THE EXPERIENCE OF REGISTERED NURSES NURSING IN THE GENERAL AUDIT INTENSIVE CARE UNIT A PHENOMENOLOGICAL [ U llIA IIV i RESEARCH 3 TU 0 V

In this article a phenomenological qualitative research study is discussed. More attention will be given to the methodology of the research. The objectives of the study are two-fold: firstly to explore and describe the experience of registered nurses nurs­ ing in the adult intensive care unit (this is the first phase of the research) and to describe guidelines based on the information obtained in the first phase to support the nurses in the form of a support programme in the second phase. The units of research are the registered nurses in the intensive care unit. The characteristics of the unit of research led to the emergence of a qualitative phenomenological research design of an explorative, descriptive and contextual nature. In the discussion of re­ search methodology attention will be given to phase one: data gathering (ethical considerations and informed consent; purposive selection, phenomenological inter­ views and field notes); data analysis (Tesch’s method of data analysis, methods to ensure trustworthiness, organisation of raw data and integration of findings supported by literature. Five themes were identified through the data analysis: impaired com­ munication with management; discrimination: white on black racism; lack of fair, com­ petitive remuneration and disregard for professional worth; non-conducive physical environment, and stressful working environment. Phase two: Guidelines were described to support the registered nurses in the inten­ sive care unit based on the information obtained in phase one of the research.


INTROQUQTICN
The purpose of this article is to describe the experience of registered nurses nurs ing in a general adult intensive care unij as well as guidelines to support these nurses.

Background sod Rationale
The problem of intensive care nurses leaving the profession due to non-conducive working environments and non competitive conditions of employment are becoming more alarming and are as relevant as ever.The researcher is con cerned about the quality of nurse aware ness nurses create in order to practice quality nurse care.
Management of health care services are at times insensitive to the needs of nurses, as nurses are not always recog nised for their inherent professional worth.The registered nurses in the adult intensive care unit where the researcher practised as unit manager were observed to be experiencing some kind of work related discomfort (dis-ease).This re quired further investigation.

Problem Statement
If obstacles that influence the registered nurses' experience of nursing in the work place can be identified, ways to address these obstacles can be instituted.If these obstacles can be addressed it can help to promote, maintain and restore the reg istered nurses in the intensive care unit's work as integral part of their health.
Two research questions can be gener ated: How do registered nurses experi ence nursing in the general intensive care unit?How can this information be utilised to describe guidelines to support these nurses?

Objectives
The objective of this study is twofold: Firstly to explore and describe the regis tered nurses' experience of nursing in the adult general intensive care unit and then to use the information obtained to de scribe guidelines for the compilation of a support programme for the nivses nurs ing in the adult intensive care unit.

METATHEORETICAL ASSUMPTIONS
The researcher will support and incor porate the Nursing for the Whole Patient Theory (Rand Afrikaans University De partment of Nursing, 1992) as a paradig matic perspective for this research.It is a world-view based on Judeo-Christian phi losophy.The following parameters of nursing are also identified: the intensive care nurse, health (wholeness), illness (dis-ease) and nursing (intensive care nursing).The intensive care nurse is de fined.

THEORETICAL STATEM ENTS
When conducting the fieldwork the re searcher will approach the field with no preconceived framework of reference.
The theoretical model used is NWPT (1990).Facilitation and support are theo retically defined.

METHODOLOGICAL ASSUMPTIONS
No preference to the type of research is stated.Due to the exploratory and de scriptive essence of the research the qualitative method of research is em ployed.The central methodological as sumption is based on the functional rea soning approach of Botes (1990:19-22).This implies that research must be appli cable to practice and must be useful.
The major objective is to solve problems as they occur in practice and by doing so improve the service character of nurs ing.The utility of research in itself is a criteria for validity and trustworthiness.

RESEARCH DESIGN AND METHOD ( t o r e b d s a g ii
The design of this study is both explora tive (Mouton & Marais,1990:43;Talbot, 1994:90) and descriptive (Mouton & Marais, 1990:44;Talbot, 1994:90) as de termined by the characteristics of the unit of research.The intensive care nurse is a unique, subjective individual.
Two major phases will structure the re search: Phase I: to explore and describe the experience of intensive care nurses.
Phase II: to use the results obtained in phase I as the framework for guidelines for the support of intensive care nurses nursing in the adult intensive care unit.
The Exploration and Description of the registered nurses' experience in the adult intensive care unit.

Objective
The objective of phase one was the ex ploration and description of the experi ences of the registered nurses in the gen eral adult intensive care unit.

Oats Gathering
Population and sampling: The interview ees of the study were five black registered nurses who had been nursing in the unit for at least two months; this was to en sure that all the nurses had been exposed to the same environmental variable.The five nurses were the total registered nurse staff contingent of the unit.Participation was voluntary.The sample was purposive to enhance contextuality.
Ethical Consideration: In conducting the study the following ethical considerations were followed: The competence of the researcher was nurtured by the two nurse specialist study supervisors as to being morally just and valid (Minichiello et al., 1990,236-244).
The research interviewer -interviewee relationship was non-threatening and emotionally safe and the human rights of the interviewees were respected.In formed consent was obtained from the interviewees in an informational letter communicating the essential information pertaining to the research.
Access was gained by formally approach ing the hospital management for written consent.The essential information com municated in the information letter were the following aspects: Voluntary partici pation and anonymity, the objectives of the study, investment, risks and benefits, duration of participation, and the possi bility of future publishing based on the research (Burns & Grove, 1993:104-106;SANA, 1991).
Phenom enological interviews: The phenomenological interview (Kvale, 1983:171-196) was used as semi-struc tured interview method.The research in terviewer asked one central question: How do you experience nursing in the adult ICU? Validity threats in semi-struc tured interviews were taken into consid eration (Hutchinson & Wilson, 1992:117-119).
The phenomenological interviews were taped via audiotapes and transcribed ver batim.
Field notes: Throughout the interviews and the whole research project, field notes were taken regarding non-verbal cues and practical problems and posi tive aspects (Guba & Lincoln,1985:327).
The field notes assisted the researcher with interpreting data during the consen sus discussion with the research-interviewer.

DATA ANALYSIS
Tesch's (1990) method of data analysis: Tesch 1990 in Creswell (1994:155) was used as method of choice for data analy sis.After all the interviews had been tran scribed, a sense of the whole was ob tained by reading through all the tran scripts.Ideas were jotted in the margin as they came to mind.The most interest ing interview was selected, and the fol lowing questions were asked: What is it about?What is the underlying meaning?Thoughts were written in the margin.This task was completed for all the interviews and a list was made of all the topics.Simi lar topics were clustered together.
These topics were formed into 3 major columns such as: major topics, unique topics and leftovers.This list was taken and returned to the data and topics were abbreviated as codes.The codes were written next to the appropriate segments of text.This prelim inary organising scheme was tried to see if any new cat egories and codes emerged.
The most descriptive wording for the top ics were found and turned into catego ries.The total lists of categories were re duced by grouping topics that relate to gether.Lines were drawn to indicate in terrelationships.A final decision was made on the abbreviation of each cat egory.
These codes were alphabetised.The data material belonging to one category was assembled in one place and a prelimi nary analysis was performed.If neces sary the existing data was re-coded.
The researcher was always on the look out for unusual or useful quotes that could later be incorporated into the quali tative story.Major and minor themes could also have been categorised and another list could then show contrasting themes.
Triangulation of the data was made by consulting a nurse researcher (independ ent coder) who analysed the interviews independently of the researcher.The in dependent coder was a nurse researcher who is familiar with conducting qualita tive data analysis.A protocol describing the method of data analysis was also pro vided to the independent coder.This pro tocol contained no pre-ordained themes or categories and was, therefore, known as open coding.After the interviews had been analysed, the researcher and the independent coder met for a consensus discussion.
The themes, as they emerged in the in terviews and as interpreted by the re searcher, were discussed with the inter viewees in the follow-up interviews.This was to ensure that information obtained was representative of what the interview ees had meant.
Literature control: The results of the re search were discussed in the light of rel evant literature and information obtained from similar studies.Referential checks enhanced the scientific trustworthiness of the study.This was a strategy used to ensure trustworthiness by means of tri angulation.
Strategies for trustworthiness (Krefting, 1991:215-222).The strategy for establish ing truth-value is credibility, transferabil ity is used to attain applicability, depend ability to establish consistency and confirmability to achieve neutrality.
(See the application of this in table 1.)

FE8ULT8
The results and literature control of the five major themes that were saturated are

Reflexivity
Field notes will be taken by both the researcher and the interviewer.

Member checking
Follow up interviews will be held with interviewees.Literature control on themes and its impact on guidelines will be discussed.
Triangulation 2 researchers, interviews and observation to ascertain it truth is reflected.

Peer examination
Services of a colleague will be required.

Authority of researcher
The researcher's two research supervisors both have Doctorates in the nursing field of research.They will nurture and supervise the researcher's capabilities and ethics.

Structural coherence
The focus will be on ICU nurses' experiences.The results will be reflected within nursing for the whole person theory.

TRANSFERABILITY
Nominated sample Purposive sampling will be used.

Dense description
Complete description of design and methodology and accompany ing literature control to maintain clarity will be used.

DEPENDABILITY Dependability audit
Personal logs and reflexivity notes will be kept.

Dense description
Research methodology will be fully described.

Peer examination
Independent checking by a colleague and supervision by experts will be done.
Code/recode procedure A consensus discussion between the researcher and the independ ent coder will be held.

IN THE ADULT INTENSIVE SAFE ONIT
The results of this study show that the registered nurses working in the general adult intensive care unit require support from the formal health-care delivery sys tem.For the purpose of the study the employer is seen as representative of the formal health-care delivery system re garding issues related to the working environment of nurses.
The registered nurses in the intensive care unit also have nursing rights that have been elaborated on by Nel (1993:181).These rights also afford an inherent responsibility: e.g. if it is the nurse's right that she must negotiate with her employer for progressive education programmes in her field of speciality so it is the employer's responsibility to pro vide scope for staff developmen pro grammes.
It is also the employer's right to expect that the nurses employed are profession ally competent and licensed.In this re gard it is then the nurses' responsibility to ensure that they adhere to the required standards and communicate their edu cational/training needs.
The findings discussed in the data analy sis indicated that work-related spiritual and emotional distress was experienced by the registered nurses nursing in the intensive care unit.The major themes that emerged were: impaired communication between management and the nurses, racial discrimination in the work place, lack of professional recognition of nurses via lack of equitable and competitive re muneration and insensitivity to their pro fessional needs, a depersonalised physi cal environment and an emotionally and spiritually stressful working environment.
The guidelines drawn up are based on Copi's (1962:381-386) criteria for ensur ing logic which are: relevance, testabil ity, compatibility with previously well-es tablished theoretical statements, simplic ity and explanatory power.
Thus if the data analysis revealed that there was a lack of communication be tween the nurses and management, it is only logic to infer that strategies to im prove communication between manage ment and the nurses would be a relevant guideline.Furthermore, there are relevant scientific literature on the aforementioned strategy which contain references to simi lar studies, testable strategies and a theo retic framework of communication.The relevant literature enhances the trustwor thiness and explanatory power of the guidelines.
These guidelines were discussed with registered nurses nursing in the general intensive care unit to confirm their appli cabilities.
See Table 3 for the overview of strategies based on the themes that emerged in the data analysis and that were supported by the literature control.In the working envi ronment of the nurse there is a recipro cal interdependency between manage ment and the intensive care nurses.They are co-responsible for the corporate cli mate of the organisation.
The following strategies were incorpo rated as guidelines: Improving commu nication with management, restoring the human dignity and professional worth of the registered nurses by eliminating ra cial discrimination in the work place as well as employing strategies to increase the professional worth of nurses, estab lishing collaborative interpersonal rela tionships with all the members of the health team, and creating a personalised work environment.

Improve the Professional Status of the A M Intensive Qape Nurses
Revise existing systems of remunera tion (Booyens,1995:671) Transparency of remuneration without sacrificing competitive salaries is re quired.To a certain degree categories should be standardised.Personal at tributes, qualifications, degree of respon sibility and experience should be taken into consideration for incentive bonuses.Define the roles within the organisation.
Nurses need to communicate and define their rights and responsibilities in the adult intensive care unit (Nel,1993:181).
Nurses should communicate their scope of practice to all the members of the health team and it should be respected by all persons involved in the health serv ices.
Employ adequately trained ratios of permanent staff (Booyens,1995:202) The adult intensive care unit needs more permanently employed registered nurses to reduce stress and provide a more pre dictable work environment.This will also ensure the fair distribution of work-load and responsibilities.
To establish teamwork a team has to ex ist.More permanent staff is needed to dis courage an unmanageable working en vironment.

G0NQU8I0N
In conclusion it can be said that the study has shown that registered nurses nurs ing in the intensive care unit are at risk of developing work-related illness.Due to the reciprocal interdependence between management and the registered nurses; nurses need to communicate their needs and nursing rights to management and other health team members.
Management in return needs to be sen sitive enough to support registered nurses in achieving their work-health ideal.It is of utmost importance that in tensive care nurses should be adamant about their responsibility in supporting each other so that in making intensive care nurses nurse-aware that they can promote, maintain and restore nursecare.
Develop systems of staff development.(Booyens,1995:672)Nursing autonomy and excellence should be the goal of all staff development.Plan-

sensitivity and awareness by management of incidences of social in justice (Booyens,1995:644-676).
Promote leadership in nursing (Booyens, 1995:403); as well as prob lem solving and decision making (Booyens, 1995:507) Nurse leaders should practice nurse ad vocacy and ensure strategies for deliver ing nurse-care.These leaders can build

TABLE 3 : OVERVIEW OF STRATEGIES TO SUPPORT THE IC U STAFF
Management should respect the needs for privacy of the nurses and should pro vide a tearoom where the nurses can have some time-out.The nurses should make use of the relaxation systems pro vided by the work place.Nurses should work in comfortable theatre-like overalls to reduce the possibility of contaminat ing both patients at work and families at home.Staff lockers should be provided and the infection control policies should be revised, updated and communicated.