h - i:HT. ■. -P

f: I 1 ;:<, '' :

\q5.;'V :*1 ::Vi ■■ /■.*

4 ‘r , "■"■ :

' X ' -11 V- “i

282

Student Nurses were allocate for one to three months or shorter periods of time, for example prior to or following annual leave, examinations and attendance at college,

TA BLE 5:105

Trauma unit staffing establishment Staffing norm, 1972

Nursingstafftotal

Number of nursing personnel

Registered Nurse Non-reglstsred nursing personnel

SanlorFVN

m ST/N N/A

25 2 2 13 8Day 19 1 10 6Night 6 1 3 2

Stafflii0 norm, 1984

Nursingstafftotal .

Number of nursing personnel

RegisteredNurse

Non-registered nursing personnel E,N,

27 11 15 1Day 17 7 . 9 1Night 10 4 6 0

Average bad oooupanoy

21.72

TABLE SHOd

The number of nursing personnel allocated to the unit per month (November, 1983 « April, 1984)

Monih Stalling no ml

Tolnl numbor of nursing

stall nllocnlod

Porconlngool

norm

Numbor ol nursing stall nllocnlod lo unit'

Floglslored Nurso E,N. Non-roglstarod personnel

SonlorFUN

I W ST/N FomploN/A

Novombor, 1003 25 10,0 70 1.0 0,0 . 9,0 1,0 ’ *Docombor, 1000 26 10,0 72 1,0 6,0 9,0 2,0Jnnunry, 100,1 21) 10,0 52 4,6 • 7,6 1,0Fobrunry, 1004 27 17,6 65 1,0 4,5 1,0 10,0 1,0Mnroh, lOO'l 27 10,0 70 1,0 7,0 1.0 10,0April, 1004 27 21,0 70 1,0 4.6 1,0 14,0 0,6

Full llmo oqtilvnlonls," Tho nursing .ftsolslnnig wow bolh malus,• " In nddlllon ono session sltlor wns ompleyod throughout Iho six monlhs, As lha suasions vorlod Irgm wooli |o wook sho has nol boon

Inoludod In lira cata ilatas ,

HnansnwHRTeiw w«niwMWN.tKM«a tww-1

Avorngp dally bod

occupancy

<0,9311,131-1,10

10,6914,0611,27

TABLE 5:107

The ratio of registered and non-registcred nursing personnel in the unit, according to the established norm

November, 1983 - January, 1984 Staff ratio Ratio as percentage

Total R/N ; ST/N : N/A RN I ST/N : N/A

25

COCO 16 ; 52 132

February, 1984-April, 1984 Staff ratio Ratio as percentage

Total R/N ! EN : ST/N/N/A R/N : EN : ST/N/N/A

' 27 11 : 1 ! 15 41 : 4 : S5

According to the staffing norm for the months November, December and January, there should have been a total of 25 nursing personnel with a ratio of four Registered Nurses; 21 non-rogjstered nursing personnel* During February, March and April there should have been 27 nursing personnel with a ratio of 11 Regintered Nurses: one Enrolled Nurse: 15 non-registered nursing personnel (Student Ntaes and/or Nursing Assistants.) Therefore, according to the staffing norm throughout the six months, the unit appeared to be understaffed, However the bed occupancy was below the expected level thus this provided some compensation,

TABLE 5:108

The actual ratio of Registered Nurses and non-registered nursing personnel per month (expressed as percentages)

Month Total no, o

Percentage of norm Staff ratio as percentage

staffR/N EN ST/N N/A R/N EN ST/N N/A

November, 1983 25 225,0 . 69,0 12,5 47,0 - 47,0 6,0

December, 1983 25 175,0 - 69,0 25,0 39,0 - 50,0 11,0

January, 1984 25 113,0 ■ 58,0 12,5 34,0 *• bu.o 8,0

February, 1984 27 50,0 100,0 73,0 31,0 6,0 63,0

March, 1984 27 73,0 100,0 67,0 42,0 b,0 53,0

April, 1984 27 50,0 100,0 97.0 26,0 5,0 69,0

The actual Registered Nurse : non-registered nursing personnel ratio changed per month. During the months of November, 1983 - January, 1984 the percentage of Registered Nurses on the staff establishment was more than that sUUed in the norm, but

284

both the Student Nurse and Nursing Assistant percentages were below tile norm. During the months of February - April, 1984 the percentage of Registered Nurses, Student Nurses and Nursing Assistants was less than the norm. The percentage of Enrolled Nurses was equal to the norm.

The staffing norms were based oil a bed occupancy of 24 and 21.72 respectively. The actual bed occupancy of the unit was 12.05 and 11,97 respectively, therefore bed, occupancy was only 50 percent of the norm. Perhaps this was the reason, that throughout the six month period of the study, the authorities decreased the staff allocation, Other possible reasons for apparent understaffing that have not been proved by the researcher include:(i) A general shortage of both registered and non-registerod nursing personnel,(ii) Ineffective allocation of hospital staff,(ill) Annual vacation,(iv) Resignation of staff.

The staff allocation in the unit during the periods of observation

TABLE 5:109

The staff allocation and the overall patient dependency during the periods of observation

Observationperiod

Number of nursing

^ 'ty 0"

Total number of patients

Overall patient dependency

Total Intermediate Mobile

07h00-13h00 12 12 7 2 36 16 7 6 39 17 8 3 66 11 3 5 a5 11 6 3 a

13ll00*19h00 6 18 6 12 06 13 9 2 26 3 7 0 14 5 2 1 24 6 4 1 1

I9hoo.oihoo 4 14 7 3 45 12 5 1 66 11 10 1 04 10 S 0 14 15 9 2 4

oihoo.o7hoci 4 19 9 6 4a 18 6 2 103 18 4 5 33 11 3 6 25 14 4 9 1

\

The total number of staff on duly during the observation period varied according to the shift rather than to the number of occupied beds and overall patient dependency (vide pl39), Reasons cited by the researcher for variations to the staff-shift allocation include:1. The nursing, medical and paramedical shift activities.2. The off-duty allocation and requests of the nursing personnel.3. Caro requirements.

The monitoring and routine nursing care requirements for high dependency head injured patients remains constant throughout a 24 hour period although the need for medloal attention and investigations may vary.

The staff were allocated to the various cubicles in the unit by the ntirse-in-chfjrgc of the shift,

TABLE 5:110

The staff allocation, number of patients and nursing assignment tin the specific cubicle during the periods of observation

Cfl60 ' num ber

Shllt N urs ing s ta ll a llo co to d to enro (or patlonta In cub icle

N u m b e r o f p a tlo n ls po r oublclo

N urs ing ass ig n m en t

T o ta l R a n k

FVN 8 T /N N /A T o ta l H o a dInlurloB

T ra u m a

1 07-13h00 2 1" 1 G 3 0 T o ta l p a tlo n t car<iM ‘

2 1o-oihoo 2 1" 1 2 a 0 T o ta l pa tlo n t caro

0 o?*lohoo N il spoolllod * * 6 1 ,6 F u n c tio n a l ass ig n m en t

<1 13-101)00 3 2 " 1“ 3 0 0 T o ta l pa tlo n t e n ro '

5 1o-oihoo Nil specified * * 4 2 2 F u n c tio n a l ass ig n m en t

8 ■|3-10h00 2 1 " 1" 2 2 0 T o ta l p a tien t caro

7 07*13h00 8 1 " 2 G 2 1 T o ta l p a tien t caro.

0 10-01 hon 2 1 1" <1 <t 0 T o ta l p a tien t caro

0 19-011)00 2 1 1" 4 4 0 T o ta l pa tlo n t c aro _

10 13-10M)0 1 1" <1 <1 0 T o ta l pa tlo n t caro

11 lo»iohoo N il specified * 1 1 0 fu n c tio n a l aas lg n m o n t

18 01 -07h00 1 1*' 4 3 1 T o ta l pa llo n t caro

10 01*071100 1 1“ 3 3 0 T o ta l patlon t caro

14 oi-o7hoo 1 1“ 2 0 T o ta l pa llo n t caro

15 oi-o?hOo 1 1“ 2 2 0 T o ta l pa llo n t caro

18 10-011100 1 1" 3 3 0 T o ta l pa llo n t card

17 10-101100 1 1“ 1 1 0 T o ta l pa llo n t caro

10 07-101)00 a 1" 1 2 2 0 T o ta l pallon t carfl

10 07-101)00 1 1“ 0 3 0 T o ta l pa tlo n t core

20 01-071)00 Nil s p tv lllo d A 4 2 2 F u n ctiona l aas lg n m o n t

‘ R n n k o f portion a lthough not spoolllod , w ho actually p rov id ed m oot o l lira enre lo r tho Im n d In ju red pa tlo n t undor study, po r (h ill." RanU o l pornon a llo ca ted to c a re lo r tho h ond In ju red p a tien t undor study, por shill.

W h a n S tu d o n t N uraos/N u ro ln ft A ssistants w o re n ss lonod lor total pa tlo n t caro oil d ru g a n d I.V . fluid ad m in is tra tion w a s choolted by o R eg is tered Nurso.

Registered Nurses and non-registered nursing personnel combined were allocated to work in eight of the selected patient's cubicles, This did not of necessity mean that die nursing care was given by the Registered Nurse or under the direct, supervision of the Registered Nurse as there was more than one patient in the cubicle and the individual staff mcmbor then solccted his/her case assignment.

In total:Six patients were eared for mainly by Registered Nurses! Three patients were cared for by a combination of registered and non-rcgistercd

personnel! 11 patients were cared for mainly by non-registered nursing personnel with little

Registered Nurse supervision.In six cases only non-registered nursing personnel were allocated to the cubicle:» On four occasions only one Student Nurse was allocated to the cubicle to care for

four, four, two and three patients respectively.- On two occasions only one Nursing Assistant was allocated to the cubicle to caro for

three and two patients respectively. ^- The allocation of the above non-registored nursing personnel occurred mainly during

the night shift when staff numbers were decreased (vide TABLE Si 110)In four cases (lie staff were allocated generally.

Kraogel (Cleland, 1982) states that If nurses are to bo used effectively, patients' needs must dictate case assignment. Calculation of patient dependency on a dally basis may load to more effective allocation and utilization of staff. Rush-Presbyterian-St. Luke's Medical Center (1976) states that staff perform bolter in the presence of excellence, An important comment to remember when allocating nursing staff is that by Adylotte

(Cleland, 1982! 36)

"The quality of nursing care can be no greater than the quality of the staff providing that caro,"

Perhaps the situation in the unit stemmed not so much from the quantity but the

quality of staff,

E V A L U A T I N G T H E Q U A L I T Y O F C A R E R E C E IV E D B Y T H E M O D E R A T E A N D SE V E R E L Y H E A D IN JU R E D P A T IE N T

INTRODUCTION

Prior to commencing the study all the care that was selected as relevant Indicators of quality care was to be examined. After commencing the study it became necessary to differentiate between, recorded care and actual care received by head inured patients in torms of the frequency, extent, norm and weighted norm of care received; a concept that warrants further discussion.

(S) RECORDED CARE ,

DEFINING RECORDED CAM » The oaro as documented.

The term recorded cave refers to all care documented as being performed, whether or not the care was actually undertaken, Certain proscribed modalities of care wore documented and figures recorded as having been performed, yet the activity was not performed at the time of the recording, Recorded care Includes actual care (see below) as pari of the documented care,

Care that was documented as being performed but was not undertaken is referred to as 'inappropriate recording'. When this occurred the observer/s wrote "INAPPROPRIATE RECORDING' on the top of the schedule and deleted the item contents. For the purpose of calculating the frequency, extent, norm and weighted norm of oaro received a score of 0 porcent was allocated to the particular schedulo. Inappropriate recording of care occurred in relation to pationt assessment and not in relation to patient care and patient independence (vide pl40). Recording of care without performing the said intervention drastically lowers tlio quality of nursing intervention received by tlio patient,

(li) ACTUAL CARE,

DEFINING ACTUAL CARE - The oaro as performed.

The term actual caro refers to proscribed care that was observed as being undertaken, by staff members, during the period of observation. The aspect of cure actually performed was

documented after the assessment of the patient or the performance of the prescribed Intervention.

Both data sets must bo utilized in order to reflect the quality of care received, Tin* uso of one or the othor data set on its own would result In an inaccurate assessment of the quality of care received by the head injured patient. As the ovorall quality of care received by head injured patients was examined, it is necessary to discuss recorded care in terms of its offect on the ovorall quality of care received, As both actual care and inappropriate recordings aro included in recorded care, the presentation of the research findings only In relation to recorded care will reflect poorly on the quality of care received by head injurod patients, The importance of inappropriate recording of care must not be underestimated, It is important to tako cognisance of dishonest documentation of observations in order to obviate its occurrence,

As recorded caro does not necessarily reflect the actual care received the comments on recorded care are limited.The rcseatohor has chosen to discuss actual earn in detail believing that this is amoro accurate reflection of the quality of actual care received by (he head injuredpatients, The detail of recorded caro is available in APPENDIX R,

.1 T E E P R E S C R IP T IO N O F M O D A L IT IE S O F C A R E R E C E IV E D B Y M O D E R A T E A N D S E V E R E L Y H E A D IN JU R E D P A T IE N T S

No written, standard nursing protocol for tho management of (ho head Injured patient was available in tho unit, Therefore, the proscription of caro modalities and tho frequency of performing the care deponded on tho knowledge and clinical expertise of tho nurse. Tho registered nurso-in-chargo of tho shift or tho nurso-in-cliargo of tho patlont, was responsible for proscribing the necessary modalities and frequency of individualised nursing intervention, As (here was little direct supervision of non-rogistored nursing personnel they wore observed to bo proscribing the modalities and frequency of nursing intervention for patterns under their caro,

The researcher, using standard texts, compiled standards of practice referred la as patient caro standards (APPENDIX K), relating to the modalities and frequency of care that arc regarded as the ideals of care for the moderate and severely head injured patient. The standards of praclicc are defined as care that equates with nursing excellence, that should be prescr ibed according to the needs of the individual patient.

The prescription of care received by moderate and severely head injured patients was compared with the patient caro standards, In the presence of nursing excellence the prescription of care and die standards of practice should equate.

THIS PRESCRIPTION OP CARE M ODALITIES, THE EXPECTED FREQUENCY OF PERFORMANCE AND THE PATIENT CARE STANDARDS

The discussion in relation to caro modalities and the expected frequency of performance of care takes place in toms of patient assessment and patient care only, Patient independonce has been excluded, as based on multidisciplinary intervention, only ono schedule was completed per obervaiion period,

T A I IM i i l l ; U

cutsnumbor

Dopon-donoyrfillno

Modality ot ooro (to nonroot hour)

L,0 ,0 ,' PI’ U* 0 ,3 ,1V S,A,‘ BP' P' IT r B* O' B1 U‘ 0,0 p,*

P s p S P S P B ,P S P P S P a p P S p a P & p 3 p 8

i IV P. 1 i 1 , 1 * 2 1 2 1 2 1 2 4 a 2 2 a 2 2 0 0 2 2

2 IV 2 1 & 2 2 2 . 1 1 2 1 2 1 2 1 s 2 2 a 2 2 2 0 4 2 2

a 111 . 0 . G . 0 . . 4 4 4 4 . 4 4 4 4 a a 2 m m 0 4 2 2

A IV 2 1 2 2 2 2 • it , 2 1 2 1 3 1 2 1 2 2 a a 2 ‘ a 0 O 2 2

IS IV 1 1 1 1 1 1 , 1 1 1 1 1 1 1 1 2 2 2 a 2 2 0 0 2 2

0 IV 1 1 1 1 . 1 0 . 1 1 1 1 1 1 1 1 2 2 2 a a 1 0 4 2 a

■ /> ' IV 1 1 1 1 1 1 * « . 1 1 1 1 1 1 1 1 i a a 2 2 a 0 0 a 2

a IV 2 1 2 1 , 1 • . 2 1 2 1 2 1 2 1 2 2 a, a 2 a a 0 a 2

0 " IV 1 1 1 1 1 1 » , 1 1 1 1 1 1 1 1 2 a a a 2 a 0 0 a 2

10 IV . 1 1 1 1 1 ' . 1 1 1 1 . 1 1 1 2 a a a 2 a 0 0 2 2

it IV i! 1 R 1 . 1 . 2 1 2 1 2 1 a 1 2 2 a a 2 a 0 6 2 a

u IV 2 1 2 1 . 1 . 2 1 2 1 . 1 2 1 » a ■ a m m 0 0 a a

10 IV . 1 1 1 . 1 . 1 1 1 1 1 1 1 1 2 a a a 2 a 0 0 2 a

14 IV . 1 . 2 . 1 . 4 1 4 1 4 1 4 2 a a 2 a a 0 0 2 a

10 IV e 1 2 1 . 1 N . . 2 1 2 1 2 1 2 1 a 2 2 a a 1 0 0 2 a

10 IV 2 1 2 1 2 1 * 2 .. g 1 2 1 . 1 2 2 a a a 2 a 0 0 a a

17 " IV i 1 1 1 1 1 » . . 1 1 1 1 1 1 1 1 a a a a a a 0 0 a a

10" IV 1 1 1 1 1 1 * . . 1 1 1 1 1 1 1 1 2 a a a 1 1 0 0 a a

10 IV i 1 1 1 1 1 1 . 1 1 1 1 1 1 1 1 2 2 2 a 2 a 0 0 2 a

20 IV4

1 4 2 4 2 * 4' '• ■ 4 1 4 1 4 1 4 2 3 a a 2 a 0 0 2 a

KEVI p - ptoMrlbodlioquonoy £1 «■ Pntlont qnro ttlttrwtnrdoIroquonoyI Vkfo p tor oxplnnnilon o( nbbrovlnllono,II Tlw prooctlpllon ol modnllllon and Irotiuotwy ol onro and llm pnllom onro olnnijnrdit oqunlod lor lour potlonlo «nd dllloiod lor 10 pitllonio, • This pnllonl Imd bfonfnlnl lolloi proaorlbod on lour Inulond ol ihroo oooMbno liV ttio tlx hour ohm,

1 ,

' /

r 't ,.A

TA IJLE S; 112

Tho modalities of care and expected frequency of performance omitted from the prescription of care according to the patient care standards, per patient

291

onaonumbor Modallly of oaro Proquonay (hourly)Prooorlbod Patlonta onru atrandardt

3Obworvatlonn:Uovol of eonoolouonoHB Nil 1213 Lovnl of conoolouanoun Nil 114 Lavol of oonoalouonoou Nil 4a PUpllB Nil 314 Pupllo Nil 4'I Umbo Nil 1a Llmbu Nil 12G Ulrnbo Nil 1a Umbo Nil a10 UlmbB Nil 1

11 Limbs Nil 212 Llmbu Nil 2IQ Umbo Nil Si14 Limbo Nil 1IS Limbs Nil 410 Gorobrouplrml fluid loal< Nil 1ao Gorobroaplnnl fluid look Nil 43 noapirntlon Nil 410 Rooplratlon Nil 112 Rooplrntlon Nil a16 Roraplratlon Nil p.

1BPntlont eni*o; Gyo onro Nil a12 Oropharynnoul onro Nil .. * ....

TABLE 5U13

Tho overall expected frequency of cure accosrding to the prescription for care and tho patient care standards, per modality

Modality of onro Ovorall frequency of performance Percentage of patlont care standards proscribed

Carecategory

Proscribed(N«776)

Patient oaro

Lovel of consciousness 73 114 64,04 MediocrePupllo 79 102 77,46 GoodLimbs •17 105 44,76 DangerousCerebrospinal fluid look 3 11 87,87 DangerousSeizure activity 1 1 100.00 ExoollentBlood pressure 02 114 71,93 GoodPliIbo 88 114 71,03 GoodRespiration 60 114 60,66 PoorTemperature OS OS OK,82 excellentEye oaro GG 00 00,33 RxoellontOropharyngeal oare 67 60 06,00 BxoiillontBronchial toilet ei 61 100,00 ExcellentUregonltal oaro 23 83 100,00 ExoollentOhango of position 61 61 100,00 Exoollent

AVERAGE 74,60 Good

Tho total number of schedules in relation to patient assessment and patient caro that should have been used according to the prescription tor caro was 775 and according to tho patient caro standards was 1039. The proscription of rare modalities, expected caro frequency and tho patient caro standards for basic nursing intervention sucli as SEIZURE ACTIVITY, EYE CARE, OROPHARYNGEAL CARE, BRONCHIAL TOILET, UROGENITAL CARE and CHANGE OF POSITION were similar. Tho proscribed frequency for caro such as PUPILS, BLOOD PRESSURE and PULSE were included In the category 'good caro', LEVEL OF CONSCIOUSNESS (64.04 percent) equated with 'mediocre caro', LIMBS (44.76 percent) and tho assessment of CEREBROSPINAL FLUID LEAK (27.27 percent) were included in tho range 'dangerous care'.

Tho overall percentage expected frequonoy that was prescribed by nursing staff in tho unit according to tho patient earo standards was 74.59 percent ('good caro'), Thus according to the patient care standards, 25,41 percent of tho caro that should have been received by head injured patlonts was not proscribed for tho patients.

THE PRESCRIPTION OP CARE ACCORDING TO THE INDIVIDUAL PATIENT

TABLE StI14Tho overall expected frequency 0? fini’o according to the prescription for care and the patient core stondn«d?is per patient

Oboqnurnbor

Ovornll frocuionoy ) Poroontnno ol'...... . .............

Coropntlora onroroltinclnratipraoorlbod

oo 'oBcr,Praoorlbod

(M~776)Patlont ear®w - w #

1 27 40 S0,SS Poorz ao 40 7fe00 | Gooda 10 aa 72*73 Qaod4 34 40 00,St! | Modloora15 64 S3 101.07 i E.'taollor\t0 68 GO 00.03 I Vj«e>ollontr an SS 100,000 31 66 HO,30 Pooro 66 66 100,00 tiiiootiom

10 30 GO WhOO ■Qood11 31 GG 30,30 (r>oor18 10 e a 3(5.34 Demonrous18 4a GG 70,1(3 floo d14 81 40 42,aa ftartB ilir*"')10 aa 67 67.0010 31 66 60,36 Popr17 SB (j>6 100,00 Exoallam ,10 130 60 100,00 iSxoolirtnt10 6t! 01 DG.on Exooltont80 87 40 60,86 Poor

AVBfWaB 7<l.89 Oood

293

The expected frequency of prescription ol care of (lie nurse in-charge of tile individual patient based on the patient care standards revealed the following:The percentage expected frequency of care of:Seven cases was in the 'excellent care' category;- In four cases the frequency of prescribed care and the patient care standards equated;- Case Number 5's care was over-prescribed as the patient received bronchial toilet on

four occasions in the six hour period,Four cases were Included in the 'good care' category;One case was included in the'mediocre care'category;Six cases were included in the 'poor care' category;Two cases were included in the 'dangerous care' category, In these cases less than 50 percent of the expected frequency of care that should have been prescribed was prescribed.

B ISC U SSIQ N

The prescribed modalities and the expected frequency of performance of care according to the patient care standards should be calculated daily by a Registered Nurse, preferably the primary nurse, The prescription of modalities of care, the expected frequency of care and padent care standards depend on Uie needs of the individual patient and should equate. Comprehensive assessment of the patient, by means of die following, allows for effective prescription of modalities and the expected frequency of care required by moderate and severely head injured patients: ■1. Assessment of the patient - Day of admission (APPENDIX El).2. Assessment of the patient -Day of observation (Appendix E2)>3. The patient dependency rating (APPENDIX E3.I),4. The padent care standards (APPENDIX K),5. The nursing care plan (vide p432),6. Protocols of management (vide APPENDIX T),

With reference to the prescription of care modalities and the frequency with whioh care should be undertaken, cure was under rather than over-prescribed. According to the patient care standards, the prescription of general modalities of nursing intervention appeared to be satisfactory (EYE CARE, OROPHARYNGEAL CARE, BRONCHIAL TOILET and CHANGE OF POSITION). It was those modalities of intervention specific to the care of the head injured patient that were lacking, These included the

A

assessment of LEVEL OF CONSCIOUSNESS, LIMBS, CEREBROSPINAL FLUID

LEAK and RESPIRATION.

The following may account for the under-prescription of care.1. Lack of use of the nursing process to facilitate care.2. Inaccurate assessment of the patient's needs.

Not being aware of the importance or significance of certain modalities of caresuch as the assessment of limb function and respiration.

3. Lack of documentation of patient dependency.4. Inadequate knowledge and clinical expertise of nursing staff.5. Inadequate staff utilization.6. Poor work assignment.7. Shortage of nursing staff,8. Lack of teaching and limited meaningful learning at the lime of clinical

assignment,

Because of intervening variables such as patient placement, allied health personnel and family intervention an assessment of the patient's outcome with regard to the effectiveness of the prescription of care is not possible. Prescription of care is discussed further in relation to the frequency of care received by the moderate and

si'vercly head injured patient (vide p299).

2 OVERVIEW i

A total of 708 schedules relating to recorded care and 639 schedules relating to the actual care in as far as the frequency, extent, norm and weighted norm of care received

were complcied.

The rcsearchcr examined the quality of care received irrespective of who delivered the care. This resulted in various categories of personnel being involved in the research, therefore the number of persons within the categories varied. The researcher believes that as care received was examined comparisons can be made, but that the reader must be made aware of the varying group size. Statistical tests that handle data with categories of variable size have been employed when testing for

statistical significance.

TA BLE 5:115

Number of Schedules used in study per type of intervention

Modality of care Care received

Recorded care Actual care

N u rs in g In te rven tio n : 5 2 7 4 5 8 |Patient assessment 437 368Patient care 90 90C o m b in e d 3 8 3 8M u lt id is c ip lin a ry 1 43 1 4 3

TOTAL 708 63a

TABLE SJ1W

A comparison of the number of schedules for recorded care and actual' care received per modality per category of personnel

M o d a li t y o ( c a r e N u m b o f o f

e c h o d u t o s

R a c c f d e d c o r e A c tu a l c a r o (^ a p p r o p r ia te ro co n JIn g o '

o m p lo y o u N u m b o r C a t o o o r y o | p o r s o n n o l

fi/N S T / N N /A C o m b M ulti

N e u r o l o g i c a l o o c * 8 o m » n t : 1 6 0 1 6 0 1 11 5 7 2 0 2 0 n

U v o l o f c o n s c io u s n o s s 61 61 30 31 u 12 5P u p ils 66 66 60 6 4 2U in b s 37 37 17 20 15 1C w a b r o s p l n n ! liuM M k 3 3 3S o l z u r o A ctiv ity 1 1 1 „

V i t o ! « ) g n e ; 2 6 9 2 6 9 2 5 7 1 2 , 3 «

B l o o d p f o s s u r o 70 70 60 2 . 2P u l s o 72 72 70 2 „ 2R o s p lm t to n 60 60 55 5 2 9T e m p o fu tu re 67 67 64 3 1 2s u b t o t a l 4 3 7 4 3 7 turn 6 0 3 2 2 0P a t i e n t c a r a m 1 2 0 1 2 0 -

E v o ca r© 10 10 10 . „

O r o p h m y n o o n l c o r o 22 22 22B r o n c h lu l to ltot 30 00 30 .

U r o g o r t t a l c a r s 11 11 11 ,

C l i a n g Q o f p o sitio n 39 30 30 .

P a t i e n t l n d e p » n d « n o a 1 4 3 1 4 3 w .

C o m m u n lc a O o n 1 20 20 20C o m m u n ic a t io n II 0 Q 0 .

M o b ility 20 20 20E a c r c l s o th o r a p y

M o t i v a t i o n e n d ( s t i m u l a t i o n :

20 20 fcO * '

G o r w r n l 20 20 20 % .

A c t iv i t y 20 20 20 „ ,

R a d i o 13 13 13 , „

T o p « 1 1 1 • •

P r o m o t io n o f I n d o p o n d o n o o 20 20 20 - - - • -

T O T A L 7o o 700 639 69 32 29 0 0

The problem of falsifying findings did not occur In relation to patient hygiene and patient independence, only In relation to patient assessment (therefore it is not applicable to the Combined personnel and the Multidisciplinary feam). The falsifying of vital information regarding the patients' status is unctlifcai and places in question the responsibility, integrity and honesty of those delivering care to the head injured patient. The inappropriate recording of care occurred in 16 percent of the observations regarding patient assessment, 34 percent of the observations regarding neurological assessment and 4 percent of the observations regarding vital signs i.e. 10 percent of the overall care under study, The percentage of inappropriate recordings made by Registered Nurses, Student Nurses and Nursing Assistants in relation to the total number of sohedules utilized by that particular rank was 13 percent, 15 percent and 14 percent respectively. The percentage of inappropriate recordings made by Registered Nurses, Student Nurses and Nursing Assistants in relation to the total number of schedules used by that particular rank for patient assessment alone was 34 percent, 34 percent and 33 percent respectively. Inappropriate recordings occurred with greater frequency in relation to neurological assessment l&an the performance of vital signs. The Chi square test proved that at n 5 percent confidence level there was no significant difference In the number of inappropriate recordings performed per shift (P 0,037) or per category of personnel (P 0.382) (As no inappropriate recordings were made by Combined and Multidisciplinary personnel they were excluded from statistical testing in this regard).

Reasons cited by (he researcher for inappropriate documentation include:1. The lack of knowledge relating to the importance and significance of assessment,

in particular neurological assessment, of the head injured patient (vide p379),2. The fact that many of die patients wore ventilated and received muscle relaxants

therefore the belief that accurate assessment was not necessary! The researcher believes that if the latter be the case then no documentation of findings except to state "Pavulonised1 should be recorded,

3. The lack of professional responsibility and accountability of staff,

This leads one to believe that:a, Staff must be allocated according to the patient dependency ratings (APPENDIX

F2, E3.1/E3.2).b, The method of nursing assignment must bo altered to primary nursing,c, There should be greater supervision of staff.

297

The inappropriate recording of earc re-affirms Die belief of the researcher that concurrent auditing of care is the most effective method of evaluating the quality of care received, Had the researcher chosen to use retrospective auditing this discrepancy in care would have passed unnoticed as the care was always recorded oven if not performed; therefore auditing of die records and not the care performed would have occurred,

The professional status of the nurse and the role of the nurse in die multidisciplinary team is placed in jeopardy by this dishonest documentation, This finding is distressing and it makes one icel that it is no surprise that medical staff see the need to r0poat patient observations!

T A B L E S.-117 ^

The overall percentage performance of actual care received per category of personnel

Category of personnel No. of, schedules (N-639)

Percentage of oare performed

Nursing personnel: 458 72Registered Nurse 221 35Student Nurse 170 27Nursing Assistant 67 10O om blned 38 6Multidisciplinary 143 22

Results of recorded care: APPENDIX R2

Although (lie care demands of the head injured patients were intensive and continuous requiring skill and clinical expertise, 37 percent of the overall care of the moderate or severely head injured patients was carried out by non-registered nursing personnel. When examining nursing intervention only, 52 percent of the nursing car® was performed by non-registered personnel, The care assignment employed was eilhor 'total pationt care1 or a general allocation with minimal Registered Nurse supervision (vide TABLE 5:110). Thus the quality of cave received was dependent bn the level of knowledge and clinical expertise of the staff member delivering the care,

The following abbreviations and keys have been used In the figures:

MODALITY OF CARE

PATIENT ASSESSMENT:

LOC Level of consciousnessPI PupilsLI LimbsCSF Cerebrospinal fluid leakSA Seizure activityIvP Blood pressuret3 PulseR RespirationT Temperature

PATIENT CARE:

E Eye care: 0 Oropharyngeal care

B Bronchial toiletU Urogenital careCoP Change of position

PATIENT INDEPENDENCE:

Cl

........................................................................................................................................................

Communication 1Oil Communication IIMOB MobilityEX Exercise therapy

M&S Motivation and stimulation:G GeneralA ActivityR Therapeutic use of radioT Therapeutic use of tape recorder

Pol Promotion of Independence

KEY CATEG O R Y OF PERSO N NEL

m R /N

■ S T /N

■N /A

□ C O M

■ M U IT

KEY RANGE OP CARE

9$ <30

30-49

H 50-59

m 60-69

H 70-79

a >80

MODALITY

S Tho number of times a category of personnel performed the actual care of n modality (expressed as percentages)

APPENDIX : APPENDIX R 1 Results of recorded carol APPENDIX R 3

,2 .3 E V A L U A T IO N O F T H E F R E Q U E N C Y ' O F C A R E R E C E IV E D B Y M O D E R A T E A N D S E V E R E L Y H E A D IN JU R E D P A T IE N T S

Tho frequency of intervention relating to patlont assessment and patient caro received by tho moderate or severely head injured patient Is described. Those modalities of cure related to patient independence were not inoitulod in this seotlon as they applied to multidisciplinary Intervention over the six iiour period of observation, Although nursing intervention is prescribed, to date because of the lack of quality assurance there has been no way of ensuring that tho intervention will bo undertaken at tho set Intervals, by tho staff--member delivering the care, The frequency of care was calculated according to tho prescription for care, patient caro standards and work performance l,c, In terms of recorded caro and actual caro, how often was a prescribed modality of caro recoivcd by the head Injured patient?

TltlS FREQUENCY OF CARE PER PRESCRIBED MODALITIES

TABLE 5:118The frequency of care received per prescribed modality

M o d o lllyo l caro Frotjuoncy porcontOQoproscribedfroquoncyf a t o M

Innppropilo io rorardlnfla T w op o id n fn g op to tcrib o d(foquoncylocolvod

T w ocaro

cotogoiyf’ rosctiliod(N -77 5 )

p o ilonnod(N»G0!J)

Numbor(N -0 0 )

Porcontagopuifom m d

Lovol of cqnsdousm ias 70 Of 03.00 31 SO.02 41 ,1 0 O.mgorouo

Pupllo 70 00 03,04 0 0.00 70 ,0 0 Good

Uml»9 47 37 70,72 2 0 04 ,OS 3 0 ,1 7 Onnfloroui!

Corobittcplnal fluid look 9 a 100 ,80 0 0 .00 100 ,00 Escollonl

Oolzuro activity t t 100 ,00 . 0 0 .00 100 ,00 Excollonl

Blood prooouro 112 70 0 6 ,0 7 2 2.00 02,03 Excollonl

Puluo 02 n 07,00 2 2 .70 05 ,3 7 Excollonl

nasplfotkm 00 00 00,24 S 0,3 3 oo.oo Gxcoltonl

Tom pornluro 92 8 7 01,71 3 4 .40 70 ,0 5 Good

E y « c a ro 80 to 02 .14- O 0 ,00 32.14 Oortflorous

oio p lw rytto o n l coro 67 22 0 0 .0 0 0 0 .00 30 ,0 0 Dongoioua

Dronchlnl tollol Of ao 02 ,0 0 0 0 .0 0 0 2 ,3 0 Modlocro

Uioounltul can 23 f t 47 ,0 3 0 o.oo <17,03 D a o a m u f

Oluingo of |» » lto i \ 01 30 03,00 0 0 ,0 0 03 ,0 3 Modbcro

Suporficlal examination of tho table reveals that the percentages for the performed frequency of caro received by moderate and severely head injured patients per modality wore included mainly In (lie category 'excellent caro' (LEVEL, OF CONSCIOUSNESS! 83.5(5 percent, PUPILS; 83,54 percent, PULSE: 87.80 percent etc), 'good care' (LIMBS: 78,72 percent) and 'mediocre care' (CHANGE OF POSITION! 63,93 percent, BRONCHIAL TOILET! 62,30 percent). With regard to tho frequency of performing proscribed nursing intervention throe modalities of care were included In the category 'dangerous caro' (EYE CARE! 32.14 percent, OROPHARYNGEAL CARE! 38,60 pcrcont aud UROGENITAL CARE: 47.83 percent),

WIth regard to patient assessment only, closer examination of tho percentage frequency of caro received by head injured pationts reveals that staff members documented findings without actually performing tho prescribed Intervention (vido p287). Tims, tho above figures wore inaccurate and misleading, Further calculation was required to assess the true percentage frequency of care with which certain aspects of proscribed care wore undertaken (TABLES S;l 18/Col, 7),

CALCULATION OF TRUE FREQUENCY OF CARR RECEIVED

Calculate!

NUMBER OF PERFORMED FREQUENCY - THE NUMBER OP INAPPROPRIATE RECORDINGS = TRUE FREQUENCY OF CARE RECEIVED

Formula!

S S H S r X T B TRUE PBRCRNT PRESCRIBED FREQUENCY OF CARE RECEIVED

An example! LEVEL OF CONSCIOUSNESS

TRUE FREQUENCY RECEIVED 61 - 31« 30

41.10 TRUE PERCENT PRESCRIBED FREQUENCY OF CARE RECEIVED

Thorofore tho truo poroonlugo proscribed frequency of cure tooolvod for tho observation of LEVEL OP CONSCIOUSNESS wns 41.10 porwnt ('dangerous oiim1) and not 83.56 percent ('excellent onro1) ns ''riginnUy cmlcuhucd (TABLE 5:118 Col, 3)

Tho two poicont prescribed frequency for the following observations decreased:LEVEL OF CONSCIOUSNESS BLOOD PRESSUREPUPILS PULSELIMBS RESPIRATION

TEMPERATURE

Although tho patients included In tlio study suffered IVom severe bead injuries LEVEL OF CONSCIOUSNESS and LIM BS wore the two NEUROLOGICAL OBSERVATIONS and EYE CARE and OROPHARYNGEAL CARE wore tho aspects of general nursing intervention performed infrequently. PUPILS, BLOOD PRESSURE, PULSE, RESPIRATION and TEMPERATURE were performed frequently.

Hereafter only tho true porcoiiitago proscribed frequency of carts scores will be dismissed . (For furthor discussion of Inappropriate recording of enro vide p 287),

302

THE TRUE FREQUENCY OF* CARE OP THE PRESCRIBED MODALITIES, PER PATIENT

TABLE 5:119

The overall true percentage prescribed frequency of care received per patient

Cassnumber

Trueproscribedfrequencypercentage

Careoategory

1?.345e 7 e 0 o ■ 1 ■2

■3 '4 •5 16 ' 7 •81920

62,96 88,11 37,SO 61,76 7693 75,4763.64 60,06 60,00 63.1680.6542.1166.12 23.81 45,4565,'45 62.07 67,24 02,59

MediocreExcellentDannerouaMediocreGoodGoodMediocrepoor.MeqooreMediocreExcellentDangerousMediocreDangerousDangerousDangerousMecfloore..ledMed

ooregore

Exoalltsnt

Tito true percentage frequency of caro received by patients in the study ranged from 'excellent care' (92.59 percent) to 'dangerous care1 (23,81 poroent), Hie true percentage prescribed frequency of caro for three eases was more Hum 80 percent, for 12 cases was more than 50 percent, and for five cases was loss than 50 percent, ■

THE TRUE FREQUENCY OP CARE RECEIVED PER MODALITY UTILIZING THE STANDARDS 01? PRACTICE

According to tho standards of practice, specific nursing intervention was required for moderate and severely head injured patients (APPENDIX K). Therefore, Irrespective of tho proscription for care, the true percentage frequency of cam received was calculated according to tlio cm that llio patient should hnvo received,

\

303

TABLE S; 120

The frequency of care received according to the performed frequency of care and the patient care standards, per modality

Modality o ( oaro Proquoncy Pofqonloflo ol poltont

oaro standards! roculvod

Innppioprlulo rocordlnflfl TiUd poicunt.igy patlan t cam

olandards rocolvad

Ttuocaro

catOQoryPw lorm fid(NnSGG)

P ntlonlearn

atnndnrds(Nh103D)

Nurobor(N-60)

Porcontngopm form od

l.oyo! o f am acfousnoao 61 114 53,51 31 SO.02 20.32 DangorousPupils m 102 04,71 0 9,00 60.02 poorLimbs 37 10S OS,24 20 64.05 10,10 DangerousC oiobfoaplflnl llu k ilo n k a 11 27.27 0 0.00 27.27 DnnflorounSdlzuro ncilvliy 1 1 100.00 0 0,00 100.00 B to o llon lQlood fHosoufo 70 114 01.40 2 2,06 SO,05 PoorP u b ?a 114 63,10 2 2,70 01.40 Modlocrailosplrn llon 60 114 52.63 B 0.33 40.25 D nngorou*tom porftiuro 67 00 07,66 a 4.46 04.6U M odlacmEyo caro 10 60 30,00 0 0,00 00.00 DaogorousOrophnryogoal pttro 22 eo 30.67 0 0,00 30.07 DangorouaUronchhl jollot on 01 62,30 0 o.on 02.30 ModlocroUroflonllnl « uo 11 23 47.03 0 0.00 47.03 DnogornnoChungo of position 30 01 63.03 0 0.00 63.03 Modlocro

When comparing the trac percentage prescribed frequency of care received per modality(TABLE 5:118) with the true percentage of care calculated utilizing the patient care

standards (TABLE 5:120) the percentage frequency of carc received remained unchanged for SEIZURE ACTIVITY (100,00 percont), CHANGE OPPOSITION (63,93 perccut), BRONCHIAL TOILET (62,30 percent) and UROGENITAL CARE (47,83 percont),

TABLE S’: 121

Changes that occurred in the overall true percentage frequency of care received according to the prescription for care and the patient care standards, per modality (Vide TABLE 5;Hit and 5:120)

Modality of oaro Truo fraquonoy pofoontngo

proEorltod Pntlcmt emm amnanrdo

Uovol of oonuolouonoafi 11.10 aa.aaPupllu VS.os 60.03Umbo 00.17 10,10Oorobrooplnaf fluid locxk 100,00 87,07Oloaci prooouro 02,03 SO,OSPuloo 05.07 01,40RQoplrntion ao.ao Ao,:mTampornturo 70,05 04,058y« onm aa. i 4 30,00OrophnrynaorAl anro no, oo 30,07

According to the standards of practice, the reasons for the above decrease in the true porcont frequency of carc received wow iluiu(i) When offering cttro, nursing intervention Hint should have boon prescribed, was

omitted from tlio proscription and therefore the carc was not undertaken (vide TABLE S; 111 and TABLE 5: 112),

(ii) Care that was prescribed (N« /73) was not undertaken (N-565) (vide TABLE S; 118).

The overall percentage prescribed frequency of care received was 72,90 percent, Whereas the overall true percentage prescribed frequency of care received was 64,00 percent 1.0, 'mediocre care.' Tlws as tlio care was not actually performed although it was recorded the Inappropriate recording of care dropped the percentage frequency of performance of care by 8.90 percent from ’good care' to 'mediocre caw'. When one compares the true frequency of performance and the standard of practice of care that should be performed, the overall true percentage frequency of care dropped to 47.74 percent ('dangerous care'). In tlio light of this finding, according to the established standards of practice the patients were not receiving quality musing care;(i) Nurses were not prescribing the nursing intervention required by moderate or

severely head injured patients.(li) Caro was grossly undcr-pnxicribed and therefore not performed as expected,(ill) Care was not porformcd as prescribed.

THE FREQUENCY OF CARE RECEIVED ACCORDING TO THE STANDARD OS? PRACTICE PER PATIENT

TABLE S-.m

The overall frequency of care received according to (he performed frequency of care received and the patient care standards, per patient

Cniianumbor

Numbor (it Bchoilulon Porcontngo In o p p ro p iln lo lo o ir tlln o o Truo poiCTinlnoo TllJOo iro

calO floryP W lo im o d(N«OOS)

M o n ttinio

otnndnrds<N«1030)

potlont enro olnndntds incolvod

N um bor(N « 0 0 )

Pareontapoporloimotl

p n lkm l coro stan d ard s rocalvod

1 17 40 3 0 ,4 8 0 0 ,0 0 3 0 .4 8 Dnnfloioua2 82 40 0 0 ,0 7 1 3,10 0 4 .0 0 M adlocro(S 0 22 2 7 ,2 7 ' 0 1 0 ,0 0 2 7 ,8 7 Dflngo (ous<1 21 4 0 4 2 .0 0 0 0 ,0 0 4 2 ,0 0 D nnooroun0 <17 113 0 0 ,0 0 12,77 77 ,0 0 G ood0 <10 59 7 0 ,2 7 8 11,11 0 7 ,0 0 Modlocro7 07 SO 0 7 ,2 7 8 6 ,4 0 03 ,0 4 Modlocro0 SO OS 0 0 ,0 0 2 10,00 3 8 ,7 3 Dnngqroun« 0 0 M 7 0 ,0 1 0 1 0 ,3 0 0 0 ,0 0 M ndlocra

to SO CO 0 2 .0 0 £ 7 ,0 0 4 0 ,0 0 ftnngorousI t so r.s 4 7 ,2 7 1 3 ,0 4 4 0 ,4 0 Onnoorouo12 14 0 8 2 0 ,0 2 0 4 8 ,0 0 16,30 Dnrifliiioiir,13 0 0 00 K4.GQ 2 0 ,0 7 60,01 Poor14 0 40 10 ,2 0 0 0 ,0 0 10,80 D nngorouii10 S3 87 4 0 ,0 0 0 0 4 ,7 0 2 0 ,0 3 Dnr«EJ0foijs10 10 08 2 7 ,2 7 P, 13,33 23 .0 4 Ctanfloroun17 <14 65 00,01) a 10,10 0 0 .4 0 M odlocrti111 «4 00 7 0 ,0 0 0 1 0 .10 0 8 .0 7 M m llocto10 40 01 78 ,4 1 7 10,82 0 3 .0 3 M ix llo c ia* 0 SO 40 SO,Oil 3 0 ,8 0 8 8 ,0 0 Poor

Where modalities of prescribed care and die standards of practice equated die expected frequency of care received remained constant, In cases 7, 9, 17 and 18 the overall percentage expected frequency of prescribed care equated with the patient care standards (TABLE 5:114), In these instances modalities of care equated but the said care was not performed thus the scores of 63,64 percent, 60,00 percent, 65.45 percent and 62,07 percent respectively were obtained (TABLE 5:122).

Cases 11 and 20 showed that where care was prescribed and the care was performed it was possible to score a high true percentage frequency of care (80.65 percent and 92.59 percent respectively) (TABLE 5:119). When the patient care standards were introduced the true percentage frequency of care dropped to 45.45 percent and 52,08 percent respectively (TABLE 5:122) as the prescription for care was inadequate. Therefore, if all the relevant modalities of care that should be prescribed had been prescribed and undertaken the percentage frequency of care received would have been higher.

The researcher believes that:(i) The reason for tile discrepancy in the frequency of care percentages lies in the

lack of comprehensive knowledge regarding the needs and management of the head injured patient.

(ii) Uniform head Injury management protocols, based on accepted standards of practice, should be implemented, This will ensure that the prescription and frequency of performing care required by the head injured patient is in the best interest of the patient and that care remains consistent.

TABLE 5:123

Changes that occurred in the care category when the patient care standards were introduced

Care category Number of patients In category

True porcentage prescribed frequency True porcentage paflent care standards

Excellent 3 0Good 2 1Medloore g 7Poor 1 2Dangerous 5 10

Prior to introducing the patient care standards the care of three patients rated 'excellent care1, two 'good care1, nine 'mediocre care', one 'poor care' and five 'dangerous care'.

306

After introducing the patient Care standards no patients rated 'excellent care, the majority of patients achieved 'poor care' or 'dangerous care'.

DISCUSSION

The findings with regard to the frequency of performance of patient care arc of conccrn primarily from the point of view of carc, as well as their importance to credibility and education. The results.showed that the true percentage prescribed frequency of care received was 64 percent and when the patient care standards were introduced the figure dropped to 47.74 percent. In the opinion Of the researcher 'mediocre care' and certainly 'dangerous care' are unacceptable when discussing nursing excellence and quality carc. The researcher suggests possible reasons for these findings:

1. The eduoation of the staff involved in caring for these patients may be inadequate. The following need to be investigated (vide p372):- The educational level and clinical awareness of the staff member.- The level of knowledge regarding die significance/consequences of performing

the proscribed care modalities.- The orientation, in-service eduoation programme, clinical experience and

expertise of staff members.- The supervision of staff.

2. The stress in nurse leaching has been towards general observations rather than specific neurological observations,Perhaps tho staff do not see the need for oonstant, repetitive observation. Greater emphasis should be placed on the importance of neurosurgical observations as they are a critical element in the care of the head injuicd patient.

3. The inappropriate allocation of stalf to patients:3.1 At the central organisational level:3.1.1 Staff quantity.

Staff must be allocated to tlio unit according to the patient's needs,Back-up servioes must bo provided to release the nurse from non-nursing

duties.3.1.2 Staffqiw.lity (vide p285/372),

Qualifications and clinical expertise must be considered when selecting staff forthe unit,

3.2 At the unit level,

There is poor staff utilization. Junior instead of senior staff are allocated to care for high dependency patients (vide p285).

4, The method of nursing assignment is inappropriate (vide p285),5, Inadequate maintenance of standards of pi aotice,5.1 A lack of set protocols of management detailing the comprehensive care required

by moderate and severely head injured patients, exist (vide plSl/288).5.2 The prescription for care is inaccurate, either care is over or under-prescribed.

The problem here lies with under-prescription and lack of performance of care.5.3 A lack of quality assurance to check care received by head injured patients

exists.6, The level of motivation of staff members who are delivering the care is

insufficientLack of interest in the management of tlio head injured patient and the belief that these patients are a lost, cause' and in the 'incorrect environment' may affect (lie performance of care.

7, Staff ignorance.Do the staff members have sufficient Insight into the care of head injured persons?

The above-mentioned require serious consideration in order to maintain nursing excellence,

A E V A L U A T IO N O F T H E Q U A L IT Y O F C A R E R E C E IV E D B Y M O D E R A T E A N D 'S E V E R E L Y H E A D IN J U R E D P A T IE N T S IN T E R M S O F T H E E X T E N T , N O R M A N D W E IG H T E D N O R M O F C A R E R E C E IV E DTH E O VERALL PERCEN TAGE OF CARE REC EIV ED BY MODERATE AND SEVERELY HEAD INJURED PATIENTS

TABLE 53124

The overall percentage of care received by moderate and severely head injured patients (extent, norm and weighted norm)

Variable Recorded care (N-703)

Aotual oare (N«o39)

Extent of oaro S3 59Norm of oaro 36 40Weighted norm of oara 41 43

The overall percentage actual care received by all patients included in the study showed the percentage extent of care (vide pl48) to be 59 percent ('poor care1), the percentage norm of care (vide pl48) to be 40 percent ('dangerous care') and the percentage weighted norm of care (vide pi49) to be 45 percent ('dangerous care'). It must be remembered that to calculate extent of care the item weightings (<?i» 3, 2, 1,0) were utilized, to

calculate norm of care the arbitrary scale of 5 -> 0 was used and to calculate the weighted norm of care the item weighting and the norm of caro scale were utilized (vide pl64 - 174).

The overall figures showed that staff members were more conscientious at undertaking the procedure (extent of care) than the standard of their practice (norm and weighted norm of care). Although the overall percentage extent of cine received was above 50 percent this is not regarded by the researcher as safe, effective therapeutic, practice,

An interesting finding in this study was that the extent of care values were always higher than the norm of care values (except TEMPERATURE vide p3l4). In fact most extent of care percentages were above 50 percent; whereas the majority of norm and weighted norm of care percentages were below 50 percent The researcher believes that had extent of care (i.e. whether the criterion was undertaken/not undertaken) been examined alone die standard of performance (norm of care) would have been ignored and therefore the results would have been biased, In order to evaluate nursing excellence it is crucial to assess the level of performance.

Examination of shift using a one way analysis of variance and the paired T-test procedure established that at a 5 percent confidence level there was a significant difference in tho extent of actual care (P 0.0091), norm of actual care (P 0,0053) and weighted norm of actual caro (I5 0,0252) per shift,

Closer examination of tho four shifts employed In the study revealed the following:The extonl. of aotual care of tho shift 13h00-19h00 showed a significant difference at a 5 percent confidence level to that of tho shifts 07h00 - 13h00 and 19h00 - QlhOO, Tho caro on tho shift 13h00 - 19h00 was superior to that of tho shifts 07li00 • 13h00 and 19h00 - OlliOO,The norm of actual care of the shift 13h00 • 19h00 showed a significant difference at a 5 percent confidence lovol to that of tho shift 19h00 - OlhOO and OlliOO»07h00, Tho norm of caro on the shift 13h00 - 19h00 was superior to that of tho shifts botweort the

. hours 19h00 and 07h00.There was a significant difference at a S percent confidence level in the weighted norm of actual care of the shifts 13h00 - 19h00 and 19h00 - OlhOO. The weighted norm of actual caro of the former was superior to that of the latter. In as for as the weighted norm of care was concerned no other shifts showed a significant difference in the weighted norm of care per shift,

Tho researcher believes that these differences in caro per shift related to such aspects as tho staff quality and quantity, shift activities, the lack of supervision of non-reglstered nursing personnel during the night shift, multidisciplinary Intervention and tho presence of the family during the afternoon shift,

TABLE 5:125

The overall percentage ot‘ care received per patient (extent, norm and weighted norm)

Casenumbor

Shift Rocordod oaro Actual enro

No,

Poraont

No.

Percent

EXT N WN EXT N WN

r AM 24 s4 34 37 24 64 34 372 END 40 66 38 41 30 68 30 42

3* AM 1a 43 34 37 13 48 34 37

4* PM 29 63 30 42 20 63 39 42

s END 64 61 33 37 48 67 37 426 PM S3 66 30 41 40 61> 42 46

7 AM 44 60 44 .40 42 62 46 620 END 26 66 37 41 26 00 40 44

0 END 4S 66 36 43 40 62 44 6010 PM 34 67 43 40 32 60 46 5211 PM 34 64 47 62 88 66 40 S3

'12 ND 20 40 26 20 14 67 36 4113 ND 86 S2 40 47 34 66 42 6014* ND 12 61 33 37 12 61 33 3718 ND 30 37 10 22 22 60 20 30

16 END 21 63 33 37 10 50 97 •11

17 PM 81 64 37 41 48 64 44 401Q AM 52 60 as 40 44 60 41 47

10 AM S3 40 83 37 46 66 36 4320 ND 34 66 34 37 31 G'l aa 41

K E Y : AM - 07li00 - lahOO, PM » 13hOO - 10hQO, END » lOhOO»OlhOO,ND u 011100-Q7IHM.No, « Numbor of uohoduloa amployod.This appllon throughout tho study,Ext » Extont of onro, N « Norm of oaro, WN a Wolgluod norm of ooro TIiIb opplloo throughout tho utudy,* o No Inappropriate recording of oaro occurred,

The average percentage extent, norm and weighted norm of care received por patienL based on all schedules relevant to the individual patient showed:The overall percentage extent of recorded care of three patents achieved 'mediocre care', 13 patients achieved 'poor care' and the remaining four patients achieved 'dangerous care', As fair as the norm and weighted norm of recorded oare 19 patients received care that was included in the 'dangerous care' category,As far as actual care was concerned in 10 patients, nkte patients and one patient the percentage extent of actual care achieved 'mediocre cart ', 'poor care' and 'dangerous care' respectively. Hie percentage weighted norm of actual care received of five patients was included in tho 'poor care' category. The percentages for weighted norm of actual care of tho remaining 15 patients were included in 'dangerous care'.

This /reflects tlio effect that inappropriate recording of care had on (lie overall percentage of caro received by tlio head injured patient.

THE OVERALL PERCENTAGE EXTENT, NORM AND WEIGHTED NORM OF CARE RECEIVED PER CATEGORY OP PERSONNEL

(W i m m ce mat m iun to muu tw mi hi/, m wxtEXTENT OF OAIIG NonMQPOAHB WfflQinUDNonMOFOAnti

QUAUIVOI’ CAIIG

The overall percentage of recorded care received per category of personnel (extent, norm and weighted norm)

V- ^■V - / •

-V..t r» ' ' ''.A:'-'.'-A'--'-' J:

9 p - S r : Z ° ' ' ^ 'r , “ vr.. ■ -v

f ' 'l"' ' ■ v , .

' ;V';>

- ■> , i - .. ,

, 'd, ■ •" - ' '.'I■ : <, •

&>• ■ ;s: - -;'V * 1 + y\ ■ '■ ‘V -f* ■ . "

i t

• ’ ’ ‘ I f

n

• f*

- yv\ i

*v ,

' Is , *

311

Recorded care shows nil llio overall percentages extent of cure except that of the

care') to be in Hie range 'poor care'. Hie percentages for the norm of recorded care of all categories of personnel were included in 'dangerous care', The percentage weighted norm of recorded care of the Combined category was above 50 percent ('poor care) die others were included in ’dangerous care', As so few schedules (N»38) wera performed by the Combined personnel tills may have been die reason for the improved scores, Alternatively each group gave a better account of tlioir actions when seniors and juniors worked together,

1

OTiN HIS CO MUEXTENT OF OAHE

I 111 I !,, ^UN OHM m CO IMT

NOnMOPOARE

QUALITY OP OARS

NfA CO MATWBBimSD NORM 01s OAR13

Pig. Si7 The overall percentage of actual care recoivcd per category of personnel (extout, norm atid weighted norm)

*• ■N Vi,’

r ; . : ‘ V '’• ' W

• V - '1 V I

kV ‘ '■ '

■>

i1 //

The overall percentages of actual care received showed the extent of care of all categories of personnel oxcopt Multidisciplinary ('clangorous care1) to bo In 'mediocre care', Registered Nursos and Studuiit Nurses each achieved 63 percent, the Nursing Assistants 62 percent and the Combined category 66 percent. All categories of personnel except the Multidisciplinary team ('dangerous caw') achieved 'poor care' tor Uie percentage weighted norm of caro received. When the Combined personnel delivered caro the extent, norm and weighted norm of caro improved. During tlio periods of observation on clay shift, as well as, where applicable on night shift no allied hoallii personnel, except the physiotherapist and those staff attending a mujor ward round attended to the pntionts, honoe the low overall scores for the multidisciplinary intervention. '

A paired T-test was employed io analyse the data concerning the extent, norm and weighted norm of aotual care and the category of personnel involved in the delivery of care, '

The extent, norm and weighted norm of aotual caro of the Multidisciplinary personnel showed a significant difference at the 5 porcerit confidence level when compared with that of tlio Registered Nursos, Student Nurses, Nursing Assistants and Combined Personnel, Tlio oaro of the latter categories of personnel was superior to that of tlio Multidisciplinary team, There was no significant differences between the extent of actual caro of the other categories of personnel,

Thoro was a significant difference at the 5 porceiit confidence level in the percentage norm of actual caro of the Student Nursos and the Combined personnel; the care of the latter was superior to that of the former, This supports tlio belief of the roseafchor that Studont Nursos should work In combination with other personnel In the dolivery of patient caro,

Except for the Multidisciplinary team thoro was no significant difference in the weighted norm of cam of tho other categories of personnel.

Overall statistical testing proved that tho extent and lovol of actual care of the various categories of personnel except as stated above was constant; at 'poor' or 'dangerous' levels, As Registered Nursos are trained personnel one would have expcotcd the care of tho Registered Nurse to bo superior to that of tho Student. Nursos and Nursing Assistants as well as at a consistently higher level,

Tlio overall percentages of actual caro received showed the extent of care of all categories of personnel except Multidisciplinary ('dangerous care') to bo In 'mediocre care'. Registered Nurses and Studont Nurses cach achioved (53 percent, the Nursing Assistants 62 percent and tlic Combined category 66 porcont, All categories of personnel oxcoptthe Multidisciplinary team ('dangerous care') achieved'poor care' for the percentage weighted noim of caro received. When lire Combined personnel delivered caro tho extent, norm and weighted norm of care improved, During the periods of observation on day shut, as woll as, where applicable on night shift no allied health personnel, except the physiotherapist and those staff attending a major ward round attended to tho patients, lienee the low overall scores for tho multidisciplinary intervention. '

A paired T-tcst was employed to analyse tho data concerning the oxtent, norm and weighted norm of actual caro anti (ho category of personnel involved in die delivery of caro. '

The extent, norm and weighted norm of actual care of tho Multidisciplinary personnel showed a significant difference at the 5 porcont confidence level when compared with that of the Registered Nurses, Student Nurses, Nursing Assistants and Combined Personnel. The caro of the lattor categoric*] of personnel was superior to that of the Multidisciplinary team. Thorc was no significant differences botwoon the extent of actual caro of tho other categories of personnel,

There was a significant difference at tho 5 percent confidence lovol in tlio percentage norm of actual caro of tlio Studont Nursos and tlio Combined personnel; tho caro of tho lattor was superior to that of the former. This supports tho belief of tlio resoni'ohcr that Studont Nursos should work in combination with other personnel in the delivery of patient care.

Except for tlio Multidisciplinary team thoro was no significant dlfferonco In tlio woighted norm of caro of the other categories of ixsrsonnol,

Ovomll statistical testing proved that the oxtont and levol of actual caro of tho various categories of personnel except as stated above was constant; at 'poor' or 'dangerous' levels, As Registered Nursos are trained personnel one would liavo expected tlio caro of tho Registered Nurse to he superior to that of tho Student Nurses and Nursing Assistants as woll as at a consistently higher lovol.

The overall percentage of care received per grouped modalities (extent, norm and weighted norm)

Grouped modalities ofoaro

Recorded cars Actual care

N

(708)

Percent N

(639)

Percent

EXT N WN EXT N WN

Patlont aasesam ont: 437 54 40 40 368 04 47 54

Neurological assessment 168 <14 32 33 111 67 48 50Vital signs 269 60 45 53 257 63 47 56

Patient oaro 128 59 40 41 128 59 40 41Patlont Independence 143 46 23 25 143 46 23 25

In as far ns pallont assessment is concorrtod the overall performance of actual caro received altered tho care category for tho extent of cure from 'poor care' to 'mediocre care', As the majority of inappropriate recordings occnrrcd In relation to neurological assessment the percentage extent of caro altered from 'dangerous care' to 'mediocre care'. Thus demonstrating tho effect that tho Inappropriate recording of caro had on tho overall extent of care received, Tho percentage norm and weighted noon of actual care for patient assessment also showed an Improvement to 47 percent and 54 percent respectively, As no inappropriate rocording of oaro took place In relation to patient care and patlont independence there was no difference In tlio percentages obtained for recorded and actual caro received, Except for tho overall percentage oxtent of actual oaro for patlont caro all other overall percentages related to patient caro and patlont independence wore included in 'dangerous care1.

Tho numbor of itoms undertaken affected tho percentage extont, norm and weighted norm of care for the particular schedule and altered the overall percentages of care, Tho findings show tho overall percentage extent of actual oaro to bo grotuor than tho poreontngo norm of care In all grouped modalities.

No further discussion in as far as recorded care will lako place, Figures for recorded care are available in k ^ N D IX R .

b. THE EXTENT OF CARE RECEIVED BY MODERATE AND SEVERELY HEAD INJURED PATIENTS

(i) TH E PERCENTAGE EXTENT OF ACTUAL CAKE RECEIVED PER MODALITY

314

MOOAUTY

Fig. 5:8 The overall percentage of actual euvo per modality, (extent of care)

Results of recorded cnvc: APPENDIX! R 4

Tho percentage extent of actual caro rccoivcd by head injured patients in tho study per modality ranged from 0 * 73 percent, Tho lowest score was obtained for THE USE OF THE TAPE RECORDER ('dangerous caire') and tho highest for tho assessment of PUPILS Cgood care'),

Whon utilizing tho figures related to the percentage extent of actual care the assessment of PUPILS, BLOOD PRESSURE and BRONCHIAL TOILET woro included in 'good caro', LEVEL OP CONSCIOUSNESS, PULSE, RESPIRATION, CHANGE OF POSITION, MOBILITY, MOTIVATION AND STIMULATION; GENERAL and PROMOTION OF INDEPENDENCE wore Included in 'mediocre caro'; whereas SEIZURE ACTIVITY, UROGENITAL CARE and COMMUNICATION I woro all included in 'poor care', All oilier core modalities woro in tho category 'dangerous care',

The figure obtained for llte assessment of the PUPILS (75 percent) ratal the overall care category tor the percentage extent of neurological assessment to 'mediocre carc1 (67 percont). Tlio assessment of LIMBS and CEREBROSPINAL FLUID LEAK were included In the 'dangorous care' category, As these patients suffered severe head Injuries this must bo regarded as a serious matter.

Wlien considering tlio percent oxtoni of actual care the assessment of PUPILS, BLOOD PRESSURE, PULSE and BRONCHIAL TOILET appeared to bo the best performed of Die modalities of care, followod by patient care ami patient Independence. Perhaps the reason for this occurrence Is the stress In nurse teaching on general nursing science. The inability of staff to apply or relate scientific principles of nursing to specific fields of nursing may bo the reason for the 'mediocre/poor' results relating to patient care and patient Independence,

All aspects of are of Importance to the multidisciplinary approach to the head injured patient's Independence except for COMMUNICATION I, MOBILITY, MOTIVATION AND STIMULATION: GENERAL and PROMOTION OF INDEPENDENCE were included In the rnngo 'dangerous care', The communication of stoA "■w: .{he patient was better than that of the family, but most communication was in.v S. "if;' *■'> tiaro, rather than an active effort to communicate with the patient as par: yl therapeutic programme, No form of EXERCISE THERAPY was undertaken for six patients thus the low figure.

The percentage extent of care relating to the motivation of the patient was 40 porcont ('dangerous care'), Tlto staff eating for l oad Injured patients wore unaware of the patients' pre-injury Interests therefore they wore unable to include these Interests In the therapeutic plan, Tho radio as a moans of stimulation was used for 13 patients although THE USE OF THE RADIO as a moans of thorapeutic stimulation was potmlsslble for one of those patients only (vide p241). THE USE OF THE TAPE RECORDER scored 0 percont for extent, norm and wolghted norm of care as tho tape recorder was played betweon OlhOO - 07h0() when tho patient should hove been allowed to rost, In the opinion of tho researcher, thci most; accurate assessment of the percentage extent of caro regarding tho motivation of tho patient is to examine tho percentage for MOTIVATION AND STIMULATION! GENERAL and ACTIVITY and this was 52 potcoiU ('poor cure').

(it) THE PERCENTAGE EXTENT OF ACTUAL CARE RECEIVED PER MODALITY ACCORDING TO RANGE

MODALITY

Fig. 5:9.1 Tlte range of overall percentage of actual care received for neurological assessment per modality (extent of care)

MODALITY

Pig. 5:9.2 Tin1; range ol' overall percentage of actual care received for assessment of vita' signs per modality (extent of carc)

* / <

•v- ..■■■&{i ■>■ ■> : yt:'# S»

. . ■$': .’■■■■-.() V *!■}!» A,#'-’ . ,

V ' . f > '

,v’v

>s

y ''',

■'s

"H .• '•V , ,

\

317

Mo d a l it y

Fig. S;9.3 The range of overall percentage of actual care received for patient care per modality (extent of care)

UlsUlOIS-

OH MOUMODALITY

EX Pol

Fig. 5:9,4 The range of overall percentage of actual care received for patient independence per modality (extent of care)

1 '

MODALITY

Pig, 5:9.5 The range of overall percentage of actual care received for motivation and stimulation per modality (extent of carc)

Results of r«corded care: APPENDIX R 5 ,

As far as percentage ox,tent of aotual care received per modality per range was concerned, the distribution of the percentage extent of aotual care demonstrated why the overall percentages obtained for tlio extent of actual care received per modality wore in the various categories, Exocpt for LIMBS, CEREBROSPINAL FLUID LEAK, TEMPERATURE, EYE CARE, OROPHARYNGEAL CARE, COMMUNICATIONII, EXERCISE THERAPY, MOTIVATION AND STIMULATION; GENERAL, THE USE OP THE RADIO and TAPE RECORDER the majority of the actual care received was included in the range above 50 percent,

PERC

ENTA

GE

EXTE

NT

OF CA

RE

(Hi) THE PERCENTAGE EXTENT 0I? ACTUAL CARE RECEIVED PER CATEGORY OP PERSONNEL

P U T MODAL, ITY

Pig. S;10.1 The overall percentage of actual care received per patient assessment and patient care modalities per category of personnel (extent of care)

MODALITY

Fig, 5:10,2 The overall percentage ol' actual caro received per patient independence modalities per category of personnel (cxtenl of care)

Results of recorded care; APPENDIX Rfi

Not all categories of personnel undertook all modalities of care. Registered Nurses aohieved 'good care' for four modalities, 'mediocre care' for three modalities, 'poor care' for two modalities and 'dangerous care' for five modalities of cafe. Student Nurses aohieved 'good care', 'mediocre care', 'poor care' and 'dangerous care' for one, five, two and three modalities of care respectively. Nursing Assistants obtained 'good care', 'mediocre care', 'poor caro' and 'dangerous care' for two, four, one and two modalities of wire respectively.

c. THE NORM AND WEIGHTED NORM OF CARE RECEIVED BY M ODERATE AND SEVERELY H EAD INJURED PATIENTS

(i) THE PERCENTAGE NORM AND WEIGHTED NORM OF ACTUAL CARE RECEIVED PER MODALITY

180*o40

t « pi il ea> m oi» p n t ( o o u cac q ou un tx o A n t p«i •

MODALITY

Fig. 5! 11 The overall pcvceutage of actual caro received per modality (norm of care)

4

u x n u a t u w p n 1 t e » u w si on too a a a n r p it

MODALITY

Fig, S'. 12 The overall percentage of actual care received per modality (weighted norm of carc)

The range for norm and weighted norm of actual care received was 0 - 63 percent and 0 ■ 69 percent respectively, Tlio sdnxiule that showed (lie greatest positive shift between the norm and weighted norm of care was that of PULSE, Tho percentages obtained for tho weighted norm of PUPILS and BLOOD PRESSURE woro included In 'mediocre care' and those for PULSE, TEMPERATURE and MOBILITY were Included in 'poor care', The remainder of tlio percentages for the weighted norm of care received for tho various modalities were included In 'dangerous euro', Thus although tho extent of care for most of tlio modalities was above 50 percent tlio norm and weighted norm of care of the majority of modalities foil in the category 'dangerous carc' i.e. below SO percent,

(II) THU PERCENTAGE NORM AND WEIGHTED NORM OF ACTUAL CARE RECEIVED PER MODALITY ACCORDING TO RANGE

MODALITY

Fig. 5:13*1.1 The range of overall percentage of actual care received for neurological assessment per modality (norm of care)

MODALITY

Fig. 5:13.1.2 The range of overall percentage of actual care received for neurological assessment par modality (weighted norm of care)

MODALITY

' /

X

Pig. 5.13.2 1 The range of overall percentage of actual care received for vital signs per modality ( norm of care)

Vig. Si 13.2.2 The range of ovomit percentage of actual care received for vital sians per modality (weighted norm of care) ’

‘ m: >

(t" r

) '/

l^ i . Il ■■* ---- ■ .-L.^.lt 11" I’->V

/

/■<

»• U

. ■ ■ ' '•'» 'i'- ■ .. % ,t * , ’■*•>Q • . ,4 ■ * ,^ r ' ,

s y ' ’■tP- „ t :

J..

■K’ ' A

X

, ’' i

V !

324

MODALITY

Pig. 5:13.3.1 The range of overall percentage of actual care received for patient enro (>««* modality (aoi'in of caw)

d& 100g noS 00B 70

1 (10

§ Q0

iS '10g 00

i SOra 10

0B 0 o

MODALITY

u C«P

Pig. Si 13.3.2 Tho range of overall percentage of actual caro received for pntiont care per modality (weighted norm of care)

■ \

MODALITY

Pig. 5il3.4.1 Tho range of overall percentage of actual care received for patient independence per modality (norm of cure)

MODALI1Y

Fig, S: 13,4,2 The range of ovorall percentage or actual oaro received for pm lout independence per modality (weighted norm of w e )

... / i& i a i , , KmtoWfflNMMVMiA

modality

Pig, 5:13.5,1 The range of overall pes'centngo of actual enre received for motivation nud stimulation per modality (norm of caro)

Ip

,J=LO. LISEL

MODALITY

Pig. 5:13.5.2 The rout go of overall percentage of actual enre received for motivation and stimulation per modality (weighted norm of cure)

.> < \ i V '

v ■ lt \

Results of recorded cm'tss APPENDIX R7

Tho norm mid weighted norm of cure reflects tho level of performance of criteria that were undertaken.

Tlio weighting of critical items in LEVEL OF CONSCIOUSNESS resulted in a drop in the porcontage norm of actual care i.o. more care was included in tho range loss than30 percent. Tho major redistribution of tlio woighted norm of care percentage occurred within tho two lowor ranges,

The weighting of items in PUPILS resulted in an improvement in the woighted norm of actual core in Uio range above 70 percent. After introducing the weighting 15 percent of tho care occurred in tlio > 80 porcont mngo, Tho percentage woighted norm of actual cat's below 50 porcont altered only marginally,

Tltoro was no change When weighting tho norm of actual care regarding the assessment of LIMBS, AH care was included in the ranges loss than 49 porcont.

The percentage nmn and woighted norm 'of actual caro fur CEREBROSPINAL FLUID LEAK and SEIZURE ACTIVITY remained in tho range loss than 49 percent,, Those aspects of care must bo vlowcd wit h caution as only threo and one schodulo respectively woro used throughout tlio study,

Tho percentage weighted norm of actual care receive;! Improvo'd when items in tho schodulo BLOOD PRESSURE woro weighed, Prior to weighting 65 porcont of the norm of actual care rocoivod was above tho 50 porcont rango, 3 porcont being in tlio rung'’ '.’0-79 percent, After weighting 90 porcont was above tho 50 porcont range and 21 percent was In tho ranges above 70 porcont, indicating that critical items woro being undertaken,

The weighting of items in the schoduio PULSE resulted in a major alteration in tho weighted norm of actual care received, Prior to tho weighting of items 86 porcont of tho care was included in Use ranges below 50 percent, After weighting only 12 porcont of tho caro was Included in this rango, therefore tho most Important Itoms woro being undertaken,

328

Redistribution of the percentage weighted norm of actual care received when practice was weighted, occuired in the schedule RESPIRATION. After weighting less care was included in the less than 49 percent range. Changes occurred in the ranges over 50 percent, especially in the range 60 - 69 percent.

The weighting of items for the assessment cf TEMPERATURE did not affect the weighted norm of actual care received groatly, although some improvement did occur. 2 percent of the norm and 2 percent of the weighted norm of actual care occurred in the 70 - 79 percent and > 80 percent range.

The weighting of the norm of actual care for the schedule EYE CARE resulted in no major alteration in the care percentages. After weighting 11 percent of the care received was included in (he range above 50 percent

When OROPHARYNGEAL CARE was weighted the weighted norm of aotual care received resulted in a drop in the 50 - 59 percent range, thus care deteriorated indicating that important criteria were being omitted.

The weighting of itsms in BRONCHIAL TOILET resulted in little improvement in the level of care received.

The weighting of the norm of actual care received for UROGENITAL CARE resulted in no change.

Minimal change in the distribution per range of the percentage norm of actual oare occurred in CHANGE OF POSITION, Prior to weighting 74 peroent of the care received was included in the categories less than 50 percent. On weighting only 67 percent of the weighted norm of aotual care received was included below 50 percent.

There was little alteration in the percentages obtained for (he norm and weighted norm of actual care for modalities of care related to PATIENT INDEPENDENCE (except for MOBILITY) and MOTIVATION AND STIMULATION. Perhaps this was because so little of the actual care was undertaken,

\

PEnC

ENTA

GEN

OR

M

OF C

AR

E

(iii) THE PERCENTAGE NORM AND WEIGHTED NORM OF ACTUAL CARE RECEIVED PER MODALITY PER CATEGORY OF PERSONNEL

Fig. 5:14,1 The overall percentage of actual care received for patient assessment and patient care modalities per category of personnel (norm of care)

m o d a l it y

Fig. 5:34.2 The overall percentage of actual care received for patient independence modalities per cahgory Of personnel (norm of care)

Results of recorded care: APPENDIX R 6

The range of percentages for the norm of actual carc for Registered Nurses, Student Nurses and Nursing Assistants, Combined and Multidisciplinary categories were 19 - 65 percent, 20 - 63 percent, 8 - 55 percent, 44 - 56 percent and 0-49 percent respectively.

Por all three categories of nursing personnel the highest scores were obtained for the assessment of PUPILS and the lowest for the assessment of LIMBS.

Except for the norm of actual! care of PUPILS and BLOOD PRESSURE for Registered Nurses, the norm of actual care of PUPILS, BLOOD PRESSURE and TEMPERATURE for Student Nurses, the norm of actual care of PUPILS and TEMPERATURE for Nursing Assistants find the norm of actual care of BRONCHIAL TOILET for Combined personnel all the actual care percentages were in the 'dangerous care' category.

The percentage norm of care of the Multidisciplinary team for all modalities were included in 'dangerous care',

Pig, 5:15.1 The overall percentage of actual care received for patient assessment and patient care modalities per category of personnel (weighted norm of care)

m o d a l it y

Pig. 5:15,2 The overall percentage of actual care received for patient independence modalities per category of personnel (weighted norm of care)

The percentage weighted norm of care for all categories of nursing personnel with regard to LEVEL OF CONSCIOUSNESS dropped oven further. Overall the percentage weighted norm of care scores were better than those of tl;c percentage norm of care scores. Registered Nurses and Student Nurses achieved 'good care' for PUPILS. All three categories of nursing personnel achieved 'mediocre care’ for the assessment of BLOOD PRESSURE, Registered Nursos achieved 'poor care' for RESPIRATION and CHANGE OF POSITION, Student Nurses for PULSE and TEMPERATURE, Nursing Assistants for PUPILS, PULSE arid TEMPERATURE, Combined personnel for BRONCHIAL TOILET and the Multidisciplinary team for MOBILITY. Tlio remainder of the percentages indicated 'dangerous care1,

When care regarding BRONCHIAL TOILET was performed the combination of personnel demonstrated a higher percentage norm and weighted norm of actual care, than when cither category performed tho procedure on their own.

A n overview of llte q ttn llly of nclunl oaro rocolvotl jlio w ln s Iho u n fio o f nooroi and ovorall cnro category p er in o d M lty (extent, norm unit Weighted norm )

M odality ol onto N

(N -60O )

Exlont ol onro Norm ol onro W olghtod norm ol onro

Avontgo( * )

Hnnflo o l oooroo

(V*)

Ovornllonro

onwgory

Avorngo(% )

Rnngd ol tc o r o i

(% )

Ovorallonro

ontogoiy

AvorngoW

Rnngo ol oooroo

'< * !

Ovornllonro

ontogory

P » I I » m M a m m t n t i o « a 0 4 2 0 • 44 M o d lo o r * 4 7 6 > 02 D n n g e r o t in 3 4 7 • < 0 P o o rN o u f o lo g lo n l ob e o rV A t|o n *t 111 87 31 • 00 M o J Io o r * 4 0 « • 74 D n r tg n r o u * 6 0 7 * 0 0 P o o r

u v o l o l oonooiousnoon DO 06 4 0 .0 0 Modlooro 40 2 0 - 0 2 D nngo m u t 40 1 6 .0 0 DnngorouoPupllo 00 75 0 0 - 0 2 Good 00 3 0 - 7 4 Modlooro 60 2 0 * 0 0 M od loo nU m bo 17 47 0 1 - 7 0 Danoorous 10 0 - 4 6 Dnntfarouo 10 ? » 6 0 DnngorouoOacobronplnnl lluld loAK 9 44 4 2 - 4 0 Dnngorouo 24 2 3 - 2 0 Dnngorouo 01 2 0 - 0 6 DnhgorouiS o |*u ro notlvlty 1 62 62 Poor M 00 Dnngorouo 00 99 Dnngorouo

V l u i n lg n m a s? 6.1 20 • 04 M * d l6 o r o 4 7 1 0 - 3 2 D « n g » ro u » 86 16 . DO P o o r

Blood p im ouro 80 74 6 0 - 0 0 Good 64 i!4 - 7 2 Poor 09 3 0 . 0 2 ModlooroPulod 70 67 0 0 - 0 0 Mddlooro 41 2 0 - 7 6 Damgoroun 60 40, * 0 0 PoorRooplrnllon SB 00 4 1 - 0 4 Modlooro 41 1 0 .0 2 Dnngorouo 40 1 6 .0 4 DniidorounT o ifljio in lu io 64 40 2 6 - 0 0 Dnngorouo 60 3 0 - 7 0 Poor 62 3 1 . 0 0 P o w

P o t lo h t onros 1 2 0 00 08 * OS P o o r 40 10 > 74 D n n g o r o u * 41 11 * 0 0 D n n g o ro u o

Gyo onro 10 40 ■40,62 D nngorow 20 1 8 - 6 3 Dnngorouo 91 1 3 .6 0 . GnngorouoOfOphnryngonl onro 22 40 0 0 - 7 4 Dnrtgoroun 01 1 0 - 6 2 Dnngorouo 01 1 1 - 6 2 DnrtgorouoBfqnohlat lollot 00 70 4 0 - 0 6 flood 47 1 4 - 7 4 Dnngorouo 47 1 6 * 0 0 DnngorouoUrooonllnl onro 11 62 4 R ‘ 72 Poor 06 S 3 .6 7 DnniJoroun 00 2 9 . 6 3 DnngorouitOhA'too ol pooltlon 00 02 4 0 - 7 7 Modlooro 44 2 0 - 0 9 Dnngorouo 40 0 0 * 7 0 Dnngorouo

p o l lo n l In d o p o n d o n o n i 1 4 0 46 0 . 100 D n n g o ro u * 20 0 • 100 D n n g o fo u * 2 6 0 « 1 90 D n n g t iro u t

Oommunlonllon 1 SO 62 . . 1 0 . 0 0 Poor 17 0 - 2 0 D n n g o n w 10 0 -8 0 Dnngorou*Qommunlonllon II 0 41 2 1 - 0 9 Dnngorouo 17 0 -0 1 Dnngorouo 20 0 * 9 6 DnngorouoMobility 20 02 26 .IS O Modlooro 40 2 6 -1 0 0 Dnngorouo 60 2 6 *1 0 0 PoorExorclno Ihornpy 20 22 0 .6 7 Dnngorouo 11 0 -0 0 Dnngafoun 11 0 * 3 4 Dnngorouo

M o tiv a tio n nm l o tlm u ln tlo m 54 40 0 *100 D n n g o ro u * 20 0 >00 D nngo rouo 20 0 • 00 D nngorouo

Q orw nl 20 00 0 2 -1 0 0 Modlooro 10 4 *0 7 Dnngorou* 20 6 . 4 4 DnngorouoActivity SO 00 0 -0 0 Onngorouo 03 0 .0 0 Dnhoorouo 39 0 * l!0 DnngorouoRndlo 10 0 0 -7 0 Dnngorouo 0 0 *4 1 Dnngoiouo 3 0 *0 0 DnnoorouoTapftrfteordor 1 0 0 Onngorouo 0 0 Dnngorouo ,0 . 0 Dnngftftua

Promotion ol Indopondorwo a 41 12*71 Dnngorouo 20 20 <03 Oungoiouo 26 1 0 .3 4 Dnngorouo

IN SUMiVIARY

333

A three, way analysis of variance and die T-tcst procedure proved that when one considered the interrelationship of the variables- shirt, category of personnel and tho modality of care received there was a significant difference at a 5 percent confidcnco level between the three variables. This occurred in relation to exicnt ol carc (P0.0001), norm of caro (P 0.0001) and weighted norm of care (P 0,0001). Further examination revealed that shift and modality of care were the variables that caused'the

differences to occur.

The percentage of actual caro received by moderate and severely Head injured patients varied according to tho modality of cars that was performed. The paired T-tosl. determined that there was a significant difference at tho 5 percent confidence level in the extent, norm and weighted norm of care between the various modalities of care examined. Tho range of caro with regard to extent, norm and weighted norm of actual caw received extended from 0-100 percent in certain modalities of actual care. On all occasions except TEMPERATURE the extent or actual care was higher Ilian the norm or weighted norm of actual caro. This implies that in this series the quality or carc not so much tho quantity was defective, although both need to be improved,

Tho following discussion lakes place in terms of actual care received,

PATIENT ASSESSMENT

Comparison of figures must bo viewed with caution as Registered Nurses, otudent Nurses and Nursing Assistants performed patient assessment a total of 169,133 and 66 times respectively,

78 percent, 84 percent and 80 percent of ihc extent of caro or tho Registered Nurses, Student Nurses and Nurshvj Assistants was above 50 percent. 11 porcont, 15 percent and 3 percent or tho caro or the respective personnel was included in the category > 80 percent.

67 percent, 70 porcont and 70 percent of die overall percentage weighted norm of care for Registered Nurses, Student Nurses and Nursing Assistants respectively was above 50 porcont, 22 porcont of tlio woighted norm of caro of tlio Registered Nurses was included in the ranges above 70 porcont, It is interesting to note that with regard to patient assessment the overall percentage extent of actual care received (64 percent) oqtuited with 'modlooro care1, and the ovorail percentage woighted norm of actual carc

(54 percent) equated with 'poor care', Therefore overall on patient assessment the extent of performance outweighed the level of performance.

NEUROLOGICAL ASSESSMENT

Level of consciousness

92, percent, 100 percont and 100 percent of the percentage extent of actual care regarding LEVEL OF CONSCIOUSNESS of the Ret, stored Nurses, Student Nurses, and Nursing Assistants was above 50 percent.

Registered Nurses and Student Nurses achieved 26 porcont and 15 pcrcent of the weighted norm of care above 50 percont. The percentage weighted norm of caro for Nursing Assistants was below 50 percent, Tho results showed the extent of performing LEVEL OF CONSCIOUSNESS to be 'mediocre' but the norm of performance was inadequate.

Pupils

Throughout the study tho best scores were obtained by all three categories of nursing personnel foi' the assessment of PUPILS. 100 percent of the extent of care of the Registered Nurses, Student Nurses, and Nursing Assistants was above 50 percent. 29 percent, 38 porcont and 18 percent of the percentage extent of caro of the Registered Nurses, Student Nurses and Nursing Assistants was in tho range > 80 percont.

96 percent, 95 percont and 73 porcont of tho Registered Nurses, Student Nurses and Nursing Assistants norm of caro and 96 percent, 100 percent and 73 percent of tho weighted norm of caro wore above 50 percent, Tho range 70 - 79 percent was tho most common.

This demonstrated tho extent of performance of PUPILS to bo in the 'excellent care1 category for all nursing porscmnol, The high scores obtained for tho assessment of PUPILS may bo asorlbcd to a number of factors:1, The significance placed on tho observation of pupils.2, The familiarity of staff with pupil observation,3, Tho oaso with which pupil observation can bo undori aken,

Limb function

Tlio oxtont, norm and weighted norm of care regarding the assessment of LIMB FUNCTION revealed that (lie only category of personnel who achieved above 50 percent wore the Registered Nursos. 11 percont of the extent of cafe of the Registered Nurses was included in tho category 70 • 79 percent. All other assessment of tho percentage extent, norm and weighted norm of caro was included in ilio range less than 50 percent.

Cerebrospinal fluid leak and seizure activity

Assessment of CEREBROSPINAL, FLUID LEAK and SEIZURE ACTIVITY was performed by Registered Nurses only. Except for tlio percentage extent of caro for SEIZURE ACTIVITY (100 percent in tho range 50 - 59 percont) the percentages for extent, norm and weighted norm of care for tho assessment of CEREBROSPINAL FLUID LEAK and SEIZURE ACTIVITY wore, included in the rango loss titan 50 percont ('dangerous care').

V ITAL SIGNS

Blood pressure

Assessment of BLOOD PRESSURE was undertaken most frequently by tho Registered Nurses, J00 percent of tho Registered Nurses and Student Nurses! extent of caro was above 60 porcont, 100 percent of the oxtont of caro of Nursing Assistants was above 50 percont 10 percent of tho Registered Nurses and 19 percont of tho Student Nursos extent of caro were included in the range > 150 percent No Nursing Assistants achieved this level of expertise, Tho oxtont of performance was superior to tho norm of performance.

86 percent, 88 porcont and 100 percent of the Registered Nurses, Student Nurses awl Nursing Assistants weighted norm uf oaro regarding tho observation of BLOOD PRESSURE was found in the ranges above 50 percent; mostly in tlio range 60 - 69 porcont, Tho assessment of BLOOD PRESSURE by all categories of personnel appeared to bo well performed with regard to tlio oxtont and weighted norm of care,

Pulse

The assessment of PULSE was performed most frequently by Registered Nurses, Student Nurses and Nursing Assistants respectively. 100 jjefWI «rf the Registered Nurses and Student Nurses percentages and 92 percent of ‘h<# Nuffllaf! Assistants extent of oaro received were abovo 50 percent! most frequently bfitween 60 ■ 69 percent, the Registered Nurses and Student Nursos achieved 6 percent and 4 percent in tho range > 80 percent respectively,

The distribution of tho weighted norm of cure for tho Registered Nurses, Student Nurses and Nursing Assistants above 50 percent was 96 percent, 81 percent and 83 percent respectively.

With regard to the assessment of PULSE tho extent and level of practice of the Registered Nurses was superior to that of tho non-rogistercd personnel.

The favourable results regarding tho extent and norm Of actual care for tho assessment of BLOOD PRESSURE and PULSE may Indicate!1, Tho stress placed on the recording of vital signs In gcnoral nursing science,2, Tho significance of these observation in head Injury management.3, Tho routine ease of performance of tho observations,

Respiration

Tho assessment of RESPIRATION was performed most frequently by Registered Nursos (28 times), Student Nursos (15 times) and Nursing Assistants (12 timos) respectively,

89 porcent, 80 percent and 100 percent of the extent of caro of tho Registered Nursos, Student Nursos and Nursing Assistants assessment of RESPIRATION was abovo 50 porcent. 17 percont of the Registered Nurses and 13 porcont of tho Student Nursos achiovcd > 80 percent for tho extent of oaro received; whereas 57 percent, 40 porcont and59 porcont of the weighted norm of caro was abovo 50 porcont,

Emphasis noods to bo placcd on tho assessment of RESPIRATION in tho head Injured' patient,

Temperature

The assessment of TEMPERATURE was performed most frequently by Student Nursos (27 times), Registered Nurses (24 times) and Nursing' Assistants (13 times) respectively. 100 percent, 59 percent and 69 porcont of the extent of caro related to tlio assossmont of TEMPERATURE by Registered Nurses, Student Nurses and Nursing Assistants was below SO percent. Tlio most common range for all three categories of personnel was 30 - 49 percent.

50 percent, 70 porcont and 100 porcont of the performance of Registered Nursos, Student Nukm? and Nursing Assistants respectively regarding the weighted norm of caro for TEMPERATURE was above SO percent.

Tho performance of non-rcgistered personnel was superior to that of registered porsonnol with regard to tlio assessment of TEMPERATURE.

PATIENT CARE

Caro with regard to patient caro was undertaken most frequently by Registorod Nurses (52 times), Combined personnel (38 times), Studont Nurses (37 tlmos) and Nursing Assistant (1 time) respectively,

63 percent, 70 percent, 100 percent and 90 percent of tlio extent of care of the Roglstei ul Nursos, Student Nurses, Nursing Assistants and Combined personnel was above SO porcont.

25 percent, 8 porcont, 0 porcont and 42 percent of the weighted norm of care of tho Rogistorcd Nursos, Studont Nursos, Nursing Assistants and Combined porsonnol was above 50 percent. Tho combination of porsonnol cither Registered Nurses plus Studont Nurses and Nursing Assistants or the physiotherapist improved tho overall percentage extent and weighted norm of care received,

Eye care

Tlio majori ty of BYE CARE was distributed In tho range 'dangerous care'. 50 percent and 34 percent of the extent of enre performed by Registered Nurses and Student Nursos respectively was above 50 porcont. Tho percentage weighted norm of caro with regard

to EYE CARE demonstrated only 9 percent of the care of the Registered Nurses and 17 porcont of that of tho Student Nurses to be above 50 percent, Both tho extent and norm of performance of eye care was inadequate.

Orophna'yngiml cure

31 percent, SO porcont and 100 percent of OROPHARYNGEAL CARE performed by Registered Nurses, Student Nurses and Nursing Assistants respectively with regard to the extent of care was above 50 percent. OROPHARYNGEAL CARE was not being undertaken to its fullest extent neither was the weighted norm of care satisfactory ('dangorous caro1),

Bronchial toilet

BRONCHIAL TOILET was performed most frequently by Combined porsonnol (16 times), Student Nurses (13 times) and Registered Nurses (9 times) respectively. 100 percent of the Registered Nursos and Combined personnel and 92 porcont of tho Student Nurses extent of care received was above 50 percent. 23 porcont, 8 porcont and 6 porcont of tho extent of caro of Registered Nursos, Studont Nursos and Combined personnel was in the rango > 80 percent.

Tho percentage weighted norm of care showed tltfit45 percent, 8 percent and 63 percent of the performance of the Registered Nurses, Stafont Nurses and Combined porsonnol was above 50 porcont. 19 percent of the Combined categories performance was in the rango 70 *• 79 percent,

The majority of performance of the norm and woighted norm of caro by Studont Nursos was included in tho category 'dangerous care', This is a disturbing fact as Studont; Nurses performed the procedure a total of 13 times i.e. 34 porcont,

Urogenital ewe

43 porcont and 50 percent of tho care of Registered Nurses and Studont Nurses regarding UROGENITAL CARS was bolow 50 porcont, Tho weighted norm of caro of tho Registered Nursos achieved 14 porcont abovo 50 percent, The percentage woighted norm of caro for Student Nurses achiovcd dangorous caro only, Although tho extent of ca?o exceeded the norm of care both woro Inadequate,

J

339

Change of position

CHANGE OF POSITION was performed most frequently by Combined personnel (22 times), Registered Nurses (11 times) and Student Nurses (6 limes) respectively,

91 percent, 100 percont and 95 percent of the extent of caro regarding position change of Registered Nurses, Student Nurses and Combined personnel was above 50 percent, Registered Nurses, Studtmt Nurses and Combined personnel achieved 55 percent, 17 percent and 27 percont In the range above 50 percent respectively for the weighted norm of care. The percentage extent and weighted noun of care of Student Nurses was bolow that of the Registered Nursos and Combined personnel with rogard to position change. This jlhowed that tho combination of various categories of personnel directly affected tho quality of care, in that when staff combined to deliver caro tho percentage of caro improved although the percentage norm and weighted norm of care remained In the 'dangerous euro'category,

PATIENT INDEPENDENCE

54 percont of tho overall extent of actual caro and 18 porcont of the overall weighted norm of care of the Multidisciplinary team with regard so patient independence was above 50 percent, Tho minority of caro relating to the weighted norm of modalities of caro included in PATIENT INDEPENDENCE occurrcd in tho range < 30 percent,

Communication

Smff may have communicated with patients and families but the extent and level of communication was inadequate, Tills is totally unacceptable in tho unconscious head injured patient who needs to maintain contact with tho environment,

Communication I

60 percont of the extent of care regarding communication with the patient was above 50 percont, The porcontago norm and weighted norm of care revealed that all care relating to the level of communication with the patient was bolow 50 porcont. Some of the staff did attempt to communicato with the patient but tho quality of tho communication was Inadequate, Interdisciplinary communication was minimal,

Communication I I

The percentage extent of care relating to communication with the family was lower than that of communication with the patient. 44 percent was included in the range above SO percent. The percentage norm and weighted norm of care for communication with the patient and the family demonstrated that the level of Communication was included in the range 'dangerous care'. Families were not referred to the multidisciplinary team members for support and guidance.

Moil Uity

The schedule MOBILITY was utilized for all patients but many of the items were regarded as NOT APPLICABLE as the patients were confined to bed. In the patients confined to bed, using applicable items staff scored well on mobility. It is in those patients who were allowed out of bed that the percentages were lowered because of poor care. 90 percent of the extent of care and 80 percent of the weighted norm of care relating to MOBELITY'was above 50 percent.

Exercipy therapy

Both the percentage exterlt and norm of care relating to exercise therapy were grossly inadequate. Six patients received no form of exercise therapy during the period of observation hence the low values, 85 percent of the extent of care and 100 percent of the norm and weighted norm of care for EXERCIvSE THERAPY was below 50 percent

MOTIVATION AND STIMULATION (OVERALL)

When considering the overall motivation and stimulation of the head injiired patients on a multidisciplinary basis, 39 percent of the overall extent of care and 17 percent of the overall norm and overall weighted norm of care was above 50 percent, The quality of care with regards to overall motivation and stimulation of the patient wais grossly inadequate,

Motivation and stimulation: General

This demonstrated dial certain criteria regarding the stimulation of the patient were met. The percentage extent of care above 50 percent was 45 percent but the level of

performance of the criteria was inadequate as the percentage weighted norm Of care above 50 percent was 0 percent. The multidisciplinary team undertook criteria but it was (he level of practice that was sub-standard.

Motivation and stimulation: Activity

The percentage extent, norm and weighted norm of care of the multidisciplinary team regarding ACTIVITY demonstrated that 55 percent, 45 percent and 45 percent of the care was above 50 percent.

Use of the radio

7 percent of the extent of oar© achieved 70-79 percent. 93 percent of the extent, norm and Weighted norm of care of the multidisciplinary team achieved < 30 percent for the use of die radio as a means of stimulation as the radio Was used inappropriately (vide . p241),

Use of the tape recorder

All scores achieved 0 percent as the tape recorder should not have been used for the patient (vide p315).

Promotion of independence

95 percent of the extent of care was above 50 percent. The percentages obtained for the norm and weighted norm of oare were below 50 percent. PROMOTION OF INDEPENDENCE contained many items that were regarded as NOT APPLICABLE to the patients under study. Where items were applicable staff achieved well on the extent Of caro but failed abismally with regard to the norm and weighted norm of care.

The research has shown the extent, norm and weighted norm of care received by moderate and severely head injured patients to be inadequate. Seldom was excellent or good care achieved. Certainly the extent of care is superior to the level of performance of care but both need to be improved,

,5 Q U A L IT Y C O N T R O L

In order to ensure objectivity quality control was introduced in 25 percent of the sample (i,e, five patients) (vide pl78),

TABLE 5:128

The overall performance of actual care received per category of personnel as noted by the co-observers

Category of personnel , Number of schedules

Percentage of care performed

N ursing personnel 141 76

Registered Nurse 99 53Student Nurse 42 23Nursing Assistant - -C o m b in ed 10 SM u lt id is c ip lin a ry 35 19

TOTAL 186 100.............. .......... ..................... .

TABLE 5;129A comparison of the observers' scores for (the overall percentage of care received by moderate and severely head Injured patients (extent, norm and weighted norm)

Variable Recorded care {%)

Actual .care ' (%)

Researcher(N*220)

Observer(N“ 220)

Researcher(N~186)

Observer(N=186)

Extent of care 50 61 59 60Norm of care 33 33 39 39Weighted norm of care 37 37 44 44

The overall percentage extent of aotual care of (lie researcher was included in 'poor care* and of the observer was included in the category 'mediocre care', The percentages for norm and weighted norm of actual care of tho researcher and observers were included in the 'dangerous care' category.

Statistical testing by means of the T-test procedure proved that at a 5 percent confidence level there was no significant difference between the scores obtained by the researcher

Author Abelson N MName of thesis The Comprehensive care of the Moderate and Severely Head injured Patient 1987

PUBLISHER:U niversity o f the W itw atersrand, Johannesburg © 2013

LEGAL NOTICES:

Copyright Notice: All materials on the Un i ve r s i t y of the Wi t wa t e r s r and , J ohanne sbu r g L i b r a r y website are protected by South African copyright law and may not be distributed, transmitted, displayed, or otherwise published in any format, without the prior written permission of the copyright owner.

Disclaimer and Terms of Use: Provided that you maintain all copyright and other notices contained therein, you may download material (one machine readable copy and one print copy per page) for your personal and/or educational non-commercial use only.

The University of the W itwatersrand, Johannesburg, is not responsible for any errors or omissions and excludes any and all liability for any errors in or omissions from the information on the Library website.