil and grease, making them easy to remove by cleaning.

Do not use hand soap for cleaning instruments and other items, because fatty acids contained in the soap will react with the minerals of hard water, leaving a residue or scum that is difficult to remove.

Avoid using steel wool or abrasive cleaners such as Vim or cement as they scratch or pit metal or stainless steel, which results in grooves that can collect micro-organisms. This also increases the potential for corrosion of the instruments.

Sterilisation

This is the process that eliminates all micro- organisms such as bacteria, viruses, fungi and parasites, including bacterial endospores.

Sterilisation is recommended for instruments and other items that come into contact with the bloodstream or tissues under the skin.

Sterilisation can be performed using steam under pressure (autoclaving or moist heat), dry heat

or chemicals.

Boiling and flaming are not effective sterilisation techniques because they do not effectively kill all micro-organisms. The effectiveness of sterilisation depends on:

∙The amount and type of micro-organisms

∙Absence of organic material (blood, other body fluids and tissues) or other matter such as dirt present on the instrument or other items

∙The potential the item has to hide or conceal micro-organisms

You are therefore to clean instruments and other items thoroughly before sterilisation to:

∙Reduce the number of micro- organisms

∙Eliminate blood, other body fluids, or tissue remains

∙Remove contaminants that may collect in joints, grooves and teeth of instruments and other items

Sterilisation is preferable to high level disinfection for instruments and other items that come into contact with the bloodstream and tissues, because it kills

micro-organisms including bacterial endospores

You will now move on to cover the three types of sterilisation one by one, starting with steam sterilisation

1.Decontaminate, clean and dry all instruments and other items to be sterilised.

2.Open or unlock all joined instruments and other items, for example, hemostats.

3.Disassemble scissors with sliding or multiple parts to allow steam to reach all surfaces of the item. Do not arrange the instruments and other items tightly together, or wrap gloves into tight balls because steam will not reach all surfaces.

4.Wrap instruments and other items in two layers of paper, cotton or muslin fabric before steam sterilisation. If you are using a drum, make sure the holes are open

5.Arrange all packs, drums or unwrapped items in the chamber of the autoclave in a way that allows steam to circulate freely.

6.Always follow the manufacturer’s instructions on how to operate the autoclave but sterilise wrapped items for

30 minutes and unwrapped items for 20 minutes at 121º C (250ºF) and 106 Kpa (15 Ib/in2 ) pressure.

7.If the autoclave is automatic, the heat will shut off and the pressure will begin to fall

once	the	sterilisation	cycle
is complete.

8.If the autoclave is not automatic, turn off the heat or remove the autoclave from the heat source after 30 minutes if items are wrapped, or after 20 minutes if items are unwrapped. Wait until the pressure gauge reads “zero” to open the autoclave.

9.Open the lid or door to allow the remaining

steam to escape. Leave instrument packs or items in the autoclave until they dry completely.

10.Remove the packs, drums or unwrapped items from the autoclave using sterile pick ups.

11.Place packs or drums on a surface padded with paper or fabric until they are cool to prevent condensation

12.Wait until the packs, drums or items reach room temperature before storing.

Storage of Autoclaved Items

Wrapped Items

Shelf life is the length of time a wrapped sterile item is considered sterile. Shelf life depends on whether or not a contaminating event occurs. Shelf life is affected by a number of factors which include:

∙Type of packaging material used

∙Cleanliness of the store

∙Humidity in the store

∙Temperature of the storage area

∙Storing the packs on open or closed shelves

∙Usage of dust proof covers

Storage time and handling of sterile packs should be kept to a minimum, since the likelihood of handling and contamination increases over time. Place sterile packs in closed cabinets in areas that are not heavily trafficked, have moderate temperature and are dry.

Unwrapped Items

Unwrapped items should be used immediately after removal from the autoclave. They can also be kept in a covered, sterile container for up to one week.

Dry Heat Sterilisation or Hot-Air Oven (Electric Oven)

This is the method of sterilisation that requires heat for a specific period of time.

This method is used for sterilising glass or metal objects because high temperatures are necessary. The steps to be followed in dry heat sterilisation are:

1. Decontamination: clean and dry				all
instruments	and	other	items	to
be sterilised.

2.Wrap the instruments and other items using foil or double layered cotton or muslin fabric on a tray or shelf.

3.Put unwrapped instruments and other items on a metal tray or shelf.

4.Place instruments and other items in the oven and heat to the designated temperature. The oven must have a thermometer or temperature gauge

5.Ensure that the designated temperature is reached:

Temperature	Time
170ºC (340ºF)	1 hour
160ºC (320ºF)	2 hours
150ºC (300ºF)	2½ hours
140ºC (285ºF)	3 hours

6.Leave instruments and other items in the oven to cool before removing.

7.When they are cool, remove instruments and other items using sterile pickups.

8.Immediately use unwrapped items.

9.Store wrapped items (storage procedure is as discussed under steam sterilisation).

Chemical Sterilisation

This is the method of sterilisation used for instruments and other items that are heat sensitive or when heat sterilisation is unavailable. Instruments and other items can be sterilised by soaking them in a chemical solution such as glutaraldehyde, followed by rinsing in sterile water.

Glutaraldehyde is irritating to the skin, eyes and respiratory tract. Wear gloves and limit your exposure time. Keep the area well ventilated when using it. Always follow manufacturer’s instructions before use

High Level Disinfection (HLD)

This is the process that eliminates all micro- organisms (including bacteria, viruses, fungi and parasites), but does not reliably kill all bacterial endospores which cause tetanus and gas gangrene.

HLD is suitable for instruments and other items that will come into contact with broken skin or intact mucous membranes.

HLD can be performed by boiling, use of chemicals or steaming

High Level Disinfection by Boiling Steps of HLD by Boiling:

1.Decontaminate and clean all instruments and other items to be high level disinfected.

2.Completely submerge all instruments and other items in the water in the pot or boiler. Open all hinged instruments and other items and dissemble those with sliding or multiple parts. Place any bowls and containers upright, not upside down, and fill with water.

3.Cover the pot or close the lid of the boiler and bring the water to a gentle, rolling boil.

4.When water comes to a rolling boil, start timing for 20 minutes. Use a timer or make sure to record the time that the boiling begins. Do NOT add or remove anything until 20 minutes are over.

5.Lower the heat to keep the water at a gentle rolling boil; too vigorous a boil will cause the instruments to bounce against each other and around the boiler. Lowering the heat at this level of the procedure saves fuel/energy.

6.After 20 minutes remove instruments using dry, high level disinfected cheatle forceps in a sterile (or high level disinfected) container. Protect from dust and insects. Allow to air dry before use or storage. They can only be used within one week provided they are properly stored.

Never leave the instruments in water. They can become contaminated as the water cools down.

High Level Disinfection Using Chemicals

∙Instruments and other items must be completely submerged in chemical solution. All hinged instruments must be disassembled.

∙Soak for 20 minutes, starting from the time when you dropped the instruments into the chemical.

∙Do not add or remove anything once the timing begins.

∙Rinse all instruments thoroughly with sterile water before use.

It is important to perform these steps in the appropriate order. Study the graphic illustrating this order.

To avoid contaminating instruments and other items after sterilisation or HLD, proper storage is as critical as properly processing the items.

Housekeeping

You may be wondering why should you learn house keeping and yet you are working in a health facility. Ask yourself, what is housekeeping?

Housekeeping refers to the general cleaning of baths, sinks, wash basins, beds, tables, floors, walls and other service areas.

What is Your Role in Housekeeping?

You are to ensure that a clean environment is achieved. Those charged with the cleaning responsibility remove visible dust and dirt routinely with water and detergent.

When it comes to micro biological control of the health care facility environment it relies on maintenance of smooth, dry and intact surfaces, prompt cleaning of spillage of body fluids, secretions and excretions and prompt removal of these substances from patient treatment areas.

Cleaning and maintenance prevent the build up of soil, dust or other foreign material that can harbour pathogens and support their growth. Cleaning is accomplished with water, detergents and mechanical action. It reduces or eliminates the reservoirs of potential pathogenic micro-organisms.

Warm, soapy water is adequate for cleaning areas not directly involved in patient care such as offices and duty rooms.

A disinfectant is required when cleaning areas with a large number of pathogens such as isolation areas, toilets, surfaces contaminated with infected body fluid spillages or areas

where susceptible patients are housed such as operating rooms, the neonatal unit, ICU or burns unit.

Cleaning Routine

The cleaning routine will depend on whether the area has a low risk or high risk of infection.

Low Risk Areas

These are areas such as walls, ceilings and floors. Clean walls and ceilings with water and detergent using a damp cloth.

Ensure routine damp dusting is performed. Always keep surfaces dry. Wipe chairs, lamps, tabletops and counters with a damp cloth, water and detergent.

Clean the floors regularly to keep them clean, using detergent and water, do not use dry brooms to avoid raising dust

High Risk Areas

To clean sinks, use a disinfectant cleaning solution with a cloth or brush, then rinse with clean water.

When cleaning toilets and latrines wear utility gloves and rubber boots. Use a disinfectant cleaning solution, scrub daily or as required with a separate cloth or brush.

Wear rubber gloves when cleaning waste containers. Use a detergent solution, scrub to remove soil and organic material. As a supervisor you may be required to demonstrate what you would wish to be done.

Cleaning Solutions

Solutions used for cleaning in a health facility include

Plain Detergent and Water

This is used for low risk areas and general cleaning tasks. Detergents remove dirt and organic material and dissolve or suspend grease and oil which can then easily be removed

by scrubbing

0.5% Sodium Hypochloride Solution (disinfectant solution)

Disinfectants rapidly kill or inactivate micro- organisms during the cleaning process. They are also used to decontaminate an area so that it is safer for staff to clean. Other alternative disinfectants containing 5% carbolic acid such as phenol or lysol can be used.

Disinfectant/Detergent Cleaning Solution

This solution contains a disinfectant, a detergent and water. It is used for cleaning areas that may be contaminated with infectious materials.

The solution must contain both a disinfectant and a detergent. Disinfectants rapidly kill or inactivate infectious micro-organisms during the cleaning process. Detergents, on the other hand, remove dirt and organic material, which cannot be done by water or disinfectants alone Your responsibility will therefore include providing adequate resources such as brooms, dusting cloths, detergents, disinfectants and protective gear for the supportive staff who are charged with the cleaning of the health facility. You will also need to supervise and guide them appropriately so that the health facility remains clean at all items.

Always wear gloves, preferably heavy utility gloves, and sturdy shoes when cleaning.

Waste Disposal

There are three types of waste found in health care facilities

General Waste

This is non-hazardous waste that poses no risk of injury or infections, for example, uncontaminated paper, boxes, packaging materials, bottles, plastic containers and food- related trash

Medical Waste

This is material generated in the diagnosis, treatment, and/or immunisation of clients. This may include:

∙Blood, blood products and other body fluids as well as materials containing fresh or dried blood or body fluids such as bandages and surgical sponges.

∙Organic waste such as human tissue, body parts, placentas and products of conception.

∙Sharps (used and unused) such as hypodermic and suture needles, scalpel blades, blood tubes, pipettes, and other glass items that have been in contact with potentially infectious materials such as glass slides and cover slips

Hazardous Chemical Waste

This is chemical waste that is potentially toxic or poisonous, for example cleaning products, some disinfectants, cytotoxic drugs, and radioactive compounds.

Disposal of medical and hazardous chemical waste requires special attention in order to maintain a safe and pleasant environment.

This is important in order to:

∙Minimise the spread of infections and reduce the risk of accidental injury to staff,

patients,	visitors	and	the
local community

∙Help provide an aesthetically pleasing atmosphere

∙Reduce odours

∙Reduce the chances of attracting insects and animals

∙Reduce the likelihood of contaminating the soil or ground water with chemicals or micro-organi

Anyone who handles medical or hazardous chemical waste from the time it is thrown out by a service provider until it reaches the site of disposal is at risk of infections or injury. This includes a large percentage of staff who collect and remove waste, both inside and outside the health care facilities. Those reporting high rates of medical waste related injuries include nurses, midwives, supportive staff, cleaning and maintenance staff. Thus it is advisable that these staff are vaccinated against Hepatitis B.

Members of the community also face exposure to potentially infectious medical waste when contaminated dressings, sharps and other waste are not disposed of properly. Often children while playing risk injury and infections. Lack of proper waste disposal practices also put the community at risk of infections when waste such as syringes and needles are scavenged.

Managing Solid Medical Waste

There are four aspects of medical waste management:

∙Sorting

∙Handling

∙Interim Storage

∙Disposal

Sorting

Sorting the waste at the point at which it is generated can greatly reduce the amount that needs special handling, thus reducing risks. Ensure that separate containers are used for disposing of general and medical waste. Use coloured plastic containers/bags, painted drums or labels that can be easily read to help distinguish between general and medical containers. For example, use red containers/plastic bags for medical waste.

Handling

Handle medical waste as little as possible

beforedisposal. Empty waste containers in operating rooms,

procedure rooms, toilets, latrines and sluice rooms when they become three quarters full (at least once daily). Do not collect medical waste from client care areas by empting it into open carts or wheelbarrows. This may lead to contamination of the surroundings and

scavengingofwaste. This may also increase the risk of injury to staff, patients

and visitors.

Always wear heavy utility gloves and shoes when handling medical waste. Always wash your hands after handling waste and after removing your gloves

Interim Storage

If it is necessary to store medical waste on site before disposal:

∙Place waste in an area that is minimally accessible to staff, patients and visitors.

∙Make sure all containers have lids.

∙Cover the containers so that insects, rodents and other animals cannot get into them.

∙Plan for only short term storage (usually for several hours), but no more than one or two days.

Disposal

When possible, medical waste should be disposed of on the premises. This allows staff that understand the risks involved to supervise the disposal process. Burning is preferable to burying medical waste. This is because high temperatures destroy micro-organisms and reduce the volume of waste. Burning in an incinerator or oil drum is recommended. Open burning is not recommended, as it causes scattering of waste which is dangerous and unattractive. If open burning must be done, carry the waste to the site just before burning, and burn it in a small, designated area. Remain with the fire until it is extinguished.

If medical waste cannot be burned on the site, burial is the next best option. Burial is feasible only when there is sufficient ground to accommodate the amount of medical waste generated at the facility. The pit should be surrounded by a fence or a wall to limit access to it and to prevent scavenging.

General waste can be taken to the community waste disposal site

General Guidelines for Disposal of

Medical Waste

Use washable, leak proof containers for disposal of medical waste in rooms and procedure rooms.

Plastic or galvanised metal containers with covers are the best type because they are not likely to corrode. Use small receptacles that use step on levers/pedals to open the cover.

∙Always keep waste containers in

convenient	places
for users.

∙Empty the container daily or when it is

threequartersfull. Never put hands into containers with medical waste.

∙Always dispose of medical waste correctly; never simply throw it outside or leave it in an open pile.

∙Always wear heavy utility gloves and shoes when handling and transporting medical waste.

∙Wash both the gloves and your hands afterwards.

∙Wash containers used for medical waste with a disinfectant cleaning solution and rinse them with water daily (or move often if they are visibly contaminated after the medical waste is dumped).

Disposal of Sharps, Liquid Medical Waste and Hazardous Chemical Waste

Sharps, liquid medical waste, and hazardous chemical waste require special disposal procedures.

Sharps

All used sharps are to be disposed of in puncture resistant containers. Puncture resistant containers can be made out of a heavy cardboard box, an empty plastic jug or a metal container. Sharps containers should be located close to the place in which procedures are performed so that staff do not have to walk across the room carrying used sharps. Keep a sharps disposal container in the laundry in case sharps are found in linen.

Close sharps containers securely when they are three quarters full. If the containers become full, people may push the sharps into the containers, which may cause injury Sharps are not destroyed by burning, therefore, you need to render them harmless by placing needles, plastic syringes and scalpels in a metal container. Then, when the container is three quarters full, pour in fuel, ignite and burn it until the fire goes out on its own.

Plastic syringes will melt and, when they cool, become a solid block of plastic, with the sharps embedded in the block. The block can then be buried.

Decontaminate the sharps and bury them in a pit to make it difficult for others to scavenge them. If it is not possible to bury all medical

waste on-site, sharps should be given first priority for burial, since they pose the biggest risk of injury and infections.

Always wear heavy utility gloves and shoes when handling or transporting sharps disposal containers. Wash both the gloves before ungloving and your hands afterwards

To reduce the risk of needle stick pricks, never bend, break or remove needles from the syringe before disposal and do not routinely recap needles

Liquid Medical Waste

When carrying or disposing of liquid medical waste, be careful to avoid splashing the waste on yourself, other people or surfaces. Carefully pour liquid waste down a sink, drain, flushable toilet or latrine. If this is not possible bury it in a pit. Rinse the sink, drain, or toilet thoroughly with water to remove residual waste, again avoiding splashing. Clean with a disinfectant cleaning solution at the end of each day, or more frequently if heavily used or soiled.

Decontaminate the container that held the liquid waste by filling it with a 0.5% chlorine solution and soaking it for 10 minutes before washing. Always wear heavily utility gloves and shoes when handling or transporting liquid medical waste. Wash both the gloves before ungloving and your hands afterwards.

Hazardous Chemical Waste

Cleaning solutions and disinfectants, such as glutaraldehyde, should be handled as described for liquid medical waste. Rinse containers thoroughly with water, wash glass containers with detergent and water, rinse thoroughly, and reuse. Do not reuse plastic containers. Always wear heavy utility gloves and shoes when handling or transporting hazardous chemical waste. Wash both the gloves and your hands afterwards.

Disposing of cytotoxic chemicals and

radioactive waste requires special consideration beyond the scope of this training course.

SECTION 2: BASIC NURSING PROCEDURES

Introduction

In section one, you covered the concepts of infection prevention and control, which you will apply in nursing practice.

In this section, you will cover some of the basic procedures which include lifting and moving patients; collection of specimens; neurological assessment; taking vital signs; drug

administration; incision and drainage; monitoring intravenous fluids; care for the terminally ill and last offices

Objectives

By the end of this section you will be able to:

∙Describe the lifting and moving of patients

∙Discuss the collection of specimens

∙Explain how to make neurological assessment on a patient

∙Describe drug administration

∙Manage incisions and drainages

∙Discuss the monitoring of intravenous fluids

∙Discuss the care of the terminally ill

∙Discuss last offices

Nursing Practice (1 of 2)

Nursing practice involves the application of knowledge and skills that improve an individual’s level of health. In view of this, all nurses, regardless of their level of educational preparation, learn basic skills that are fundamental to the practice of nursing.

In unit one of this module you studied the definition of nursing. The American Nurses Association (1980) states that, “Nursing is the diagnosis and treatment of human responses to actual or potential health problems. Nursing involves skills that are beneficial to sick or well individuals.”

You are being prepared to provide services in many diverse settings such as hospitals, schools, industry and home care.

The major goals of nursing are to:

∙Promote health and prevent diseases

∙Restore health

∙Relieve suffering

The nursing skills help patients to:

∙Breathe normally

∙Eat and drink adequately

∙Eliminate body wastes

∙Move and maintain desirable postures

∙Sleep and rest

∙ Select	suitable	clothing,	dress
and undress

∙Maintain body temperature within normal range by adjusting clothing and modifying the environment

∙Keep the body clean and well groomed and protect the integument

∙Communicate with others in expressing emotions, needs fears or options

∙Worship according to ones faith

∙Work in such a way that there is a sense of accomplishment

∙Play or participate in various forms of recreation

∙Learn, discover and satisfy the curiosity that leads to normal health and use of the available health facilities

In the provision of comprehensive care you will be required to apply sciences such as

anatomy, physiology, sociology and psychology. You will also be required to incorporate certain skills such as assessment, caring, counselling, and comforting skills.

Lifting and Moving Patients

Basic Guidelines when Transferring a Patient

Certain techniques are used when transferring a patient to help prevent injury to the patient as well as to the nurse.

The basic recommended guidelines for you to follow are:

∙Know the patient’s diagnosis, capabilities, weaknesses and any movement they are not allowed to undertake.

∙Put on braces and other devices a patient may use before getting them out of bed.

∙Plan exactly what will be done while transferring a patient so that appropriate techniques will be utilised. This is because without planning you or the patient may acquire an injury.

∙Explain to the patient what will be done. Then use the patients ability to assist as much as possible to reduce the workload on you, the nurse.

∙Remove obstacles that may make transferring more difficult prior to transferral.

∙Elevate the patient’s bed as necessary so that work is being done at a safe and comfortable level.

∙Lock the wheels of the bed, wheelchair or stretcher to prevent them from sliding as the patient is moved

Basic Guidelines when Transferring a Patient

∙Observe sound principles of body mechanics so that muscles are not strained and injured.

∙Be sure to keep the patients in proper alignment during transfer procedures so that the patient is also protected from strain and muscle injury.

∙Support the patient’s body, especially near the joints. Avoid grabbing and holding extremely by the muscles, which will injure tissues and often put unnecessary strain on joints.

∙Avoid causing friction on the patient’s skin. Roll or push the patient when possible rather than pull them across bed linens. Friction can be reduced by sprinkling powder or cornstarch on the patient’s skin and linens.

∙Use smooth rather than jerky movements when transferring the patient. Jerky motion tends to put extra strain on muscles and joints and is uncomfortable for the patient.

∙Be realistic about how much you can safely do without injury

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Transferring a Patient To and From a Stretcher

You must take great care, when transferring a helpless patient, to prevent injuring the patient and yourself.

The extremities and the head must be supported well. The most convenient way to move a patient is to place a sheet underneath them, then pull carefully on the sheet under the patient to another point, such as from a bed to a stretcher and from a stretcher back to a bed.

When a patient must be lifted and carried, a three-carrier lift is recommended.

Transferring a Patient From a Bed to a Chair and Back to Bed

The chair in which a patient sits should make it possible for them to maintain good posture. If a patient can assist and stand while they are being transferred from a bed to a chair or wheel chair, use the following techniques:

∙Use equipment with firm and stable surfaces. If the mattress is soft and the patient sinks into it, place a bed board under it before transferring the patient to a chair or wheelchair

∙Take the patient’s condition into account

∙Make distance for transferring as short as possible

∙Place the chair or wheel chair parallel to and near to the head of the bed. Be sure that the wheels of a wheelchair are locked and the foot supports are in the upright position

∙Place the short bed rails in the up position so that the patient can grasp a rail to sit up in bed and steady their self as they move.

∙Stand on the side of the bed on which the patient will be moving. Do not reach across the bed to assist the patient. Help the patient to a sitting position.

∙Allow the patient to sit a few seconds until you are sure they are not feeling faint.

∙Pivot the patient appropriately as they sit at the side of the bed. If they are going to walk, help them put on shoes and stockings. Hard soled and well fitting shoes will give them more support than loose, floppy slippers.

∙Place the bed in the low position or have a foot-stool handy on which the patient can stand on as they get out of bed.

∙Face the patient, spread their feet to provide a wide base of support and balance, put one of your feet forward between the patient’s feet, and flex the knees to provide stability. The patient puts their hands on your shoulders, while you hold in the ancillary area. Grasping the patient on their chest wall is uncomfortable and restricts breathing

Some nurses prefer to lock arms to assist the patient to a standing position. This entails the following procedure:

∙As the patient’s upper body is lifted, ask the patient to lift their self from the bed. If a footstool is used, assist the patient off of it while continuing to hold them.

∙Maintain a wide base of support while pivoting with the patient so that their back is towards the chair.

∙Bend the knees and keep the back straight as the patient is lowered into the chair or wheel chair.

After helping the patient to their feet, you should assist them into their chair. A chair with arms would provide another means for the patient to help support and guide them into the chair.

Have the patient assist by holding onto the armrests of the chair or wheelchair if they are available as they are being lowered onto it.

When a patient cannot assist with the transfer, for example, a patient cannot stand before they sit in a chair, it is best to have two persons lift the patient from the bed into a chair. One person can do so unless the patient is too heavy.

The single person technique is handy for home use and in situations when only one person is available. With the chair near the bed, and while supporting the patient from the back, gently move the helpless patient into the chair. You should have a wide base of support. Bend your knees and rock back as the patient slides to the chair. Place the patient’s feet and legs onto the bed first as you roll them off the chair and onto the bed.

Collection of Specimens

You are conversant with most of the procedures involved in the collection of specimens from patients because you have been performing these procedures. You may have assisted a doctor or clinical officer in the collection of specimens.

You have already studied infection prevention and control. During these procedures you will be dealing with body fluids and sharps. You therefore need to apply the knowledge you have acquired on infection prevention to be able to protect yourself, the patient and co- workers.

You also need to recall the body structures where the body fluids will be collected from and your knowledge of microbiology. You should not only know the techniques of collecting the specimens but also the interpretation of the findings. The specimens you will study include: blood, urine, stool, swabs and sputum.

Blood Collection

The indications for the collection of blood

specimeninclude: anaemia, infective conditions e.g. septicaemia, severe haemorrhage and so on.

Think about what you require for the collection of blood specimens?

A nurse should have a tray containing:

∙Disposable syringes and needles

∙Sterile swabs and spirits swabs in separate containers

∙A receiver for used swabs

∙A rubber tourniquet

∙Assorted specimen containers

∙Strapping

∙A pair of scissors

∙Laboratory request forms

∙Container for sharps

∙Gloves

∙Two blood slides

∙Lancet/needle, which is sterile

The collection procedure will vary, depending on the type of investigation required. Whatever the case, you will need to prepare the patient, environment, equipment and yourself. The following preparations need to be undertaken

Patient

Explain the procedure to the patient and put them in a comfortable position.

Environment

Screen the bed. Ensure adequate working place.

Equipment

Wash the tray with soapy water, rinse and dry. Clean with antiseptic swab. Arrange the equipment neatly on the tray and take to the bedside. Label specimen bottles and slides.

Nurse

Wash your hands and put on gloves.

Method of Sample Collection

The following is standard procedure when collecting blood samples from a patient:

1.Identify the site

2.Apply the tourniquet

3.Decontaminate the skin at the site of puncture

4.Identify the vein

5.Introduce the needle and withdraw the required

amount of blood

6.Release tourniquet

7.Withdraw needle

8.Apply pressure to the puncture site immediately

after the needle is with drawn using a sterile dry swab

9.Put blood in correct specimen container

10.Put syringe and needle in sharps container

11.Ensure bottles are labelled correctly

12.Leave the patient comfortable

13.Send to the laboratory immediately with appropriate

request form

Blood Slide for Malaria Parasites

The following method is suitable for use when analysing for the presence of malarial parasites:

∙Clean the patient’s middle finger with spirit swab.

∙Pinch finger below puncture site and prick once with lancet or needle steadily.

∙Wipe off the first drop of blood using a dry sterile swab.

∙Squeeze and receive the next drop onto the blood slide and set aside.