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Ramuoodoo Sinnathamby
Ramuoodoo Sinnathamby
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24 Januari 2011 1. Saya mempunyai seorang kawan baik 2. Kawan baik saya bernama Junaidah 3. Saya duduk di sebelahnya di dalam kelas 4. Kami murid tahun satu cemerland 5. Kawan baik saya suka membaca buku My sister is four years older than me. She is in Years six Her name is Kalama. Kalama likes to play the piano 1. Good morning, father. 2. Good afternoon,Nora 3. Goodbye,Ramesh
BY EARTH GROUP YEAR 5 2011 Binatang kesayangan saya Saya mempunyai seekor binatang kesayangan yang bernama Bobo.Bobo ialah seekor anjing yang berbulu putih dan berbadan kecil. Setiap pagi,apabila saya pergi ke sekolah,Bobo akan menamani saya sampai ke pintu pagar dan melihat saya menaiki bas. Apabila saya balik dari sekolah,Bobo akan menyambut saya dengan gembiranya sambil melompat ke badan saya dan mengoyangkan ekornya berkali-kali.Saya akan peluk Bobo dengan kuat dan senyuman yang manis. Pada waktu petang,saya selalu membawa Bobo ke padang dan bermain bola dengannya.obo pun menamani sayaberlari lari disekelilingi padang dengan gembiranya. Pada suatu malam,Bobo menyalak dengan berkali-kali dan kuatnya kerana dia nampak ada pencuri hendak mencuri basikal saya yang terletak di halaman rumah saya. Ayah saya pun membawa sebatang kayu dari biliknya dan menghalau pencuri itu.Akhirnya,pencuri itu pun lari dengan cepatnya.
Setiap hari,saya akan memberi makanan dan minuman kepada Bobo.Saya juga akan memotong kuku Bobo dan mandikan Bobo supaya sentiasa kelihatan shat dan bersih. Saya berasa sangat gembira kerana menpunyai seekor binatang yang berani.SAya sangat sayang pada Bobo Pasar malam Pasar malam adalah suatu tempat yang menjual barangan keperluan harian pada waktu malam.Pasar malam di tempat saya pula biasanya diadakan pada setiap hari Sabtu dan bermula pada pukul 5.00 petang hingga 10.00 malam. Setiap hari Sabtu,saya mengikut ibu saya pergi ke pasar malam.Ramai penjaja mula memasang gerai masing-masing.Pada pukul 5.00 petang ditepi jalan bagai cendawan tumbuh selepas hujan.Terdapat banyak gerai yang menjual beraneka jenis barangan seperti sayur-sayuran yang segar-bugar, buah-buahan tempatan yang diimport,hidupan laut yang segar,pakaian,dan alat permainan yang menarik. Ramai pelangan datang berpusu-pusu bersama ahli keluarga dan membanjiri pasar malam.Pada awalnya suasana sunyi-sepi bertukar menjadi hiruk-pikuk dengan laungan para penjual yang ingin mrmperasikan barabgan menggunakan pembesar suara.Ada juga peniaga memainkan lagu-lagu bagi menarik perhatian para pelangan.Lampu yang berwarna-warni menyebabkan pasar malam terang-benderang.Para pengunjung terpaksa berjalan berhimpit-himpit kerana penuh sesak. Kebanyakan harga barangan dijual dengan berpatuan dan boleh tawar- menawar.Saya tidak melepaskan peluang untuk menikmati pelbagai juadah yang dijual di pasar malam. Keadaan mulai reda,pada pukul 10.00 malam kerana ramai pelanggan beransur
pulang.Para peniaga pula sibuk mengemas barang masing-masing.Saya pun berjalan pulangke rumah dengan emak saya.
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Soalan 1 - 21 Isi tempat kosong dengan jawapan yang paling sesuai. 1 “Ibu bangga mendapat anak seperti ____________ ,” kata Puan Jalilah kepada anak tunggalnya. A dia B kamu C mereka D engkau 2 “Pantang ____________ rakyat menderhaka kepada sultan,” kata Hang Tuah kepada sahabatnya. A beta B patik C hamba D tuan hamba
3 ____________ mangsa banjir telah berjaya dipindahkan ke ____________ pusat pemindahan yang berdekatan. A Semua ..........beberapa B Semua ..........sebahagian C Segelintir ..........beberapa D Segelintir ..........sebahagian Soalan 4 berdasarkan gambar di bawah. 4 Cikgu Anis melambai tangan ____________ memanggil Ketua Darjah 6 Melur untuk memberi pesanan. A kerana
B sambil C apabila D supaya 5 Dato’ Habib amat berpuas hati dengan kerja ____________ banglonya yang terletak di Taman Tasek Utama. A ubah suai B susun atur C kemas kini D tambah baik 6 Pada awal tahun, pihak sekolah akan mengadakan sesi ____________ bagi meraikan kehadiran murid-murid tahun 1. A tegur sapa B soal jawab C bual bicara D ramah mesra Soalan 7 berdasarkan gambar di bawah
7 Ahli-ahli pengakap itu sedang berteduh di bawah sebatang pokok ____________ menunggu jurulatih mereka sampai. A hingga B lantaran C sementara D mahupun 8 Persiapan untuk menyambut Hari Kebangsaan sedang ____________ dijalankan. A gigih B hebat C pantas D rancak Soalan 9 berdasarkan gambar di bawah.
9 Fatin ____________ ketakutan apabila melihat seekor ular keluar dari dalam semak. A menjerit B meraung C melaung D melolong 10 Puan Rohana berasa berat hati meninggalkan sekolah setelah bertahun-tahun menabur bakti sebagai guru besar di situ. Perkataan seerti bagi bakti ialah A jasa B budi C kerjaya D khidmat
11 Api yang marak telah membakar kilang perabot itu hingga hangus dalam jangka masa yang singkat. Perkataan berlawan bagi singkat ialah A lama B cepat C ringkas D pendek 12 Syahirah belajar membilang dengan menggunakan beberapa ____________ biji saga. A butir B buah C batang D tangkai 13 Setelah jatuh sakit, nenek tidak menjamah walaupun se____________ nasi dan se____________ air. A biji ... titis B buah ... titik C butir ... teguk D pinggan ... teguk
14 Vijay ____________ apabila diminta untuk menjawab soalan itu kerana dia sedang berkhayal. A terkial-kial B terkebil-kebil C terpinga-pinga D tersentak-sentak Pilih jawapan yang paling sesuai bagi soalan yang diberikan. 15 Di manakah awak akan menunggu saya? A Berdekatan dengan pejabat pos. B Sudah lama saya menunggu awak. C Saya akan menelefon apabila saya sampai. D Kita akan berjumpa pada pukul 10.00 pagi. Pilih ayat tanya yang sesuai bagi ayat di bawah. 16 Keuntungan yang diperoleh pada Hari Kantin tidak begitu memberangsangkan. A Bilakah Hari Kantin diadakan? B Mengapakah Hari Kantin tidak diadakan lagi? C Berapakah keuntungan yang diperoleh pada Hari Kantin? D Mengapakah keuntungan Hari Kantin tidak memberangsangkan?
Pilih ayat yang sama maksud dengan ayat yang diberi. 17 Gotong-royong yang diadakan itu adalah untuk mengeratkan hubungan kekeluargaan dalam kalangan penduduk taman ini. A Hasil daripada gotong-royong itu, para penduduk taman ini bertambah erat hubungan mereka. B Tujuan gotong-royong ini untuk mengeratkan hubungan penduduk antara kekeluargaan taman ini. C Hubungan kekeluargaan yang bertambah erat di taman ini memudahkan program gotong-royong diadakan. D Hubungan kekeluargaan yang erat dalam kalangan penduduk taman ini adalah matlamat projek gotong-royong diadakan. 18 “Mengapakah adik kamu menangis?” tanya cikgu kepada Farhan. A Farhan bertanya kepada cikgu sebab adiknya menangis. B Cikgu bertanya kepada Farhan sebab adiknya menangis. C Cikgu bertanya kepada Farhan sebab adik kamu menangis. D Farhan memberitahu kepada cikgu sebab adiknya menangis. 19 ____________ Sharifah Aini yang bersuara merdu itu berasal dari kampung ini. A Biduan
B Seniman C Seniwati D Biduanita 20 Ayah ____________ ibu sebentuk cincin emas bertatahkan mutiara sempena ulang tahun perkahwinan mereka. A dihadiahi B dihadiahkan C menghadiahi D menghadiahkan 21 Encik Zamri bekerja siang dan malam untuk menampung ____________ sekolah anak-anaknya. A berbelanja B membelanja C perbelanjaan D membelanjakan Soalan 22 berdasarkan gambar di bawah.
22 Pak Wan mengangkat timbunan tanah yang dicangkul dengan menggunakan ____________ . A raga B nyiru C bakul D pongkes Pilih peribahasa yang sesuai. 23 Puan Salmah menyelesaikan pertelingkahan kedua-dua anak kembarnya seperti A melepaskan batuk di tangga. B menatang minyak yang penuh. C menarik benang dalam tepung. D menegakkan benang yang basah. 24 Perdana Menteri menyarankan agar rakyat mengamalkan konsep 1 Malaysia.
A Bagai isi dengan kuku. B Bagai aur dengan tebing. C Bagai duri dalam daging. D Bagai pinang dibelah dua. Pilih ayat yang betul. 25 A Pasu kristal itu terhempas ke lantai lalu pecah. B Dia akan ke Pulau Pangkor di hujung minggu ini. C Arifah lebih pintar dari kawan-kawannya yang lain. D Kami kagum dengan kejayaan anak-anak Puan Devi itu. 26 A Wah, daif sungguh kehidupan Ah Meng sekeluarga! B Aduhai, anak-anakku belajarlah bersungguh-sungguh! C Cis, banyaknya ikan yang mati di kolam Pak Syahmi ini! D Syabas, kamu terpilih untuk mewakili sekolah dalam pertandingan pidato itu! 27 I Oleh kerana cuaca panas, nenek tidur beralaskan tikar di serambi. II Calon diberi masa satu jam suku untuk menjawab soalan Penulisan. III Pengacara majlis mengucapkan terima kasih di atas kehadiran para tetamu. IV Hidayah bercadang hendak melancong ke luar negara pada musim cuti nanti. A I dan II B I dan III
C II dan IV D III dan IV 28 I Buku cerita yang tebal itu telah dibaca oleh saya. II Pendingin hawa di pusat sumber sekolah kami sedang dibaiki. III Penduduk Kampung Duyong saling tolong-menolong membersihkan kawasan sekolah. IV Antara acara yang dipertandingkan pada hari itu ialah acara balapan dan lompat tinggi. A I dan II B I dan III C II dan IV D III dan IV Pilih ayat yang menggunakan perkataan bergaris dengan betul 29 A Suasana di dalam stadium meregang apabila penonton mula merusuh. B Hubungan Zuhri dan Ramesh itu meregang akibat perselisihan faham. C Irfan meregang daun tingkap untuk membiarkan cahaya matahari masuk. D Dawai telefon mengendur pada waktu sejuk dan meregang pada waktu panas. 30 I Buah peria katak tidak digemari kerana rasanya yang pahit. II Roslan tidak dapat menerima pandangan pahit rakan-rakannya. III Hatinya pahit apabila Ruzlan memalukannya di khalayak ramai.
IV Nenek asyik bercerita tentang pengalaman pahit ketika zaman pemerintahan Jepun. A I dan II B I dan IV C I, II dan III D II, III dan IV
Soalan 31 – 35 Baca petikan e-mel di bawah, kemudian jawab soalan-soalan berikutnya. Kepada : Mariah binti Mat Daripada : Juliana binti Jusoh Perkara : Kepada sahabatku Mariah yang kini berada di Kuala Lumpur. Semoga sihat dan bahagia selalu. Saudari, Apa khabar saudari sekarang? Saya dan keluarga di sini berada dalam keadaan sihat sejahtera. Oh, ya! Lama sungguh kita tidak berjumpa. Semenjak saya berpindah ke sini, inilah pertama kali saya menulis e-mel kepada saudari.
Buat masa ini kami sekeluarga menyewa sebuah rumah di Taman Bidara Permai. Ayah saya telah pun membeli sebuah rumah di taman perumahan yang baru tetapi rumah itu masih dalam pembinaan. Mungkin tahun hadapan kami akan berpindah ke rumah itu. Kawan-kawan kita bagaimana sekarang? Saya begitu kehilangan akan mereka. Kalau saudari berjumpa dengan Hanafi, Rogayah, Azmi dan lain-lain, sampaikanlah salam saya kepada mereka. Saya juga telah cuba menyesuaikan diri di tempat ini. Murid-murid di sini baik belaka. Mereka dapat menerima diri saya dengan hati terbuka. Setakat ini dahulu yang dapat saya tuliskan. Semoga bertemu pada masa yang lain. Sekian, terima kasih. Sahabatmu, Juliana 31 Apakah tujuan e-mel ini ditulis? A Menghubungi seorang kawan yang tinggal di luar negara. B Menghubungi kawan yang lama tidak bertemu. C Mengajak sahabatnya datang ke rumah. D Meminta bantuan kewangan. 32 Di manakah Juliana tinggal? A Di Kuala Lumpur. B Di Taman Bidara Permai. C Dekat dengan rumah Hanafi.
D Berhampiran Taman Bidara Permai. 33 Antara kenyataan berikut, yang manakah tidak benar? A Juliana tidak mengenali Mariah. B Juliana pernah tinggal di Kuala Lumpur. C Juliana mengenali Azmi ketika di Kuala Lumpur. D Hanafi dan Rogayah masih tinggal di Kuala Lumpur. 34 Apakah maksud ‘menyesuaikan diri’ dalam petikan e-mel di atas? A membiasakan dengan keadaan B menagih simpati C membawa diri D berhati-hati 35 Bagaimanakah keadaan murid-murid di tempat yang baru diduduki oleh Juliana? A Cemburu atas kejayaan Juliana. B Mengecam kedatangan Juliana di situ. C Berpakat untuk melantik Juliana sebagai ketua. D Menerima kehadiran Juliana dengan senang hati.
Soalan 36 - 40 Baca petikan di bawah, kemudian jawab soalan-soalan berikutnya. Tun Abdullah bin Ahmad Badawi dilahirkan dalam keluarga yang warak di Kampung Perlis, Bayan Lepas, Pulau Pinang. Beliau menerima pendidikan menengah di Sekolah Menengah Kebangsaan Tinggi Bukit Mertajam dan di Penang Methodist Boys School, Pulau Pinang. Abdullah memulakan kerjayanya sebagai guru. Selepas menerima Sarjana Muda Sastera dalam bidang Pengajian Islam daripada Universiti Malaya pada tahun 1964, beliau menyertai sektor perkhidmatan awam sebagai Penolong Setiausaha di Jabatan Perkhidmatan Awam. Pada tahun 1969, Abdullah berpindah ke Majlis Gerakan Negara (MAGERAN), sebuah badan yang berkuasa eksekutif untuk mentadbir negara yang ditubuhkan selepas rusuhan kaum pada Mei 1969. Abdullah kemudiannya dinaikkan pangkat menjadi Ketua Pengarah Kementerian Kebudayaan, Belia dan Sukan, sebelum menjadi Timbalan Ketua Setiausaha dalam kementerian yang sama pada tahun 1974. Abdullah berkahwin dengan Datin Seri Endon binti Dato' Mahmood pada tahun 1965 dan dikurniakan dua orang cahaya mata dan empat orang cucu. Pada 20 Oktober 2005, Endon Mahmood meninggal dunia selepas bergelut dengan penyakit barah payu dara sejak 2003. Setelah dua tahun menduda, beliau berkahwin pula dengan Jeanne Abdullah. Beliau dikatakan mementingkan aktiviti makan malam bersama-sama keluarga dan gemar makanan Jepun. Beliau menghargai hasil seni Malaysia dan merupakan seorang pengumpul seni ukiran kayu serta anyaman rotan. Setiap hari selepas sembahyang Maghrib, beliau akan mengaji Al Quran. Telah menjadi kebiasaan beliau menulis nota dalam Jawi. Selain
daripada keluarga sendiri, tokoh yang banyak mempengaruhinya serta dianggap sebagai mentor ialah Tun Abdul Razak. Beliau juga adalah pencetus Islam Hadhari. 36 Di manakah Tun Abdullah bin Ahmad Badawi dilahirkan? A Perlis B Kedah C Bukit Mertajam D Kampung Perlis 37 Apakah jawatan yang disandang oleh Tun Abdullah bin Ahmad Badawi pada 1974? A Pendidik B Penolong Setiausaha C Ketua Pengarah Kementerian Belia dan Sukan D Timbalan Ketua Setiausaha Kementerian Belia dan Sukan
38 Bilakah beliau berkahwin dengan isteri keduanya? A Tahun 2003 B Tahun 2005 C Tahun 2006 D Tahun 2007 39 Pilih pernyataan yang tidak benar tentang petikan di atas? A Beliau menghargai hasil seni Malaysia. B Beliau pernah menjadi Penolong Setiausaha. C Beliau merupakan graduan lulusan ekonomi. D Beliau menggemari makanan Jepun. 40 Perkataan pencetus dalam petikan sesuai digantikan dengan A pereka B pelopor C pencipta D pengilham
By G.MAGESWARI COHORT 9 STUDENT ID: 08035555 Word count: 10 000
1.0 Introduction The working place of intensive care unit (ICU) is very busy and hectic with never ended critical cases. Workload due to continuous contemporary issue such as shortage of staff and the conflict with professional boundaries such as vertical and horizontal substitutions . These are the factors that contributing workload and stress in ICU. To discuss the performance hurdles experienced by intensive care nurses in their work environment that impairs nursing care through reflective account. To make recommendations to over come the stressful workload in ICU in order to improve nursing quality for the clients. Intensive care nurses come across with a lot of performance obstruction in their work environment. Reflexion and reflexivity should be able to identify the outcome of various performance hurdles on nursing workload, nursing quality of working life, and quality of patient care. I would use John’s Model of structured reflection in my discussion by reviewing my daily work to over come the stressful workload in ICU in order to improve nursing quality for the clients by removing performance problem. The Mechanisms of workload which I would discuss in my dissertation are empowment, time, motivation, stress, attention, violations of work- a rounds and impact on organization . At the same time I would approach my dissertation on empirics, ethics, personal and aesthetic basis by using John’s Model of Reflection (1994) .
2.3.1 Stress in ICU Working in hospital settings can be very stressful, particularly for those nurses and working in an ICU (DePew et al., 1999). Work pressures are considered as part of everyday life of health professionals (McCarthy, Power and Greiner, 2010). According to Cox, Griffiths and Rial-Ganzalez (2000) the stress response as being mismatch between the perceived demands and the capabilities of the individual to cope with this demands. According to Lally and Pearce (1996) there are multiple factors which cause stress in ICU, which include high patient mortality, the nature of death in ICU, young people dying as an outcome of acute pathology or due to traumatic injuries as well as the fast change in the pace of works and tasks. As a result, all of these factors result to an environment that is full of tension and anxiety. In addition, other studies also showed different stressors for nurses which can be found in the ICU working environment. These include, but not limited to: excessive workloads (Callaghan et al., 2000); conflict with the supervisors and co-workers (Tyson et al., 2002); dealing with death and dying patients (Lambert et al., 2004b; Mann and Cowburn, 2005); lack of support from the organization (Tyson et al., 2002); insufficient preparation or lack of resources being issued (Tholdy Doncevic et al., 1998); coping with emotional needs of the patients as well as their treatment (Kalichman et al., 2000); shift rotation (Rogers, 1997); uncertainty concerning treatment (Kalichman et al., 2000); low job control (Cheng et al., 2000); and being moved among different patient care units (Healy and
McKay, 1999). The study of Foxall et al. (1990) showed that intensive care nurses have to deal more with the stress of death and dying, while general medical-surgical unit nurses have to contend more with workload and staffing issues (cited from Burgess, Irvine and Wallymahmed, 2010). The study of Wolfgang (1988) compared the stress level of nurses with doctors and pharmacists. The result showed that nurses reported highly stressful environment and jobs compare to doctors and pharmacists. This is because of work load, needs of the patients as well as conflicts in the team. In addition, the study of Goodfellow et al. (1997) analyzed and evaluated the occupational stress between nurses and doctors within the ICU. The result showed that the doctors found that some factors in their job connected to career and achievement as well as organizational design and structure, are offering them more stressful works than the normal working setting. On the other hand, the nursing staffs reported different sources of stress compare to the doctors. The negative impacts of excessive demands that the working environment bring towards the medical staffs have been well studied and documented to offer and cause both physical and psychological impact towards individual. Stressor have an influence on most bodily systems, which produce quantifiable transient impacts which questionably lead to severe, chronic or even acute physical health problems (Mealer et al. 2007). In terms of psychological aspect, stress is connected with the feeling of anxiety, depression, subjective fatigue, reduction of confidence and self-esteem. All of these symptoms or signs have been showed
and studied to affect the capability of individual and group to perform and act in different work-related tasks (Kincey et al., 2005). The study of Mealer et al. (2007) showed that some of the traumatic events that are connected with the PTSD in ICU nurses are quite the same to the experiences of war veterans, which include handling of dead bodies and caring for trauma victims. With this, it show that ICU is a very demanding environment which leave medical staffs – particularly nurses to be anxious and depressed (Burgess et al., 2010). My workplace has been considered as an extraordinary working environment with different workloads. Environmental factors have been established to the level that meets suggested standards. Currently, in my ward healthcare facilities are experiencing overcrowding and hospital-wide waits and delays. Thus, possible risks must be identified and alleviated by matching demand to capacity (Hall, 2006). This is primarily because of the different changes and alterations in ICU , which include the development of technology, innovations, the changes in the culture and tradition of individuals and the overall organizational behavior. It is also important to consider the different social changes found in the macro- environment. I directly saw how patients and their families perceived about the quality of the medical services being offered to them. In my working place the workload demands have been changed due to the increase in the level of patient demands and expectations. Patient’s expectations have raised the level of working demands and perceived stress among us . At the present time, work in the hospital is dominantly worked with a high level of
psychosocial demands and workloads. According to the results of different epidemiological studies, the work of nurses is stressful. But, they still have to carry out their task in agreement with professional demands and without mistakes or error no matter how stressed and tired they are. Recently apart from working in ICU we are been forced to work double duty and no off day for nearly ten days in newly open dengue ward because of outbreak of dengue fever. Actually the management side failed to declare the situation to the state government to get man power. The working environment is consequently, perceived as overloaded. Additionally, the cost sare fatigue, illness and sick leaves. Nurses are in constant stress. They are worn out. Every now and then we can talk about epidemic of burnout syndrome (Vink, Konningsveld and Dhondt, 1998). These factors are very important because it directly affect the quality of the services they offered towards their patients, which consequently affect their lives and health . As a result, the question of what decrease burnout and increases retention and job satisfaction are widely studied in the field of health and medical working environment. Different studies showed that empowerment and perceptions of organizational commitment are two vital factors which are connected to job satisfaction (Kuokkaken, 2003 cited from Hall, 2006, 103). Once during my night duty I receive a Inferior all Myocardial Infarction patient to my ward. While I was doing my routine work such as taking observation and preparing medication for the gentleman. Suddenly the patient developed arrhythmia – ventricular
tachycardia so immediately I called the doctor but he is too late. And I tried to print the electrocardiogram graph of the fatal arrhythmia unfortunately the machine in not in good condition and can’t print for documentation purpose. But I am sure that it is ventricular tachycardia. Because I already under gone coronary care nursing and have advanced cardiac live support certificate moreover working in intensive care unit for nearly ten years. While waiting for him with my experience and knowledge I perform defibrillation with 200 joules and the graph reverted to sinus bradycardia and I gave intravenous medication atropine. The patient survived and the graph shows sinus tachycardia, and other observation parameters shows normal range. I really satisfied with my reflection- in- action . But the sad side of the story is, the doctor scolded me because I crossed the professional boundaries and did the procedure against the code of nursing. The only reason was I failed to print the graph and I can be charged if anything bad or the patients’ condition deterioting or die. But I still argue with him and said I really sure with the arrhythmia and you are late and I can’t lose the young gentlemen. And I assume that if he is my family member I will try my best to save him. The doctor felt guilty but he scolded there is no prove. I feel very bad and discourage and couldn’t accept the way they treat me as a senior staff nurse and scolded me in front of other clique who are very junior staffs, of course they won’t respect me. And promised to myself that I won’t repeat it again but still my feeling confront with him. The embarrassment made me depressed and I couldn’t carry out my daily duty at that night and the following week as a mother and a wife at home. I lost my appetite and good sleep for few week. Finally I
went to see a doctor and diagnosed as stress. Organizational commitment is considered as the main aspect considered as in retention and job satisfaction because it pertains on individual’s attachment, trust and involvement in the organization (Kuokkanen et al., 2003 cited from Hall, 2006, 103). It is important to consider that different environments have different stressors and sources of stress may even different from individual to individual in the same unit. For instance, the study of French et al. (2006) showed that lack or shortage of resources help to increase levels of stress in ICU (cited from Hall, 2006). In addition, French et al. (2000) added that stress is connected on the individual and influence perceived from situations and conditions on one’s physical and psychological well-being, as a result, according to Tonges (1998) workplace stress is commonly connected with workload (cited from Hall, 2006). Stress happens based on workload when the demand exceeds the ability of an individual to access resource or capacity. As a result, according to French et al. (2000), it is important for hospitals and health care organizations to develop supportive management, increasing opportunities for positive patient interactions, and creation of a wide-spread sense of autonomy as well as empowerment can help in order to lessen or distribute stress (cited from Hall, 2006). In addition,I also affected with the shortage, in my work place. As a result, the government gets the service of foreign doctors in other countries in order to ensure that there is sufficient number of doctors to handle the number of patients. However, based on my observations and experiences (primarily based on the
doctors whom I worked with), they are not as professional as our local doctors. In addition, they are also not that trained and used to speaking and understanding our language, as a result, we, the nurses serve as translator and interpreter in order to make the doctor and the patient to understand each other. Recently in my ward I face a very bad situation which was contribute to very stressful working environment. These doctors never examined the patient properly and just accept the cases from ward. The problem I face was most of the patient will die within hours. The sad part was immediately after I we done the last office he will called l and order to prepare another bed for a new patient. Even though I advice him to examine the patient use the ICU protocol to accept the case but he never bother to listen. I also no power to reject it. Just imagine how stress we are in this situation. Thus, this add additional burden for the nurse and some of the doctors are not really skillful,so that t we have to assist them in doing different procedures. In addition, we also serve as trainer, mentor superior to the junior staffs after most of our senior staffs move due to promotion. As a result, currently, we are working with junior staffs with less knowledge, skills and experiences in different procedures, tasks and responsibilities in the ICU. The performance of our junior is on our shoulder, meaning if the junior staff did something wrong, the management will overlook to the senior, and there are possibilities that we will be fired.
I also have responsibilities and roles that I must do for my family – my children and my husband. These stressors I found at work affect my relationship, including the time that I spent with them. 1 Reflection Model Reflective practice is considered as a learning process which encourages self-evaluation with succeeding professional development planning. According to (Driscoll and The, 2001) Reflection is useful strategy in nursing field because it help to differentiate between thinking regarding daily work versus reflecting regarding on experience, which requires intentionality and skills. Thus, reflective practice claims the capability of an individual to evaluate situations and make judgments pertaining to the efficiency of situational interventions and quality of outcomes (Zuzelo, 2009). Thus, reflective practice helps practitioners to make sense regarding the different challenging, complicated and complex, which eventually remind practitioners that learning is continuous, and there is a need for improving traditional types of knowledge that are required in nursing practice, at the same time, sustain nursing by different formal opportunities to converse with peers regarding the practice. There are different models of reflection, which can be used. These include: Gibbs’ model of reflection, John’s model of reflection, Kolb’s Learning Cycle and Atkins (1995) and Murphy’s model of reflection (Zuzelo, 2009). For this paper, John’s model of reflection will be used, for the author believes that it is the most applicable and suitable model for the case and
scenarios being studied. Reflectivity activity is considered as an opportunity to purposely and intentionally think regarding the practice events; analyze choices, reactions, responses and behaviors; consider possible alternatives; develop plans in order to improve or recognize learning needs; and to follow this action plan in new or the same events or problems (Zuzelo, 2009). According to John (2004) reflective practice is a holistic practice mainly because it pertained on comprehending the vitality, importance and meaning of the entire experience. There are different layers of reflection which progress from a reflection on experience towards mindful practice, which are in juxtaposition with moving from doing reflection to reflection as a way of being. With all these, reflective practice is defined as: Being mindful of self, either within or after experience, as if [there is] a window through which the practitioner can view and focus self within the context of a particular experience, in order to confront, understand and move toward resolving contradiction between one’s vision and actual practice (Johns, 2004, 3 cited from Zuzelo, 2009) The table below shows the cues offered by the said model in order to help practitioners to access, make sense of and learn via experience (Ahot, n.d.). John (1992) applied the concept of guided reflection in order to define a structured, supported approach which will enable practitioners to learn from their reflections on their experiences. It uses a model of structured reflective diary, one-to-one or group supervision and keeping of a structured reflective diary. The main advantage of this model is that it is more detailed compare with the other
models, which eventually offers advantages and disadvantages. According the different nursing literature, nurses need to be taught on how to reflect, and the detailed questions that the practitioners are required to ask of themselves in the Johns model of reflection, will, no doubt, offer a comprehensive checklist for reflection. However, the detailed structure can also offer disadvantage because it will impose a framework that is considered as external towards the practitioner, which will leave only little scope for inclusion of his or her own approach. In addition, the said model is considered as complex, while the other models are being criticized for being simple and self-evident (Davies, Finlay and Bullman, 2000). Here one of my reflection which happen in ICU that make me stress Once during my night duty I receive a patient with Inferior all Myocardial Infarction to my ward. While I was doing my routine work such as taking observation and preparing medication for the gentleman who father of four children. Suddenly the patient developed arrhythmia – ventricular tachycardia so immediately I called the doctor but he is too late. This is a main problem in my hospital because one doctor have to cover few wards during night time. And I tried to print the electrocardiogram graph of the lethal arrhythmia unfortunately the machine in not in good condition and can’t print it for documentation purpose. But I am sure that it is ventricular tachycardia. I have to act fast within 3 minutes (Cumin, 1996) if not patient will hypoxia and vegetative. Because I already under gone coronary care nursing and have advanced cardiac live support certificate moreover working in intensive care unit for nearly ten years. While waiting for him with my experience and knowledge I perform defibrillation with
200 joules and the graph reverted to sinus bradycardia and I gave intravenous medication atropine I mg.. The patient survived and the graph shows sinus tachycardia, and other observation parameters shows normal range. I really satisfied with my reflection- in- action But the sad side of the story is, the doctor scolded me because I crossed the professional boundaries and did the procedure against the code of nursing. The only reason was I failed to print the graph and I can be charged if anything bad or the patients’ condition deterioting or die. But I still argue with him and said I really sure with the arrhythmia and you are late and I can’t lose the young gentlemen. And I assume that if he is my family member I will try my best to save him. The doctor felt guilty but he scolded there is no prove. I feel very bad and discourage and couldn’t accept the way they treat me as a senior staff nurse and scolded me in front of other clique who are very junior staffs, of course they won’t respect me. And promised to myself that I won’t repeat it again but still my feeling confront with him. The embarrassment made me depressed and I couldn’t carry out my daily duty at that night and the following week as a mother and a wife at home. I lost my appetite and good sleep for few week. Finally I went to see a doctor and diagnosed as stress Reflection on the above incident using parts of the ‘structured reflection’ model by Johns (1992) and Carper (1978) Aesthetics – As a art of nursing actually I’m trying to save my patient who is having lethal arrhythmia. If I act late and still waiting for doctor I will lost the patient. As long as I concern in this situation my action was consider according to
the ventricular tachycardia algorithm which was approved by American Heart of Association. But then I really shocked when my doctor came and scolded me and make me upset. After the doctor’s explanation then only I realize that even though I had made a very best of work, on the other hand I made some inter related job offence. In this case vertical substitution which is cross the boundaries has taken place. I suppose to print the graph for documentation purpose and avoid medico-legal action. This will bring some trouble to the doctor if something happen vice versa as a result. This contradict situation make me realize that in reality this incident thought me to be more careful prevention measure. My knowing in an aesthetic point of view here involves the deep appreciation of the the patients situation and calls forth inner creative resources that transform my experience into something that would not otherwise be possible. Personal – In this unprecedented incident if I try to act of safe side of professional ethic. I m sure will lost the gentleman who is father of four. Morally my sense of sympathy and empathy was disturbed. Imagine that if the patient is my own family member sure I will try to do the best to save him because the doctor came late. I ‘m fully confident and have enough knowledge to over come the crucial situation. Personal knowing here concerns the inner experience which I have gone through . The full awareness of the self, the moment, and the context of interaction with my patient makes me to react meaningfully l to share my experience positively.
Ethics - Having a code of ethics helps guide nurses through tricky situations and serves as a common reference point for everyone on the health care team. But the primary goal of nursing ethics is to protect patients. So in order to save my patient’s life I was tended to cross the professional boundaries and act towards achieving the primary goal of nursing ethics. If anything goes wrong or the patient died I can be charged under written code of nursing ethics. Ethical knowing here involves my decision to make moment-to- moment judgments about what ought to be done, what is good, what is right, and what is responsible. Empirics - In this particular nursing practice I’m came to know that my patient is in serious condition from my experience. From my close observation not only to the patient but from the electrocardiogram( ECG) through cardiac monitor. I now it is a lethal arrhythmia through my experience bed side teaching by specialist and I have gone through special course for ECG in one of the cardiac center in my country. It really helps me to tackle this critical situation. Empiric knowing is based on the assumption that what is known is accessible through the physical senses, particularly seeing, touching, and hearing, and as a pattern of knowing draws on traditional quantitative approaches to knowledge acquisition. The Empiric knowing is expressed as scientific competence. From the reflection on action above I learned that in this critical setting ward I cannot fully avoid from facing stress all the way. But still there is a room to reduce the stress by self stress management .Anyway I m very glad and satisfied internally after I was able to recognize where the problem lies on.
2.3 Stress and Workload in ICU Stress is considered as the most popular factors which affect performance and productivity of nurses in the entire hospital environmental particularly in the ICU department. It can greatly influence how the medical staffs perform, which affect their productivity, which is directly connected to the health and condition of the patients. On the other hand, workload is considered as one of the primary factors which drive stress for the nurses in ICU. Workload is considered as an important issue in my work place which focuses on the amount of work that is placed upon the responsibility of the nurses. When work is largely a physical activity, then the major consideration is to ensure that the physical demands of work are not greater than the capacity and capability of the individual in those given circumstances. On the other hand, those works which focus on mental aspect or those involved attention or decision-making are in need to prevent overload and under load (Di Martino and Nigel Corlett, 1998). ICU practices are full of high workload situations (Oates and Oates, 1996). For me because I have to continuously entertain the demands and needs of the patients and their family. At the same time, I also have to face with intense emotions, such as death. This issue is important because different studies have showed that workload is one of the important factors which affect the quality of service and care and ICUs as well as the safety and health of the patients. The study of Australian Incident Monitoring Study for ICUs showed that the major
causes of workload are the inappropriate staffing compare to patient load (Beckmann et al. 1998). This result to incidents related to problems of drug administration, documentation, not enough supervision to patients, incorrect ventilator and other equipment and gadget setup as well as self-extubation. In addition, the study also showed that some of the problems related to insufficient staffs are physiological change, dissatisfaction of the patients and their respective families and physical injury. In addition, the study of Tarnow-Mordi et al. (2000) analyzed and evaluated the connection between mortability rates and the workload of hospital staffs in adult ICU in the United Kingdom. The result showed that those patients who are exposed to high ICU workload are more expose to death than those who are in low workload. This is due to the lack or not enough time for clinical procedures to be done in correct manner, inadequate training or supervision, errors, overcrowding as well as the consequent nosocomial infections, limited resources as well as premature discharge from the ICU. In my setting whenever patient admitted to ICU or death we really facing a big problem in doing paper documentation. I really hate this job which restrict my nursing care. I also have to write the report regarding the patient to matron and the director of the hospital every day. Imagine that how much workload I have to bear beside my routine job. The study of Malacrida et al. (1991) using Nursing Stress Scale (NSS) questionnaire and self-observation showed that for nurses, the most important stressors are dealing with death of patients and high workload. This
include staffing, paper work and scheduling problems and risks, not having enough time in order to complete the medical tasks, at the same time, support the patients about their health. High workload may also result to poor nurse- patient and doctor-patient communication (Llenore and Ogle, 1999) as well as poor relationship between the nurse and physician or doctor (Baggs et al., 1999) – which is very important in order to ensure safety and health of the patients in ICU .There are number of problems and factors that I am facing in the ICU which make me stress. This includes factors related to the management, leadership, skills, roles and responsibilities and staffing. 4.1 Description of the Experience I am experiencing high level of stress in my current work due to different factors which involved my work itself, my position in the hospital, me as a mother and a wife and me as a human. These similar and conflicting positions and roles added fuel to the fire in my current stress. Mismanagement Based on my observation and my own experience, mismanagement is one of the most important contributing factors to my stress and even my co- workers at work. As have showed in the literature review, mismanagement of the people, which include the schedule and other benefits are crucial stressors for nurses and other medical professionals. In our case, our superiors are manipulating their man power in inappropriate manner. They are opening wards without first asking for the permission of higher authority, which caused us to
work double duty. In addition, we do not have annual leave, and we really need to go for leave, we have to do night duty. We already tried to voice out our concerns but the management threatened us that they will transfer us to another place. Thus, it shows lack of professional management. I would to reflect the incident that affects me due to this matter. I and my family arranged a vacant .My husband already booked a hotel and my children were in a very happy mood. Unfortunately my ward sister called me at home and ordered me come to home because of epidemic of dengue fever outbreak. The whole family was upset and out of mood. I tried to please her by explaining my situation. But she uses her autocratic power to force me to work. Even though an internal conflict aggravates between us, finally I agreed to follow her instruction. The worst part was I have to do double duty Conflict with Co-workers and Superiors The ward sister is also very biases and would only listen and entertain those staffs who are close to her. As a result, staff like me is always a victim because of my race. Furthermore, she uses her power in order for her to work double duty, which further aggravates the conflict between us and the co-workers. Division of Labor/Rules and Responsibilities Aside from out daily activities and responsibilities, there are also times when we do the responsibility and dirty work of the doctors. IN addition, we are
also crossing vertical and horizontal substitution like physiotherapy job. This again aggravates the conflict between the doctors and the nurses. Dealing with the Patients and Their Families The patients and their families are other factors which add up to our stresses. As have tackled in the literature review, the behavior of the patients and their families, together with their conditions, their reactions, emotions, feelings and even their gestures greatly influence the nurses’ and doctors’ feelings and emotions. Commonly these factors bring us emotional and psychological stresses, which also affect our physical wellbeing. First, we have to face the rage of the families of those patients who were dying. They sometimes blame us, and accuse us that we are not doing our job properly. This is because of high expectations that they are giving us. More often than not, the families considered the medical professionals as superior and all mighty and we can do everything in order to save their dying family members. In addition, the sufferings of the patient itself while they are at the ICU also affect us emotionally and physically. In addition, there are also some times when some VIPs are admitted to the ICU. Their relatives, most often than not, do not follow the rules and regulations of the ward. As a result, we cannot do our job properly because people are watching us. The worst part is that they are commonly complaining through paper that the nurses are rude and we did not do our job properly. Again, this affects our performance in the hospital.
In addition, we, the nurses in ICU have to travel in ambulance and bring the ventilated patient for scanning and transferring. This add up to our stress and physical burden, because the journey is really motion sick and we always tend to worry and take care of the safety of the patient. If things go wrong, we have to write explanation report to the management. 4.2 Reflection Under these experiences, I always ensure that all of these stressors will be taken for granted in order to ensure that all of the responsibilities, to the management, with my superiors and co-workers and to my patients and their respective families will be met. With this, I always ensure that these stressors will not affect my performance. There were times were I already asked for the opinion of my co-workers, superiors and even the management regarding the current condition of the ICU ward, however, as have mentioned, the management has less supports to their nurses, and they commonly threat us with actions that we can experienced upon insisting our concerns. However, it is important to take note that no matter how hard we try, in spite of our effort to maintain high level of performance and services towards the patients, due to the different stressors that are always their inside and outside the ward, it affects our performance in direct and indirect manner. In my case, it affects my physical, social, emotional and psychological health. Because of the stressors, there are times, which I am not feeling well, due
to the different burdens and confusions. This further affects my responsibility and my relationship with my family, because, most often than not, I don’t have that much time to communicate and connect with them. For my children and my husband, there were times that I can no longer do my responsibility for them, including daily activities, which will show how much I care for them. There are even times, that when I go home, I will automatically sleep because of overwork and fatigue, which leaves my also tired husband caring for our children and taking care of some important business in our home. On the other hand, as have already explained, these stressors affect our relationship with our co-workers, because of unequal or unfair treatment, at the same time, due to overwork, there are times that we are in bad mood, and because of pressure, we commonly end up in arguments. During this time, it is normal that I am feeling tired, angry at some times, and sometimes concern – concern about my job stability and security, my patient’s health and of course, my family. For the patients, because, they are commonly in complicated state during their stay in the ICU, they are somewhat unaware of what is going on inside the ward. However, if ever I am in the condition of the patient, I will feel mostly unease because, there are times that I can already feel the emotion, behavior and feelings of the nurses and doctors due to the challenges involved in their job, together with those stressors, at their works. 4.3 Influencing Factors
The internal factors that are affecting my decision inside the ICU ward are my roles and responsibilities. This pertains on the promises and preamble that I have made upon entering my profession. This pertains on ensuring the safety and saving the lives of the people. With this, in spite of the stressors and difficulties of my work, I always make sure that I am at my best because I am handling lives of the people. My co-workers, superiors and the overall management also affect my decision. The management itself implemented its standards and rules and regulations which influence my personal opinions and actions about different tasks and situations in the ward. The patients and their family also affect my decision, for their feelings, conditions, emotions and behaviors can influence me in either direct or indirect manner. On the other hand, the external factors which influence my decision are my family. Like any other people, I have my responsibility to be done inside our home. I have to take good care of my husband and my children, ensure their safety, at the same time, and make sure that they are healthy and experiencing good life. In my current condition, they are being affected due to my schedule as well as my health – physical, emotional and psychological. Sometimes, it is inevitable to bring home the feelings or emotions that I am getting inside the ICU. With this, I have to focus on my personal experience, the knowledge that I have learnt inside the university, at the same time, those knowledge that I have learnt via long experience – from the doctors, from my co-nurses as well as the patient in deciding about different matters. 4.4 Could I have dealt with the situation better?
I strongly believe that I have dealt with the situation good, because in spite of the stressor I have experienced, I, together with the other nurses enable to do our job properly. However, upon analyzing, it would have been better if we pressed our concerns more towards the management. If the management will not listen in spite of that, there can be some other organizations or agencies that can help us solve the problem. I know this will cause some ruckus; however, I believe that this will serve for the betterment of the entire institution. 4.5 Learning This experience enables to show me the different factors that affect the performance of those nurses and medical professionals inside the ICU ward. Thus, it poses several challenges for those individuals who are working in the said setting, because they have to juggle different important factors – they have to focus on their responsibilities and roles as a medical professional – ensure the safety of their patients and to support their families and relatives, at the same time focus on the different stressors that are related to the management, co- workers, superiors as well as those factors that are related to the personal life. Upon writing this reflection, I still strongly believe that there are changes that must be done inside the ICU in order to ensure that all of the medical professionals working their will maintain healthy physical, mental and emotional health, which are important because it directly and indirectly influence the quality of services that they are tending or offering towards the patients and their
families. It is important to take note that just like other people – nurses and doctors are ordinary human being who also has their personal lives, which can affect their performance, and which their professional or career development will be affected. In my case, the fact that there are no annual leave available affect my relationship with my husband and my children, for I cannot spend more time with them, to bond, coordinate and communicate with them. In addition, because of the stressors that I am experiencing due to mismanagement, chaos and ruckus with the doctors, superiors and other co-workers, it influence my overall mood, which I can bring to our home, therefore, can affect my approach towards my husband and my children. The setting of the ICU, itself is very stressing – seeing those people dying, seeing the agony of their patient before their last breath, seeing the blood, flesh and everything. At the same time, we always see the torment, hurt and pain of their families – sometimes blaming us for their loss of their relative or love ones. All of these negative emotions we always encountered, every day! With this, it is important for an individual to have a sense of balance, which can be achieved with proper support from the management – by improving the policies, rules and regulations and ensuring that all of the staffs – from the upper management up to the lower one about their individual rules and regulations and their accountabilities. With this, it can help in order to lessen the burden of every one – and ensure that everyone are working and doing their job properly, therefore it can help to create a more cooperative and sound working environment.
4.6 SWOT Analysis Strengths My strength mainly focuses on the ability to cope with the different stressors in my working environment. Based on my credential and past experiences, I can also say that I am much knowledgeable and skilled, which makes me reliable and efficient at the work. In addition, I can also handle the pressure of my work and personal life. I can also work well with different people – with my doctors and co-nurses. Weaknesses I must admit that I am weak, when it comes to those aspects that are related to emotion – I am human after all. In spite of my past experiences with the dying patients and the reactions of their families, I can be easily affected by their feelings and emotions, which leave me weak and stressed. Sometimes, I can bring this feeling at home. Opportunities The opportunities will focus on the aspect of proper management – division of labor, increase in staffs and the use of new technologies, which will help us to manage our job in more efficient and faster manner. It is important to focus on employing already-trained new staffs, in order to lessen our burden or job. In addition, it is also important to ensure that all of the doctors to be hired are all properly trained in terms of language and culture of the country and the hospital setting.
Threats The treat will remain on the aspect of decreasing number of medical professionals in the country. In addition, the emotional and physical burden of the nurses in the ICU-environment is another factor. With this, it is important to ensure that there are some programs or activities to be done in order to support the feelings, emotions and behaviors of their nurses and doctors. It is important to ensure that they are properly rested in order to ensure good performance from them.
5.0 Integration of Literature Review 5.1 The ICU Environment Based on the assessment and reflection done, it had been found out that ICU is indeed, considered as one of the busiest, if not that busiest department of the entire hospital. It is considered as one of the most stressful department for the employees – nurses and doctors have to handle difficult situations and cases of the patients, considered as those emergency situations or cases. In addition, according to the study of Angus and Kelly (2000), ICU consists a vital percent of the entire health care system of America, which is more or less 6000 ICU in 2000 alone. In addition, according to Halpern (1994), there are more or less 55,000 patients that are being delivered and cared for in these units. In addition, there are different social and economic factors which influence the growing number of patients entering the unit. First is the decrease or the declining number of acute care hospital beds for the last 2 decades, which increase the number of patients in ICU for more than 250%, which accounts for more or less 10% of the entire hospital beds (Lustbader and Fein, 2000). In addition, it is also expected to increase due to the increase in the age of the entire population (Groeger and Strosberg , 1992). This is for the case of American alone. In other countries, they are experiencing shortage of nurses and doctors, particularly in developing countries, because of most of their nurses and doctors
are going to other countries in order to acquire higher salary. On the other hand, there are other developed countries, wherein people are not that interested in entering the said profession. As a result, the number of people who are willing and capable in entering the healthcare is declining, therefore, it can add up to the problems related to stress and overload inside the ICU environment. There are different factors inside the ICU which affect the mentality, physical activities, feelings and emotions of the staffs – the doctors, specially the nurses. This include those factors that are related to their working environment, co-workers, subordinates, superiors, management, their patients and their respective families, the facilities, etc. These factors have a vital influence on the overall feeling, ambiance and condition of the ICU, which can greatly influence the performance of the medical staffs, particularly the nurses, who are doing variety of jobs. With all these work-related factors, together with the personal factors which the nurses and doctors experienced and encountered outside the hospital, inside their homes – with their spouses, children, families and friends, stress is considered as inevitable. This is important, for there are different studies which show that patient safety and medical errors, together with the different adverse impact from those errors are commonly found inside the ICU (Donchin and Gopher, 1995). Medical errors are important issue in any hospital or medical institution, for it can greatly influence the overall image of that hospital, at the same time, it has a vital influence over the individual performance and position of medical professionals. 5.2 Workload in ICU
Based on the review and reflection, it had showed that nurses play different roles inside the ICU. They are considered as the busiest medical professionals inside the ICU environment, for they cater for different needs and focus on helping other medical professionals, such as the doctors, at the same time support the patients and their families. According to the study of Oates and Oates (1996), ICU is filled with high workload situations. This is because nurses have to continuously respondent to the needs of the patients and their families, at the same time routinely connect with the most intense emotional aspect of life. As a result, workload is considered as one of the most, if not the most, vital determinants of safety of the patients and the quality of services and care in ICUs (Carayon and Gurses, 2005). In my experience as a nurse in my working environment, one of the most common sources or reasons of over workload is the shortage of staffs. First, some of the head nurses have been promoted in other position, as a result, we have to focus on training and mentoring the newly hired and inexperienced nurses, which again will add up to our burden. In addition, because the new nurses are inexperienced and not that knowledgeable, we have to continuously guide them, because we will be blamed for their mistakes. Therefore, we have to cater most of the critical and difficult tasks inside the ICU. In connection, the study of the Australian Incident Monitoring Study, showed that the shortage of nursing staff in ICU can lead to compromised quality of care (Beckmann and Baldwin, 1998). The two main reasons of shortage of nursing staffs are: inappropriate staffing for current patient load and the inability of the management
to respondent in the increasing unit activity (Carayon and Gurses, 2005). These two factors can be found in our working environment, for the management is somewhat blind and not that open for change, in spite of the fact that they are continuously opening new beds for the said unit. The issue of understaff of the ICU is very important for it can cause to different medical errors and problems, such as drug administration or documentation problems, inadequate or insufficient patient supervision, incorrect ventilator or equipment setup as well as self-extubation (Carayon and Gurses, 2005). Furthermore, undesirable patient outcomes connected with the inadequate nursing staff include major physiological change, patient or relative dissatisfaction as well as physical injury. This is because nurses will have to handle to do different tasks of different types in short period of time. Furthermore, the study of Tarnow-Mordi and Hau (2000) focus on the connection of mortality rates and the workload of hospital staff in one adult ICU in the UK. The measures of workload for a given patient’s stay include the occupancy per shift, peak occupancy, ICU nursing requirement per shift, ICU nursing requirement during the first shift of the patient, the ratio of the occupied to appropriately staffed beds per shift, and the ICU nursing requirement per occupied bed per shift. The result of the study showed that those patients who are exposed to high ICU workload were more likely to die than those who are exposed to low workload. The three measures of workload most strongly connected with mortality were peak occupancy, average nursing requirement per occupied bed per shift, and the ratio of occupied to appropriately staffed beds.
Some of the explanations for the connections between high workload and mortality include: inadequate time for clinical procedures to be done in appropriate manner, inadequate training or supervision, errors, overcrowding and consequently nosocomial infections, limited availability of equipment and premature discharge from the ICU. Some of these factors can be observed in my current working environment. The best example is the inadequate training or supervision given to the new nurses. This is because, we have to train them, and at the same time do our tasks. In addition, we are also experiencing some overcrowding, particularly when VIP patients will come, they are not following orders regarding the visits and other important factors. As a result, we are having difficulties in doing our jobs, particularly when there are number of people who are watching us and asking questions while doing our jobs. 5.3 Relationship between Workload and Stress in ICU Different studies, including Crickmore (1987), Malacrida and Bomio (1991) and Oates and Oates (1996) showed the relationship between stress and workload. According to their studies, workload is considered as one of the most vital job stressors among the nurses of ICU. The practice of medicine alone is already considered as stressful. For instance, the study of Malacrida and Bomio (1991) studies the quality and frequencies of stressors in an ICU environment with the use of two different data collection methods, which include Nursing Stress Scale (NSS) questionnaire and a computer-aided self-observation method development and improved by the authors for this study. The result of the computer-aided self-observation method, 17 ICU nurses were asked to record
their experiences on a computer placed in the ICU, immediately after having stressful experiences and events. These same 16 ICU nurses and other 31 nurses working at the same hospital were asked to fill out the questionnaire. The result of both data gathering methods showed that the most vital and important stressors for nurses, where those related to death and high workload. As a result, staffing and scheduling problems, not having enough time in order to complete nursing tasks and not having vital and enough time in order to offer emotional support to patients were all connected to workload or considered as workload- related issues or problems. Again, all of these factors can be observed and experienced in my current working environment. The staffing and scheduling problems due to the inconsistency and inability of the management to connect with the nurses regarding the different changes as well as the different actions to be implemented in the hospital, greatly influence the grievances and the roles of the nurses inside the hospital. Having the enough or sufficient time catering the demands and needs of the patients, together with doing the jobs inside the ICU environment is another factor. This is because of the fact that we are experiencing shortage of the medical professionals, particularly those related to the experienced nurses in the environment. Even though, there are new nurses inside the ICU environment, experience is always an important factor. This is particularly because of the fact that ICU is different from other units of the hospital or the medical institutions. This is because there are different emotional, psychological and physical factors that can be faced or encountered by the nurses, which are unavailable or cannot be encountered in other units of the
hospital, particularly those related to the deaths of the patients and grievances, agony and pain of their families. In addition, it is important to consider that nurses also have their lives outside the ICU and outside the hospital. This pertains on their responsibilities and roles inside their homes and their families, their friends, their clubs and organizations, their religions and their society they are included in. In my case, I have my own family, my husband and my children, to whom I have a responsibility to be done. I have to be there in order to support my husband and my children. Help my husband to fix his wardrobe for his work, to prepare my family’s breakfast and dinner, at the same time, to go out with them even once a month for bonding moment or time. However, the time that I am spending inside the ICU and in the hospital, together with pile of tasks that I have to do inside the ICU, most often than not I have no more energy to be spent in order to communicate and help my husband and support my children about their work or their studies. This commonly cause problems with my husband, because there are times that I am bringing some of the emotional burden from ICU, particularly related to those patients whom I have already created a certain connection. These emotional and physical stresses affect my relationship with my family at certain level. Furthermore, the study of Bratt and Broome (2000) and Darvas and Hawkins (2002), shows that in terms of working conditions and stress, there are different evidences which shows the connections between nursing working conditions and the job satisfactions. Behavioral consequences of job
dissatisfaction in nursing, which include low morale, absenteeism, turnover as well as poor job performance, can potentially threaten and affect the care quality of the patient as well as the overall effectiveness of the organization (Cavanagh, 1992). There are different nursing studies which analyzed and assessed the results or outcomes of job satisfaction. Study of McCloskey and McCain (1987) showed a positive connection between job satisfaction and job performance, while the study of Tarnowski-Goodell and Van Ess Coeling (1994) showed a positive connection between job satisfaction and patient satisfaction and quality of care. In addition, the study of Keijsers and Schaufeli (1995) and Aiken and Clarke (2002) showed that high workloads is connected to sub-optimal patient care, which can influence the decision of the care providers and nurses towards the different medical procedures (Griffith and Wilson, 1999), which will consequently lead to the reduced satisfaction of the patients (Anderson and Maloney, 1998). In addition, high workload is also expected to lead to poor nurse-patient communication (Llenore and Ogle, 1999), impaired nurse-physician collaboration (Braggs and Schmitt, 1999), nurse burnout and dissatisfaction to the job (Aiken and Clarke, 2002). All of these factors can directly and indirectly influence the individual performance of the nurses, including the quality of care that they are tendering towards their patients, then will affect the overall image of the hospital or medical organization or institution that they are in.
As a result, it is important to focus on the workload in order to lessen the stress of the nurses inside the ICU. This can be done by focus on the improvement of the working conditions, together with the improvement of the communication, collaboration and connection between the nurse and the physician or the doctors. This can help in order for the nurses to know their roles and responsibilities, which will help them in order to know what are the tasks that they must perform towards their co-workers, their subordinates, the physicians or doctors, towards their patients and their patients’ families (Evans and Carlson, 1992). References Abramson, N. A. and Wald, K. S. (1980). ‘Adverse occurences in intensive care units’. Journal of American Medical Association. 244, 1582 – 1584. Ahot. Using a model of reflection. Retrieved 23rd November, 2010, from Ahot.utu.fyi website. Aiken, L. H. and Clarke, S. P. (2002). ‘Hospital nurse staffing and patient mortality, nurse burnout and job satisfaction’. Journal of American Medical Association. 288(16), 1987 – 1993. Anderson, F. D. and Maloney, J. P. (1998). ‘A descriptive, correlational study of patient satisfaction, provider satisfaction and provider workload’. Mil Medical. 163, 90 – 94.
Angus, D.C. and Kelly, M.A. (2000). ‘Current and projected work-force requirements for the care of the critically ill patient and patients with pulmonary disease; can we meet the requirements of an aging population’. Journal of American Medical Association. 284, 2762 – 2770. Baggs, J. D. and Schmitt, M. H. (1999). ‘Association between nurse-physician collaboration and patient outcomes in three intensive care units’. Critical Care Medicine. 9, 1991 – 1998. Beckmann, U., Baldwin, I. ‘Problems associated with nursing staff shortage: An analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU)’. Anaesthe Intensive Care. 26, 396 – 400. Berenholtz, S. M., Dorman, T., Ngo, K. and Pronovost, P. J. (2002). ‘Quality review of intensive care unit quality indicators’. Journal of Critical Care. 17(1), 1 – 12. Bracco, D. and Favre, J. B. (2000). ‘Human errors in a multidisciplinary intensive care unit: A 1-year prospective study’. Intensive Care Medicine. 27(1), 137 – 145. Braggs, J.D., Schmitt, M.H. (1999). ‘Association between nurse-physician collaboration and patient outcomes in three intensive care units’. Critical Care Med. 27(9), 1991 – 1998. Bratt, M. M. and Broome, M. (2000). ‘Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses’. American Journal of Critical Care. 9, 307 – 317. Burgess, L., Irvine, F. and Wallymahmed, A. (2010). ‘Personality, stress and coping in intensive care nurses: A descriptive exploratory study’. Nursing in Critical Care. 15 (3), 129 – 141. Carayon, P. and Gürses, A. P. (2004). ‘A human factors engineering conceptual framework of nursing workload, and patient safety in intensive care units’. Intensive and Critical Care Nursing. 21(5), 284 – 301. Cavagh, S. J. (1992). ‘Job satisfaction of nursing staff working in hospitals’. Journal of Advance Nursing. 17, 704 – 711. Cohen, L., Manion, L. & Morrison, K. (2003). Research methods in education. Routledge.
Commonwealth of Learning. (2000). Manual for educational media researchers: Knowing your audience. Vancouver, Canada. Commonwealth Educational Media Centre for Asia (CEMCA). Cox, T., Griffiths, A. and Rial-Ganzalez, E. (2000). Research on work related stress. Nottingham: European Agency for Safety and Health at Work. Creswell, J.W. (1994). Research design: Qualitative and quantitative approaches. Thousand Oaks, California: Sage. Crickmore, R. (1987). ‘A review of stress in the intensive care unit’, Intensive Care Nursing. 3, 19 – 27. Davies, C., Finlay, L. and Bullman, A. (2000). Changing practice in health and social care. SAGE. DePew, C., Gordon, M., Yoder, L. and Goodwin, C. W. (1999). ‘The relationship of burnout, stress, and hardiness in nurses in a military medical center: A replicated descriptive study’. Journal of Burn Care and Rehabilitation. 20, 515 – 522. De Vos, M. (2007). ‘Quality measurement at intensive care units: Which indicators should be use?’. Journal of Critical Care. Vol. 22, 267 – 274. Di Martino, V. and Corlett, E. N. (1998). Work organization and ergonomics. International Labour Organization. Donchin, Y. and Gopher, D. (1995). ‘A look into the nature and causes of human errors in the intensive care unit’. Critical Care Medicine. 23, 294 – 300. ENotes.com. Intensive Care Unit. Retrieved on 05 November, 2010, from ENotes.com: http://www.enotes.com/surgery-encyclopedia/intensive- care-unit Evans, S. A. and Carlson, R. (1992). ‘Nurse-physician collaboration: solving the nursing shortage crisis’. Journal of American Coll Cardiologist. 20(7), 1669 – 1673. Flick, U. (2009). An introduction to qualitative research. SAGE Publications. Garland, A. (2005). ‘Improving the ICU: part 1’. CHEST. 127, 2151 – 2164. Giraud, T. and Dhainaut, J. F. (1993). Latrogenic complications in adult intensive care units: A prospective two-center study’. Critical Care Medicine. 21(1), 40 – 51.
Goodfellow, A. Varman, R., Reeds, D. and Shelly, M. P. (1997). ‘Stress on intensive care unit: A comparison of doctors and nurses’. Anaethesia. 52(11), 1037 – 1041. Griffith, C. H. and Wilson, J. F. (1999). ‘Housestaff workload and procedure frequency in the neonatal intensive care unit’. Critical Care Medicine. 27(4), 815 – 820. Groeger, J. S. and Strosberg, M. A. (1992). ‘Descriptive analysis of critical care units in the United States’. Critical Care Medicine. 20, 846 – 883. Gurses, A., Carayon, P. and Wall, M. (2009). ‘Impact of performance obstacles on intensive care nurse’s workload, perceived quaity and safety of care and quality of working life’. Health Services Research. 44(2), 422 – 443. Hall, R. (2006). Patient flow: Reducing delay in healthcare delivery. シュプリンガ ー・ジャパン株式会社. Halpern, N. A. and Bettes, L. (1994). ‘Federal and nationwide intensive care units and healthcare costs: 1986 – 1992’. Critical Care Medicine. 22, 2001 – 2007. Institute of Medicine (2004). Keeping patients safe: transforming the work environment of nurses. Washinton, DC: The National Academic Press. Keijsers, G. J. and Schaufeli, W. B. (1995). ‘Performance and burnout in intensive care units’. Work and Stress. 9(4), 513 – 527. Kincey, J., Eddleston, J., Shelly, M., Grout, C., Alexander, P., Morley, M. and Lomax, M. (2005). Greater Manchester critical care medical workforce project. Manchester: Report to Nortwest Strategic Health Authority. Knaus, W. A., Draper, E. A. and Douglas, P. W. (1985). ‘Apache II: A severity of disease classification system’. Critical Care Medicine . 13, 818 – 829. Kopp, B. J., Erstad, B. L., Allen, M. E., Theodorou, A. A. and Priestley, G. (2006). ‘Medication errors and adverse drug events in an intensive care unit: Direct observation approach for detection’. Critical Care Medicine. 34, 415 – 425. Lally I. and Pearce J. (1996). ‘Intensive care nurses’ perception of stress’. Nursing in Critical Care. 1, 17 – 25. Li, J. and Lambert, V. A. (2008). ‘Workplace stressor, coping, demographics and job satisfaction in Chinese intensive care nurses’. British Association of Critical Care Nurses. 13(1), 12 – 24.
Llenore, E. and Ogle, K. R. (1999). ‘Nurse-patient communication in the intensive care unit: A review of the literature’. Australian Critical Care. 12(4), 142 – 145. Lustbader, D. and Fein, A. (2000). ‘Emerging trends in ICU management and staffing’. Critical Care Clinic. 16, 4. Malacrida, R. Bomio, D (1991). ‘Computer-aided self-observation psychological stressors in an ICU’. International Journal of Clin Monitoring Computer. 18, 201 – 205. McCarthy, V.J.C., Power, S. and Greiner, B. A. (2010). ‘Perceived occupational stress in nurses working in Ireland’. Occupational Medicine. Accessed on 05 November, 2010, from Oxford Journal: occmed.oxfordjournals.org McCloskey, J. C. and McCain, B. E. (1987). ‘Satisfaction, commitment and professionalism of newly employed nurses’. Journal of Nursing Scholarship. 19(1), 20 – 24. Mealer, M. L., Shelton, A., Berg, B., Rothbaum, B. and Moss, M. (2007). ‘Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses’. American Journal of Respiratory and Critical Care Medicine. 175, 693 – 697. Merill, J.M. and Boisaubin, E. V. (1981). ‘Adverse occurences in the intensive care unit’. Journal of American Medical Association. 245, 1214. Oates, P. R. and Oates, R. K. (1996). ‘Stress and work relationships in neonatal intensive care unit: Are they worse than in the wards?’, Journal of Pediatric Child Health. 32, 57 – 59. Rogers, A. E., Dean, G. E., Hwang, W. T. and Scott, L. D. (2008). ‘Role of registered nurse in error prevention, discover and correction’. Quality and Safety in Health Care. 17, 117 – 121. Rubin, A. & Babbie, E. (2009). Essential research methods for social work. Cengage Learning. Tarnow-Mordi, W., Hau, C. (2000). ‘Hospitality mortality in relation to staff workload: A 4-year study in an adult intensive-care unit’. Lancet. 356, 185 – 189. Tarnowksi-Goodell, T. and Van Ess Coeling, H. (1994). ‘Outcomes of nurses’ job satisfaction’ Journal of Nursing Administration. 36 – 41. UK Neonatal Staffing Study Group (2002). ‘Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified
sample of UK neonatal intensive care units: a prospective evaluation’. Lancet. 359 – 399. Vallier, I. (1973). Comparative methods in Sociology: Essays on trends and applications. University of California Press. Varon, J. and Acosta, P. (2010). Handbook of critical and intensive care medicine. Springer. Vink, P., Konnigsveld, A. P. and Dhondt, S. (1998). Human factors in organizational design and management – VI: Proceedings of the sixth international symposium in human factors in organizational design and management held in the Hague, The Netherlands, August 19 – 22, 1998. Elsevier. Wolfgang, A. P. (1988). Job stress in health professions: A study of physicians nurses and pharmacists. Behavior Modifications. 14, 43 – 47. Zuzelo, P. R. (2009). The clinical nurse specialist handbook. Jones & Bartlett Learning.
Appendix 1 John’s Model of Reflection (1994) 1. Description of the experience · Phenomenon – describe the here and now experience · Casual – what essential factors contributed to this experience? · Context - what are the significant background factors to this experience? · Clarifying – what are the key processes for reflection in this experience? 2. Reflection · What was I trying to achieve? · Why did I intervene as I did? · What were the consequences of my actions for: Myself? The patient / family? The people I work with?
· How did I feel about this experience when it was happening? · How did the patient feel about it? · How do I know how the patient felt about it? 3. Influencing factors · What internal factors influenced my decision – making? · What external factors influenced my decision – making? · What sources of knowledge did / should have influenced my decision – making? 4. Could I have dealt with the situation better? · What other choices did I have? · What would be the consequences of these choices? 5. Learning · How do I now feel about this experience? · How have I made sense of this experience in light of past experiences and future practice? · How has this experience changed my ways of knowing Empirics – scientific Ethics – moral knowledge Personal – self awareness Aesthetics – the art of what we do, our own experiences
Source: (http://www.communityhealthcarebolton.co.uk/SHA/LLL/resources/reflectiv e/JOHNS.doc) 1.4 Review of Literature Intensive Care Unit (ICU) is considered as an area of a hospital which offer aggressive and insistent therapy, with the use of state-of-the-art and high-end technology, together with invasive and non-invasive monitoring for critically ill and high-risk patients. In these units, the physiological variables and factors of the patients are reported to the practitioner on continuous and unbroken manner, in order to offer and provide titrated care (Varon and
Acosta, 2010). With this, it shows that the main objective or purpose of ICU is simple, but the practice and standards being implemented inside is complex. Healthcare professionals who are working in the ICU rotate their shift in order to offer around-the-clock intensive monitoring and treatment of patients all throughout the week. Patients are commonly and normally admitted to an ICU if they are expected to take advantage and be benefited from the high level of care to be offered. Thus, it benefits those patients who are strictly and severely ill and unstable in terms of medical and physical condition – with life- threatening disease or illness (ENotes.com, n.d.). According to Garland (2005) ICUs are considered as vital but troubled component or aspect of the health-care systems (p. 2153). It is considered as the area within the hospital which constitutes extensive and large risk of morbidity and mortality (Berenholtz et al., 2002). In the United States alone, ICU constitutes a vital portion of the entire health care system. According to the study of Angus and Kelly (2000) the number of ICUs in the US is more or less 6,000. Thus, it is considered as important aspect of the entire health care system. Different researches and studies about ICU patient and medical staffs problems shows that unpleasant events frequently happening in Intensive Care Unit (ICU) (Abramson and Wald, 1980). The study of Bracco and Favre (2000) which was conducted as a prospective observational study of consecutive patients admited over 1 year to an 11-bed multidisciplinary ICU in a non-university teaching hospital to know critical incidents and associated risk factors. The study included
1024 patients in 2801 days treatment in the ICU. A total of 777 incidents were detected during the 1 year study period: 31% were human-related, 2% were equipment-related and 67% were patient related, the study concluded that human-related errors prolonged ICU stay by 425 patient days over 1-year period (Carayon and Gürses, 2004). The observational study of Giraud and Dhainaut (1993) examined the iatrogeniche connections relationship showed that workloads of nurses are considered as one of the most important factors which causes stress in the ICU environment. Thus, one of the major challenges for ICUs is improving the quality and safety of nursing care. The study of Kopp et al. (2006) shows that there was one error for every five medication doses administered in a medical surgical ICU, therefore, it shows that medication administration stage is very susceptible for different errors. In connection, nurses play a vital role in the care being offered in ICUs (Rogers et al., 2008). This is because they are responsible in the different procedures and processes related with the medical care towards the patient. Therefore, nurses can influence the process of healing or the other way around of the patients.

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Rajan

  • 1. 24 Januari 2011 1. Saya mempunyai seorang kawan baik 2. Kawan baik saya bernama Junaidah 3. Saya duduk di sebelahnya di dalam kelas 4. Kami murid tahun satu cemerland 5. Kawan baik saya suka membaca buku My sister is four years older than me. She is in Years six Her name is Kalama. Kalama likes to play the piano 1. Good morning, father. 2. Good afternoon,Nora 3. Goodbye,Ramesh
  • 2.
  • 3. BY EARTH GROUP YEAR 5 2011 Binatang kesayangan saya Saya mempunyai seekor binatang kesayangan yang bernama Bobo.Bobo ialah seekor anjing yang berbulu putih dan berbadan kecil. Setiap pagi,apabila saya pergi ke sekolah,Bobo akan menamani saya sampai ke pintu pagar dan melihat saya menaiki bas. Apabila saya balik dari sekolah,Bobo akan menyambut saya dengan gembiranya sambil melompat ke badan saya dan mengoyangkan ekornya berkali-kali.Saya akan peluk Bobo dengan kuat dan senyuman yang manis. Pada waktu petang,saya selalu membawa Bobo ke padang dan bermain bola dengannya.obo pun menamani sayaberlari lari disekelilingi padang dengan gembiranya. Pada suatu malam,Bobo menyalak dengan berkali-kali dan kuatnya kerana dia nampak ada pencuri hendak mencuri basikal saya yang terletak di halaman rumah saya. Ayah saya pun membawa sebatang kayu dari biliknya dan menghalau pencuri itu.Akhirnya,pencuri itu pun lari dengan cepatnya.
  • 4. Setiap hari,saya akan memberi makanan dan minuman kepada Bobo.Saya juga akan memotong kuku Bobo dan mandikan Bobo supaya sentiasa kelihatan shat dan bersih. Saya berasa sangat gembira kerana menpunyai seekor binatang yang berani.SAya sangat sayang pada Bobo Pasar malam Pasar malam adalah suatu tempat yang menjual barangan keperluan harian pada waktu malam.Pasar malam di tempat saya pula biasanya diadakan pada setiap hari Sabtu dan bermula pada pukul 5.00 petang hingga 10.00 malam. Setiap hari Sabtu,saya mengikut ibu saya pergi ke pasar malam.Ramai penjaja mula memasang gerai masing-masing.Pada pukul 5.00 petang ditepi jalan bagai cendawan tumbuh selepas hujan.Terdapat banyak gerai yang menjual beraneka jenis barangan seperti sayur-sayuran yang segar-bugar, buah-buahan tempatan yang diimport,hidupan laut yang segar,pakaian,dan alat permainan yang menarik. Ramai pelangan datang berpusu-pusu bersama ahli keluarga dan membanjiri pasar malam.Pada awalnya suasana sunyi-sepi bertukar menjadi hiruk-pikuk dengan laungan para penjual yang ingin mrmperasikan barabgan menggunakan pembesar suara.Ada juga peniaga memainkan lagu-lagu bagi menarik perhatian para pelangan.Lampu yang berwarna-warni menyebabkan pasar malam terang-benderang.Para pengunjung terpaksa berjalan berhimpit-himpit kerana penuh sesak. Kebanyakan harga barangan dijual dengan berpatuan dan boleh tawar- menawar.Saya tidak melepaskan peluang untuk menikmati pelbagai juadah yang dijual di pasar malam. Keadaan mulai reda,pada pukul 10.00 malam kerana ramai pelanggan beransur
  • 5. pulang.Para peniaga pula sibuk mengemas barang masing-masing.Saya pun berjalan pulangke rumah dengan emak saya.
  • 6.
  • 8. (
  • 10. ( ( (
  • 11. 3. ? ? ? ? ? ? ? ? ? ? ? ? ?
  • 12. ? ? ? ? ? ? ? ? ?
  • 13. 4. ? ? ? ? ?
  • 14. , ? ?
  • 15. 5.
  • 16.
  • 17. 2) ( 2) ( (
  • 18. ( - ( --- ( - ( - - - (
  • 21. Soalan 1 - 21 Isi tempat kosong dengan jawapan yang paling sesuai. 1 “Ibu bangga mendapat anak seperti ____________ ,” kata Puan Jalilah kepada anak tunggalnya. A dia B kamu C mereka D engkau 2 “Pantang ____________ rakyat menderhaka kepada sultan,” kata Hang Tuah kepada sahabatnya. A beta B patik C hamba D tuan hamba
  • 22. 3 ____________ mangsa banjir telah berjaya dipindahkan ke ____________ pusat pemindahan yang berdekatan. A Semua ..........beberapa B Semua ..........sebahagian C Segelintir ..........beberapa D Segelintir ..........sebahagian Soalan 4 berdasarkan gambar di bawah. 4 Cikgu Anis melambai tangan ____________ memanggil Ketua Darjah 6 Melur untuk memberi pesanan. A kerana
  • 23. B sambil C apabila D supaya 5 Dato’ Habib amat berpuas hati dengan kerja ____________ banglonya yang terletak di Taman Tasek Utama. A ubah suai B susun atur C kemas kini D tambah baik 6 Pada awal tahun, pihak sekolah akan mengadakan sesi ____________ bagi meraikan kehadiran murid-murid tahun 1. A tegur sapa B soal jawab C bual bicara D ramah mesra Soalan 7 berdasarkan gambar di bawah
  • 24. 7 Ahli-ahli pengakap itu sedang berteduh di bawah sebatang pokok ____________ menunggu jurulatih mereka sampai. A hingga B lantaran C sementara D mahupun 8 Persiapan untuk menyambut Hari Kebangsaan sedang ____________ dijalankan. A gigih B hebat C pantas D rancak Soalan 9 berdasarkan gambar di bawah.
  • 25. 9 Fatin ____________ ketakutan apabila melihat seekor ular keluar dari dalam semak. A menjerit B meraung C melaung D melolong 10 Puan Rohana berasa berat hati meninggalkan sekolah setelah bertahun-tahun menabur bakti sebagai guru besar di situ. Perkataan seerti bagi bakti ialah A jasa B budi C kerjaya D khidmat
  • 26. 11 Api yang marak telah membakar kilang perabot itu hingga hangus dalam jangka masa yang singkat. Perkataan berlawan bagi singkat ialah A lama B cepat C ringkas D pendek 12 Syahirah belajar membilang dengan menggunakan beberapa ____________ biji saga. A butir B buah C batang D tangkai 13 Setelah jatuh sakit, nenek tidak menjamah walaupun se____________ nasi dan se____________ air. A biji ... titis B buah ... titik C butir ... teguk D pinggan ... teguk
  • 27. 14 Vijay ____________ apabila diminta untuk menjawab soalan itu kerana dia sedang berkhayal. A terkial-kial B terkebil-kebil C terpinga-pinga D tersentak-sentak Pilih jawapan yang paling sesuai bagi soalan yang diberikan. 15 Di manakah awak akan menunggu saya? A Berdekatan dengan pejabat pos. B Sudah lama saya menunggu awak. C Saya akan menelefon apabila saya sampai. D Kita akan berjumpa pada pukul 10.00 pagi. Pilih ayat tanya yang sesuai bagi ayat di bawah. 16 Keuntungan yang diperoleh pada Hari Kantin tidak begitu memberangsangkan. A Bilakah Hari Kantin diadakan? B Mengapakah Hari Kantin tidak diadakan lagi? C Berapakah keuntungan yang diperoleh pada Hari Kantin? D Mengapakah keuntungan Hari Kantin tidak memberangsangkan?
  • 28. Pilih ayat yang sama maksud dengan ayat yang diberi. 17 Gotong-royong yang diadakan itu adalah untuk mengeratkan hubungan kekeluargaan dalam kalangan penduduk taman ini. A Hasil daripada gotong-royong itu, para penduduk taman ini bertambah erat hubungan mereka. B Tujuan gotong-royong ini untuk mengeratkan hubungan penduduk antara kekeluargaan taman ini. C Hubungan kekeluargaan yang bertambah erat di taman ini memudahkan program gotong-royong diadakan. D Hubungan kekeluargaan yang erat dalam kalangan penduduk taman ini adalah matlamat projek gotong-royong diadakan. 18 “Mengapakah adik kamu menangis?” tanya cikgu kepada Farhan. A Farhan bertanya kepada cikgu sebab adiknya menangis. B Cikgu bertanya kepada Farhan sebab adiknya menangis. C Cikgu bertanya kepada Farhan sebab adik kamu menangis. D Farhan memberitahu kepada cikgu sebab adiknya menangis. 19 ____________ Sharifah Aini yang bersuara merdu itu berasal dari kampung ini. A Biduan
  • 29. B Seniman C Seniwati D Biduanita 20 Ayah ____________ ibu sebentuk cincin emas bertatahkan mutiara sempena ulang tahun perkahwinan mereka. A dihadiahi B dihadiahkan C menghadiahi D menghadiahkan 21 Encik Zamri bekerja siang dan malam untuk menampung ____________ sekolah anak-anaknya. A berbelanja B membelanja C perbelanjaan D membelanjakan Soalan 22 berdasarkan gambar di bawah.
  • 30. 22 Pak Wan mengangkat timbunan tanah yang dicangkul dengan menggunakan ____________ . A raga B nyiru C bakul D pongkes Pilih peribahasa yang sesuai. 23 Puan Salmah menyelesaikan pertelingkahan kedua-dua anak kembarnya seperti A melepaskan batuk di tangga. B menatang minyak yang penuh. C menarik benang dalam tepung. D menegakkan benang yang basah. 24 Perdana Menteri menyarankan agar rakyat mengamalkan konsep 1 Malaysia.
  • 31. A Bagai isi dengan kuku. B Bagai aur dengan tebing. C Bagai duri dalam daging. D Bagai pinang dibelah dua. Pilih ayat yang betul. 25 A Pasu kristal itu terhempas ke lantai lalu pecah. B Dia akan ke Pulau Pangkor di hujung minggu ini. C Arifah lebih pintar dari kawan-kawannya yang lain. D Kami kagum dengan kejayaan anak-anak Puan Devi itu. 26 A Wah, daif sungguh kehidupan Ah Meng sekeluarga! B Aduhai, anak-anakku belajarlah bersungguh-sungguh! C Cis, banyaknya ikan yang mati di kolam Pak Syahmi ini! D Syabas, kamu terpilih untuk mewakili sekolah dalam pertandingan pidato itu! 27 I Oleh kerana cuaca panas, nenek tidur beralaskan tikar di serambi. II Calon diberi masa satu jam suku untuk menjawab soalan Penulisan. III Pengacara majlis mengucapkan terima kasih di atas kehadiran para tetamu. IV Hidayah bercadang hendak melancong ke luar negara pada musim cuti nanti. A I dan II B I dan III
  • 32. C II dan IV D III dan IV 28 I Buku cerita yang tebal itu telah dibaca oleh saya. II Pendingin hawa di pusat sumber sekolah kami sedang dibaiki. III Penduduk Kampung Duyong saling tolong-menolong membersihkan kawasan sekolah. IV Antara acara yang dipertandingkan pada hari itu ialah acara balapan dan lompat tinggi. A I dan II B I dan III C II dan IV D III dan IV Pilih ayat yang menggunakan perkataan bergaris dengan betul 29 A Suasana di dalam stadium meregang apabila penonton mula merusuh. B Hubungan Zuhri dan Ramesh itu meregang akibat perselisihan faham. C Irfan meregang daun tingkap untuk membiarkan cahaya matahari masuk. D Dawai telefon mengendur pada waktu sejuk dan meregang pada waktu panas. 30 I Buah peria katak tidak digemari kerana rasanya yang pahit. II Roslan tidak dapat menerima pandangan pahit rakan-rakannya. III Hatinya pahit apabila Ruzlan memalukannya di khalayak ramai.
  • 33. IV Nenek asyik bercerita tentang pengalaman pahit ketika zaman pemerintahan Jepun. A I dan II B I dan IV C I, II dan III D II, III dan IV
  • 34. Soalan 31 – 35 Baca petikan e-mel di bawah, kemudian jawab soalan-soalan berikutnya. Kepada : Mariah binti Mat Daripada : Juliana binti Jusoh Perkara : Kepada sahabatku Mariah yang kini berada di Kuala Lumpur. Semoga sihat dan bahagia selalu. Saudari, Apa khabar saudari sekarang? Saya dan keluarga di sini berada dalam keadaan sihat sejahtera. Oh, ya! Lama sungguh kita tidak berjumpa. Semenjak saya berpindah ke sini, inilah pertama kali saya menulis e-mel kepada saudari.
  • 35. Buat masa ini kami sekeluarga menyewa sebuah rumah di Taman Bidara Permai. Ayah saya telah pun membeli sebuah rumah di taman perumahan yang baru tetapi rumah itu masih dalam pembinaan. Mungkin tahun hadapan kami akan berpindah ke rumah itu. Kawan-kawan kita bagaimana sekarang? Saya begitu kehilangan akan mereka. Kalau saudari berjumpa dengan Hanafi, Rogayah, Azmi dan lain-lain, sampaikanlah salam saya kepada mereka. Saya juga telah cuba menyesuaikan diri di tempat ini. Murid-murid di sini baik belaka. Mereka dapat menerima diri saya dengan hati terbuka. Setakat ini dahulu yang dapat saya tuliskan. Semoga bertemu pada masa yang lain. Sekian, terima kasih. Sahabatmu, Juliana 31 Apakah tujuan e-mel ini ditulis? A Menghubungi seorang kawan yang tinggal di luar negara. B Menghubungi kawan yang lama tidak bertemu. C Mengajak sahabatnya datang ke rumah. D Meminta bantuan kewangan. 32 Di manakah Juliana tinggal? A Di Kuala Lumpur. B Di Taman Bidara Permai. C Dekat dengan rumah Hanafi.
  • 36. D Berhampiran Taman Bidara Permai. 33 Antara kenyataan berikut, yang manakah tidak benar? A Juliana tidak mengenali Mariah. B Juliana pernah tinggal di Kuala Lumpur. C Juliana mengenali Azmi ketika di Kuala Lumpur. D Hanafi dan Rogayah masih tinggal di Kuala Lumpur. 34 Apakah maksud ‘menyesuaikan diri’ dalam petikan e-mel di atas? A membiasakan dengan keadaan B menagih simpati C membawa diri D berhati-hati 35 Bagaimanakah keadaan murid-murid di tempat yang baru diduduki oleh Juliana? A Cemburu atas kejayaan Juliana. B Mengecam kedatangan Juliana di situ. C Berpakat untuk melantik Juliana sebagai ketua. D Menerima kehadiran Juliana dengan senang hati.
  • 37. Soalan 36 - 40 Baca petikan di bawah, kemudian jawab soalan-soalan berikutnya. Tun Abdullah bin Ahmad Badawi dilahirkan dalam keluarga yang warak di Kampung Perlis, Bayan Lepas, Pulau Pinang. Beliau menerima pendidikan menengah di Sekolah Menengah Kebangsaan Tinggi Bukit Mertajam dan di Penang Methodist Boys School, Pulau Pinang. Abdullah memulakan kerjayanya sebagai guru. Selepas menerima Sarjana Muda Sastera dalam bidang Pengajian Islam daripada Universiti Malaya pada tahun 1964, beliau menyertai sektor perkhidmatan awam sebagai Penolong Setiausaha di Jabatan Perkhidmatan Awam. Pada tahun 1969, Abdullah berpindah ke Majlis Gerakan Negara (MAGERAN), sebuah badan yang berkuasa eksekutif untuk mentadbir negara yang ditubuhkan selepas rusuhan kaum pada Mei 1969. Abdullah kemudiannya dinaikkan pangkat menjadi Ketua Pengarah Kementerian Kebudayaan, Belia dan Sukan, sebelum menjadi Timbalan Ketua Setiausaha dalam kementerian yang sama pada tahun 1974. Abdullah berkahwin dengan Datin Seri Endon binti Dato' Mahmood pada tahun 1965 dan dikurniakan dua orang cahaya mata dan empat orang cucu. Pada 20 Oktober 2005, Endon Mahmood meninggal dunia selepas bergelut dengan penyakit barah payu dara sejak 2003. Setelah dua tahun menduda, beliau berkahwin pula dengan Jeanne Abdullah. Beliau dikatakan mementingkan aktiviti makan malam bersama-sama keluarga dan gemar makanan Jepun. Beliau menghargai hasil seni Malaysia dan merupakan seorang pengumpul seni ukiran kayu serta anyaman rotan. Setiap hari selepas sembahyang Maghrib, beliau akan mengaji Al Quran. Telah menjadi kebiasaan beliau menulis nota dalam Jawi. Selain
  • 38. daripada keluarga sendiri, tokoh yang banyak mempengaruhinya serta dianggap sebagai mentor ialah Tun Abdul Razak. Beliau juga adalah pencetus Islam Hadhari. 36 Di manakah Tun Abdullah bin Ahmad Badawi dilahirkan? A Perlis B Kedah C Bukit Mertajam D Kampung Perlis 37 Apakah jawatan yang disandang oleh Tun Abdullah bin Ahmad Badawi pada 1974? A Pendidik B Penolong Setiausaha C Ketua Pengarah Kementerian Belia dan Sukan D Timbalan Ketua Setiausaha Kementerian Belia dan Sukan
  • 39. 38 Bilakah beliau berkahwin dengan isteri keduanya? A Tahun 2003 B Tahun 2005 C Tahun 2006 D Tahun 2007 39 Pilih pernyataan yang tidak benar tentang petikan di atas? A Beliau menghargai hasil seni Malaysia. B Beliau pernah menjadi Penolong Setiausaha. C Beliau merupakan graduan lulusan ekonomi. D Beliau menggemari makanan Jepun. 40 Perkataan pencetus dalam petikan sesuai digantikan dengan A pereka B pelopor C pencipta D pengilham
  • 40. By G.MAGESWARI COHORT 9 STUDENT ID: 08035555 Word count: 10 000
  • 41. 1.0 Introduction The working place of intensive care unit (ICU) is very busy and hectic with never ended critical cases. Workload due to continuous contemporary issue such as shortage of staff and the conflict with professional boundaries such as vertical and horizontal substitutions . These are the factors that contributing workload and stress in ICU. To discuss the performance hurdles experienced by intensive care nurses in their work environment that impairs nursing care through reflective account. To make recommendations to over come the stressful workload in ICU in order to improve nursing quality for the clients. Intensive care nurses come across with a lot of performance obstruction in their work environment. Reflexion and reflexivity should be able to identify the outcome of various performance hurdles on nursing workload, nursing quality of working life, and quality of patient care. I would use John’s Model of structured reflection in my discussion by reviewing my daily work to over come the stressful workload in ICU in order to improve nursing quality for the clients by removing performance problem. The Mechanisms of workload which I would discuss in my dissertation are empowment, time, motivation, stress, attention, violations of work- a rounds and impact on organization . At the same time I would approach my dissertation on empirics, ethics, personal and aesthetic basis by using John’s Model of Reflection (1994) .
  • 42. 2.3.1 Stress in ICU Working in hospital settings can be very stressful, particularly for those nurses and working in an ICU (DePew et al., 1999). Work pressures are considered as part of everyday life of health professionals (McCarthy, Power and Greiner, 2010). According to Cox, Griffiths and Rial-Ganzalez (2000) the stress response as being mismatch between the perceived demands and the capabilities of the individual to cope with this demands. According to Lally and Pearce (1996) there are multiple factors which cause stress in ICU, which include high patient mortality, the nature of death in ICU, young people dying as an outcome of acute pathology or due to traumatic injuries as well as the fast change in the pace of works and tasks. As a result, all of these factors result to an environment that is full of tension and anxiety. In addition, other studies also showed different stressors for nurses which can be found in the ICU working environment. These include, but not limited to: excessive workloads (Callaghan et al., 2000); conflict with the supervisors and co-workers (Tyson et al., 2002); dealing with death and dying patients (Lambert et al., 2004b; Mann and Cowburn, 2005); lack of support from the organization (Tyson et al., 2002); insufficient preparation or lack of resources being issued (Tholdy Doncevic et al., 1998); coping with emotional needs of the patients as well as their treatment (Kalichman et al., 2000); shift rotation (Rogers, 1997); uncertainty concerning treatment (Kalichman et al., 2000); low job control (Cheng et al., 2000); and being moved among different patient care units (Healy and
  • 43. McKay, 1999). The study of Foxall et al. (1990) showed that intensive care nurses have to deal more with the stress of death and dying, while general medical-surgical unit nurses have to contend more with workload and staffing issues (cited from Burgess, Irvine and Wallymahmed, 2010). The study of Wolfgang (1988) compared the stress level of nurses with doctors and pharmacists. The result showed that nurses reported highly stressful environment and jobs compare to doctors and pharmacists. This is because of work load, needs of the patients as well as conflicts in the team. In addition, the study of Goodfellow et al. (1997) analyzed and evaluated the occupational stress between nurses and doctors within the ICU. The result showed that the doctors found that some factors in their job connected to career and achievement as well as organizational design and structure, are offering them more stressful works than the normal working setting. On the other hand, the nursing staffs reported different sources of stress compare to the doctors. The negative impacts of excessive demands that the working environment bring towards the medical staffs have been well studied and documented to offer and cause both physical and psychological impact towards individual. Stressor have an influence on most bodily systems, which produce quantifiable transient impacts which questionably lead to severe, chronic or even acute physical health problems (Mealer et al. 2007). In terms of psychological aspect, stress is connected with the feeling of anxiety, depression, subjective fatigue, reduction of confidence and self-esteem. All of these symptoms or signs have been showed
  • 44. and studied to affect the capability of individual and group to perform and act in different work-related tasks (Kincey et al., 2005). The study of Mealer et al. (2007) showed that some of the traumatic events that are connected with the PTSD in ICU nurses are quite the same to the experiences of war veterans, which include handling of dead bodies and caring for trauma victims. With this, it show that ICU is a very demanding environment which leave medical staffs – particularly nurses to be anxious and depressed (Burgess et al., 2010). My workplace has been considered as an extraordinary working environment with different workloads. Environmental factors have been established to the level that meets suggested standards. Currently, in my ward healthcare facilities are experiencing overcrowding and hospital-wide waits and delays. Thus, possible risks must be identified and alleviated by matching demand to capacity (Hall, 2006). This is primarily because of the different changes and alterations in ICU , which include the development of technology, innovations, the changes in the culture and tradition of individuals and the overall organizational behavior. It is also important to consider the different social changes found in the macro- environment. I directly saw how patients and their families perceived about the quality of the medical services being offered to them. In my working place the workload demands have been changed due to the increase in the level of patient demands and expectations. Patient’s expectations have raised the level of working demands and perceived stress among us . At the present time, work in the hospital is dominantly worked with a high level of
  • 45. psychosocial demands and workloads. According to the results of different epidemiological studies, the work of nurses is stressful. But, they still have to carry out their task in agreement with professional demands and without mistakes or error no matter how stressed and tired they are. Recently apart from working in ICU we are been forced to work double duty and no off day for nearly ten days in newly open dengue ward because of outbreak of dengue fever. Actually the management side failed to declare the situation to the state government to get man power. The working environment is consequently, perceived as overloaded. Additionally, the cost sare fatigue, illness and sick leaves. Nurses are in constant stress. They are worn out. Every now and then we can talk about epidemic of burnout syndrome (Vink, Konningsveld and Dhondt, 1998). These factors are very important because it directly affect the quality of the services they offered towards their patients, which consequently affect their lives and health . As a result, the question of what decrease burnout and increases retention and job satisfaction are widely studied in the field of health and medical working environment. Different studies showed that empowerment and perceptions of organizational commitment are two vital factors which are connected to job satisfaction (Kuokkaken, 2003 cited from Hall, 2006, 103). Once during my night duty I receive a Inferior all Myocardial Infarction patient to my ward. While I was doing my routine work such as taking observation and preparing medication for the gentleman. Suddenly the patient developed arrhythmia – ventricular
  • 46. tachycardia so immediately I called the doctor but he is too late. And I tried to print the electrocardiogram graph of the fatal arrhythmia unfortunately the machine in not in good condition and can’t print for documentation purpose. But I am sure that it is ventricular tachycardia. Because I already under gone coronary care nursing and have advanced cardiac live support certificate moreover working in intensive care unit for nearly ten years. While waiting for him with my experience and knowledge I perform defibrillation with 200 joules and the graph reverted to sinus bradycardia and I gave intravenous medication atropine. The patient survived and the graph shows sinus tachycardia, and other observation parameters shows normal range. I really satisfied with my reflection- in- action . But the sad side of the story is, the doctor scolded me because I crossed the professional boundaries and did the procedure against the code of nursing. The only reason was I failed to print the graph and I can be charged if anything bad or the patients’ condition deterioting or die. But I still argue with him and said I really sure with the arrhythmia and you are late and I can’t lose the young gentlemen. And I assume that if he is my family member I will try my best to save him. The doctor felt guilty but he scolded there is no prove. I feel very bad and discourage and couldn’t accept the way they treat me as a senior staff nurse and scolded me in front of other clique who are very junior staffs, of course they won’t respect me. And promised to myself that I won’t repeat it again but still my feeling confront with him. The embarrassment made me depressed and I couldn’t carry out my daily duty at that night and the following week as a mother and a wife at home. I lost my appetite and good sleep for few week. Finally I
  • 47. went to see a doctor and diagnosed as stress. Organizational commitment is considered as the main aspect considered as in retention and job satisfaction because it pertains on individual’s attachment, trust and involvement in the organization (Kuokkanen et al., 2003 cited from Hall, 2006, 103). It is important to consider that different environments have different stressors and sources of stress may even different from individual to individual in the same unit. For instance, the study of French et al. (2006) showed that lack or shortage of resources help to increase levels of stress in ICU (cited from Hall, 2006). In addition, French et al. (2000) added that stress is connected on the individual and influence perceived from situations and conditions on one’s physical and psychological well-being, as a result, according to Tonges (1998) workplace stress is commonly connected with workload (cited from Hall, 2006). Stress happens based on workload when the demand exceeds the ability of an individual to access resource or capacity. As a result, according to French et al. (2000), it is important for hospitals and health care organizations to develop supportive management, increasing opportunities for positive patient interactions, and creation of a wide-spread sense of autonomy as well as empowerment can help in order to lessen or distribute stress (cited from Hall, 2006). In addition,I also affected with the shortage, in my work place. As a result, the government gets the service of foreign doctors in other countries in order to ensure that there is sufficient number of doctors to handle the number of patients. However, based on my observations and experiences (primarily based on the
  • 48. doctors whom I worked with), they are not as professional as our local doctors. In addition, they are also not that trained and used to speaking and understanding our language, as a result, we, the nurses serve as translator and interpreter in order to make the doctor and the patient to understand each other. Recently in my ward I face a very bad situation which was contribute to very stressful working environment. These doctors never examined the patient properly and just accept the cases from ward. The problem I face was most of the patient will die within hours. The sad part was immediately after I we done the last office he will called l and order to prepare another bed for a new patient. Even though I advice him to examine the patient use the ICU protocol to accept the case but he never bother to listen. I also no power to reject it. Just imagine how stress we are in this situation. Thus, this add additional burden for the nurse and some of the doctors are not really skillful,so that t we have to assist them in doing different procedures. In addition, we also serve as trainer, mentor superior to the junior staffs after most of our senior staffs move due to promotion. As a result, currently, we are working with junior staffs with less knowledge, skills and experiences in different procedures, tasks and responsibilities in the ICU. The performance of our junior is on our shoulder, meaning if the junior staff did something wrong, the management will overlook to the senior, and there are possibilities that we will be fired.
  • 49. I also have responsibilities and roles that I must do for my family – my children and my husband. These stressors I found at work affect my relationship, including the time that I spent with them. 1 Reflection Model Reflective practice is considered as a learning process which encourages self-evaluation with succeeding professional development planning. According to (Driscoll and The, 2001) Reflection is useful strategy in nursing field because it help to differentiate between thinking regarding daily work versus reflecting regarding on experience, which requires intentionality and skills. Thus, reflective practice claims the capability of an individual to evaluate situations and make judgments pertaining to the efficiency of situational interventions and quality of outcomes (Zuzelo, 2009). Thus, reflective practice helps practitioners to make sense regarding the different challenging, complicated and complex, which eventually remind practitioners that learning is continuous, and there is a need for improving traditional types of knowledge that are required in nursing practice, at the same time, sustain nursing by different formal opportunities to converse with peers regarding the practice. There are different models of reflection, which can be used. These include: Gibbs’ model of reflection, John’s model of reflection, Kolb’s Learning Cycle and Atkins (1995) and Murphy’s model of reflection (Zuzelo, 2009). For this paper, John’s model of reflection will be used, for the author believes that it is the most applicable and suitable model for the case and
  • 50. scenarios being studied. Reflectivity activity is considered as an opportunity to purposely and intentionally think regarding the practice events; analyze choices, reactions, responses and behaviors; consider possible alternatives; develop plans in order to improve or recognize learning needs; and to follow this action plan in new or the same events or problems (Zuzelo, 2009). According to John (2004) reflective practice is a holistic practice mainly because it pertained on comprehending the vitality, importance and meaning of the entire experience. There are different layers of reflection which progress from a reflection on experience towards mindful practice, which are in juxtaposition with moving from doing reflection to reflection as a way of being. With all these, reflective practice is defined as: Being mindful of self, either within or after experience, as if [there is] a window through which the practitioner can view and focus self within the context of a particular experience, in order to confront, understand and move toward resolving contradiction between one’s vision and actual practice (Johns, 2004, 3 cited from Zuzelo, 2009) The table below shows the cues offered by the said model in order to help practitioners to access, make sense of and learn via experience (Ahot, n.d.). John (1992) applied the concept of guided reflection in order to define a structured, supported approach which will enable practitioners to learn from their reflections on their experiences. It uses a model of structured reflective diary, one-to-one or group supervision and keeping of a structured reflective diary. The main advantage of this model is that it is more detailed compare with the other
  • 51. models, which eventually offers advantages and disadvantages. According the different nursing literature, nurses need to be taught on how to reflect, and the detailed questions that the practitioners are required to ask of themselves in the Johns model of reflection, will, no doubt, offer a comprehensive checklist for reflection. However, the detailed structure can also offer disadvantage because it will impose a framework that is considered as external towards the practitioner, which will leave only little scope for inclusion of his or her own approach. In addition, the said model is considered as complex, while the other models are being criticized for being simple and self-evident (Davies, Finlay and Bullman, 2000). Here one of my reflection which happen in ICU that make me stress Once during my night duty I receive a patient with Inferior all Myocardial Infarction to my ward. While I was doing my routine work such as taking observation and preparing medication for the gentleman who father of four children. Suddenly the patient developed arrhythmia – ventricular tachycardia so immediately I called the doctor but he is too late. This is a main problem in my hospital because one doctor have to cover few wards during night time. And I tried to print the electrocardiogram graph of the lethal arrhythmia unfortunately the machine in not in good condition and can’t print it for documentation purpose. But I am sure that it is ventricular tachycardia. I have to act fast within 3 minutes (Cumin, 1996) if not patient will hypoxia and vegetative. Because I already under gone coronary care nursing and have advanced cardiac live support certificate moreover working in intensive care unit for nearly ten years. While waiting for him with my experience and knowledge I perform defibrillation with
  • 52. 200 joules and the graph reverted to sinus bradycardia and I gave intravenous medication atropine I mg.. The patient survived and the graph shows sinus tachycardia, and other observation parameters shows normal range. I really satisfied with my reflection- in- action But the sad side of the story is, the doctor scolded me because I crossed the professional boundaries and did the procedure against the code of nursing. The only reason was I failed to print the graph and I can be charged if anything bad or the patients’ condition deterioting or die. But I still argue with him and said I really sure with the arrhythmia and you are late and I can’t lose the young gentlemen. And I assume that if he is my family member I will try my best to save him. The doctor felt guilty but he scolded there is no prove. I feel very bad and discourage and couldn’t accept the way they treat me as a senior staff nurse and scolded me in front of other clique who are very junior staffs, of course they won’t respect me. And promised to myself that I won’t repeat it again but still my feeling confront with him. The embarrassment made me depressed and I couldn’t carry out my daily duty at that night and the following week as a mother and a wife at home. I lost my appetite and good sleep for few week. Finally I went to see a doctor and diagnosed as stress Reflection on the above incident using parts of the ‘structured reflection’ model by Johns (1992) and Carper (1978) Aesthetics – As a art of nursing actually I’m trying to save my patient who is having lethal arrhythmia. If I act late and still waiting for doctor I will lost the patient. As long as I concern in this situation my action was consider according to
  • 53. the ventricular tachycardia algorithm which was approved by American Heart of Association. But then I really shocked when my doctor came and scolded me and make me upset. After the doctor’s explanation then only I realize that even though I had made a very best of work, on the other hand I made some inter related job offence. In this case vertical substitution which is cross the boundaries has taken place. I suppose to print the graph for documentation purpose and avoid medico-legal action. This will bring some trouble to the doctor if something happen vice versa as a result. This contradict situation make me realize that in reality this incident thought me to be more careful prevention measure. My knowing in an aesthetic point of view here involves the deep appreciation of the the patients situation and calls forth inner creative resources that transform my experience into something that would not otherwise be possible. Personal – In this unprecedented incident if I try to act of safe side of professional ethic. I m sure will lost the gentleman who is father of four. Morally my sense of sympathy and empathy was disturbed. Imagine that if the patient is my own family member sure I will try to do the best to save him because the doctor came late. I ‘m fully confident and have enough knowledge to over come the crucial situation. Personal knowing here concerns the inner experience which I have gone through . The full awareness of the self, the moment, and the context of interaction with my patient makes me to react meaningfully l to share my experience positively.
  • 54. Ethics - Having a code of ethics helps guide nurses through tricky situations and serves as a common reference point for everyone on the health care team. But the primary goal of nursing ethics is to protect patients. So in order to save my patient’s life I was tended to cross the professional boundaries and act towards achieving the primary goal of nursing ethics. If anything goes wrong or the patient died I can be charged under written code of nursing ethics. Ethical knowing here involves my decision to make moment-to- moment judgments about what ought to be done, what is good, what is right, and what is responsible. Empirics - In this particular nursing practice I’m came to know that my patient is in serious condition from my experience. From my close observation not only to the patient but from the electrocardiogram( ECG) through cardiac monitor. I now it is a lethal arrhythmia through my experience bed side teaching by specialist and I have gone through special course for ECG in one of the cardiac center in my country. It really helps me to tackle this critical situation. Empiric knowing is based on the assumption that what is known is accessible through the physical senses, particularly seeing, touching, and hearing, and as a pattern of knowing draws on traditional quantitative approaches to knowledge acquisition. The Empiric knowing is expressed as scientific competence. From the reflection on action above I learned that in this critical setting ward I cannot fully avoid from facing stress all the way. But still there is a room to reduce the stress by self stress management .Anyway I m very glad and satisfied internally after I was able to recognize where the problem lies on.
  • 55. 2.3 Stress and Workload in ICU Stress is considered as the most popular factors which affect performance and productivity of nurses in the entire hospital environmental particularly in the ICU department. It can greatly influence how the medical staffs perform, which affect their productivity, which is directly connected to the health and condition of the patients. On the other hand, workload is considered as one of the primary factors which drive stress for the nurses in ICU. Workload is considered as an important issue in my work place which focuses on the amount of work that is placed upon the responsibility of the nurses. When work is largely a physical activity, then the major consideration is to ensure that the physical demands of work are not greater than the capacity and capability of the individual in those given circumstances. On the other hand, those works which focus on mental aspect or those involved attention or decision-making are in need to prevent overload and under load (Di Martino and Nigel Corlett, 1998). ICU practices are full of high workload situations (Oates and Oates, 1996). For me because I have to continuously entertain the demands and needs of the patients and their family. At the same time, I also have to face with intense emotions, such as death. This issue is important because different studies have showed that workload is one of the important factors which affect the quality of service and care and ICUs as well as the safety and health of the patients. The study of Australian Incident Monitoring Study for ICUs showed that the major
  • 56. causes of workload are the inappropriate staffing compare to patient load (Beckmann et al. 1998). This result to incidents related to problems of drug administration, documentation, not enough supervision to patients, incorrect ventilator and other equipment and gadget setup as well as self-extubation. In addition, the study also showed that some of the problems related to insufficient staffs are physiological change, dissatisfaction of the patients and their respective families and physical injury. In addition, the study of Tarnow-Mordi et al. (2000) analyzed and evaluated the connection between mortability rates and the workload of hospital staffs in adult ICU in the United Kingdom. The result showed that those patients who are exposed to high ICU workload are more expose to death than those who are in low workload. This is due to the lack or not enough time for clinical procedures to be done in correct manner, inadequate training or supervision, errors, overcrowding as well as the consequent nosocomial infections, limited resources as well as premature discharge from the ICU. In my setting whenever patient admitted to ICU or death we really facing a big problem in doing paper documentation. I really hate this job which restrict my nursing care. I also have to write the report regarding the patient to matron and the director of the hospital every day. Imagine that how much workload I have to bear beside my routine job. The study of Malacrida et al. (1991) using Nursing Stress Scale (NSS) questionnaire and self-observation showed that for nurses, the most important stressors are dealing with death of patients and high workload. This
  • 57. include staffing, paper work and scheduling problems and risks, not having enough time in order to complete the medical tasks, at the same time, support the patients about their health. High workload may also result to poor nurse- patient and doctor-patient communication (Llenore and Ogle, 1999) as well as poor relationship between the nurse and physician or doctor (Baggs et al., 1999) – which is very important in order to ensure safety and health of the patients in ICU .There are number of problems and factors that I am facing in the ICU which make me stress. This includes factors related to the management, leadership, skills, roles and responsibilities and staffing. 4.1 Description of the Experience I am experiencing high level of stress in my current work due to different factors which involved my work itself, my position in the hospital, me as a mother and a wife and me as a human. These similar and conflicting positions and roles added fuel to the fire in my current stress. Mismanagement Based on my observation and my own experience, mismanagement is one of the most important contributing factors to my stress and even my co- workers at work. As have showed in the literature review, mismanagement of the people, which include the schedule and other benefits are crucial stressors for nurses and other medical professionals. In our case, our superiors are manipulating their man power in inappropriate manner. They are opening wards without first asking for the permission of higher authority, which caused us to
  • 58. work double duty. In addition, we do not have annual leave, and we really need to go for leave, we have to do night duty. We already tried to voice out our concerns but the management threatened us that they will transfer us to another place. Thus, it shows lack of professional management. I would to reflect the incident that affects me due to this matter. I and my family arranged a vacant .My husband already booked a hotel and my children were in a very happy mood. Unfortunately my ward sister called me at home and ordered me come to home because of epidemic of dengue fever outbreak. The whole family was upset and out of mood. I tried to please her by explaining my situation. But she uses her autocratic power to force me to work. Even though an internal conflict aggravates between us, finally I agreed to follow her instruction. The worst part was I have to do double duty Conflict with Co-workers and Superiors The ward sister is also very biases and would only listen and entertain those staffs who are close to her. As a result, staff like me is always a victim because of my race. Furthermore, she uses her power in order for her to work double duty, which further aggravates the conflict between us and the co-workers. Division of Labor/Rules and Responsibilities Aside from out daily activities and responsibilities, there are also times when we do the responsibility and dirty work of the doctors. IN addition, we are
  • 59. also crossing vertical and horizontal substitution like physiotherapy job. This again aggravates the conflict between the doctors and the nurses. Dealing with the Patients and Their Families The patients and their families are other factors which add up to our stresses. As have tackled in the literature review, the behavior of the patients and their families, together with their conditions, their reactions, emotions, feelings and even their gestures greatly influence the nurses’ and doctors’ feelings and emotions. Commonly these factors bring us emotional and psychological stresses, which also affect our physical wellbeing. First, we have to face the rage of the families of those patients who were dying. They sometimes blame us, and accuse us that we are not doing our job properly. This is because of high expectations that they are giving us. More often than not, the families considered the medical professionals as superior and all mighty and we can do everything in order to save their dying family members. In addition, the sufferings of the patient itself while they are at the ICU also affect us emotionally and physically. In addition, there are also some times when some VIPs are admitted to the ICU. Their relatives, most often than not, do not follow the rules and regulations of the ward. As a result, we cannot do our job properly because people are watching us. The worst part is that they are commonly complaining through paper that the nurses are rude and we did not do our job properly. Again, this affects our performance in the hospital.
  • 60. In addition, we, the nurses in ICU have to travel in ambulance and bring the ventilated patient for scanning and transferring. This add up to our stress and physical burden, because the journey is really motion sick and we always tend to worry and take care of the safety of the patient. If things go wrong, we have to write explanation report to the management. 4.2 Reflection Under these experiences, I always ensure that all of these stressors will be taken for granted in order to ensure that all of the responsibilities, to the management, with my superiors and co-workers and to my patients and their respective families will be met. With this, I always ensure that these stressors will not affect my performance. There were times were I already asked for the opinion of my co-workers, superiors and even the management regarding the current condition of the ICU ward, however, as have mentioned, the management has less supports to their nurses, and they commonly threat us with actions that we can experienced upon insisting our concerns. However, it is important to take note that no matter how hard we try, in spite of our effort to maintain high level of performance and services towards the patients, due to the different stressors that are always their inside and outside the ward, it affects our performance in direct and indirect manner. In my case, it affects my physical, social, emotional and psychological health. Because of the stressors, there are times, which I am not feeling well, due
  • 61. to the different burdens and confusions. This further affects my responsibility and my relationship with my family, because, most often than not, I don’t have that much time to communicate and connect with them. For my children and my husband, there were times that I can no longer do my responsibility for them, including daily activities, which will show how much I care for them. There are even times, that when I go home, I will automatically sleep because of overwork and fatigue, which leaves my also tired husband caring for our children and taking care of some important business in our home. On the other hand, as have already explained, these stressors affect our relationship with our co-workers, because of unequal or unfair treatment, at the same time, due to overwork, there are times that we are in bad mood, and because of pressure, we commonly end up in arguments. During this time, it is normal that I am feeling tired, angry at some times, and sometimes concern – concern about my job stability and security, my patient’s health and of course, my family. For the patients, because, they are commonly in complicated state during their stay in the ICU, they are somewhat unaware of what is going on inside the ward. However, if ever I am in the condition of the patient, I will feel mostly unease because, there are times that I can already feel the emotion, behavior and feelings of the nurses and doctors due to the challenges involved in their job, together with those stressors, at their works. 4.3 Influencing Factors
  • 62. The internal factors that are affecting my decision inside the ICU ward are my roles and responsibilities. This pertains on the promises and preamble that I have made upon entering my profession. This pertains on ensuring the safety and saving the lives of the people. With this, in spite of the stressors and difficulties of my work, I always make sure that I am at my best because I am handling lives of the people. My co-workers, superiors and the overall management also affect my decision. The management itself implemented its standards and rules and regulations which influence my personal opinions and actions about different tasks and situations in the ward. The patients and their family also affect my decision, for their feelings, conditions, emotions and behaviors can influence me in either direct or indirect manner. On the other hand, the external factors which influence my decision are my family. Like any other people, I have my responsibility to be done inside our home. I have to take good care of my husband and my children, ensure their safety, at the same time, and make sure that they are healthy and experiencing good life. In my current condition, they are being affected due to my schedule as well as my health – physical, emotional and psychological. Sometimes, it is inevitable to bring home the feelings or emotions that I am getting inside the ICU. With this, I have to focus on my personal experience, the knowledge that I have learnt inside the university, at the same time, those knowledge that I have learnt via long experience – from the doctors, from my co-nurses as well as the patient in deciding about different matters. 4.4 Could I have dealt with the situation better?
  • 63. I strongly believe that I have dealt with the situation good, because in spite of the stressor I have experienced, I, together with the other nurses enable to do our job properly. However, upon analyzing, it would have been better if we pressed our concerns more towards the management. If the management will not listen in spite of that, there can be some other organizations or agencies that can help us solve the problem. I know this will cause some ruckus; however, I believe that this will serve for the betterment of the entire institution. 4.5 Learning This experience enables to show me the different factors that affect the performance of those nurses and medical professionals inside the ICU ward. Thus, it poses several challenges for those individuals who are working in the said setting, because they have to juggle different important factors – they have to focus on their responsibilities and roles as a medical professional – ensure the safety of their patients and to support their families and relatives, at the same time focus on the different stressors that are related to the management, co- workers, superiors as well as those factors that are related to the personal life. Upon writing this reflection, I still strongly believe that there are changes that must be done inside the ICU in order to ensure that all of the medical professionals working their will maintain healthy physical, mental and emotional health, which are important because it directly and indirectly influence the quality of services that they are tending or offering towards the patients and their
  • 64. families. It is important to take note that just like other people – nurses and doctors are ordinary human being who also has their personal lives, which can affect their performance, and which their professional or career development will be affected. In my case, the fact that there are no annual leave available affect my relationship with my husband and my children, for I cannot spend more time with them, to bond, coordinate and communicate with them. In addition, because of the stressors that I am experiencing due to mismanagement, chaos and ruckus with the doctors, superiors and other co-workers, it influence my overall mood, which I can bring to our home, therefore, can affect my approach towards my husband and my children. The setting of the ICU, itself is very stressing – seeing those people dying, seeing the agony of their patient before their last breath, seeing the blood, flesh and everything. At the same time, we always see the torment, hurt and pain of their families – sometimes blaming us for their loss of their relative or love ones. All of these negative emotions we always encountered, every day! With this, it is important for an individual to have a sense of balance, which can be achieved with proper support from the management – by improving the policies, rules and regulations and ensuring that all of the staffs – from the upper management up to the lower one about their individual rules and regulations and their accountabilities. With this, it can help in order to lessen the burden of every one – and ensure that everyone are working and doing their job properly, therefore it can help to create a more cooperative and sound working environment.
  • 65. 4.6 SWOT Analysis Strengths My strength mainly focuses on the ability to cope with the different stressors in my working environment. Based on my credential and past experiences, I can also say that I am much knowledgeable and skilled, which makes me reliable and efficient at the work. In addition, I can also handle the pressure of my work and personal life. I can also work well with different people – with my doctors and co-nurses. Weaknesses I must admit that I am weak, when it comes to those aspects that are related to emotion – I am human after all. In spite of my past experiences with the dying patients and the reactions of their families, I can be easily affected by their feelings and emotions, which leave me weak and stressed. Sometimes, I can bring this feeling at home. Opportunities The opportunities will focus on the aspect of proper management – division of labor, increase in staffs and the use of new technologies, which will help us to manage our job in more efficient and faster manner. It is important to focus on employing already-trained new staffs, in order to lessen our burden or job. In addition, it is also important to ensure that all of the doctors to be hired are all properly trained in terms of language and culture of the country and the hospital setting.
  • 66. Threats The treat will remain on the aspect of decreasing number of medical professionals in the country. In addition, the emotional and physical burden of the nurses in the ICU-environment is another factor. With this, it is important to ensure that there are some programs or activities to be done in order to support the feelings, emotions and behaviors of their nurses and doctors. It is important to ensure that they are properly rested in order to ensure good performance from them.
  • 67. 5.0 Integration of Literature Review 5.1 The ICU Environment Based on the assessment and reflection done, it had been found out that ICU is indeed, considered as one of the busiest, if not that busiest department of the entire hospital. It is considered as one of the most stressful department for the employees – nurses and doctors have to handle difficult situations and cases of the patients, considered as those emergency situations or cases. In addition, according to the study of Angus and Kelly (2000), ICU consists a vital percent of the entire health care system of America, which is more or less 6000 ICU in 2000 alone. In addition, according to Halpern (1994), there are more or less 55,000 patients that are being delivered and cared for in these units. In addition, there are different social and economic factors which influence the growing number of patients entering the unit. First is the decrease or the declining number of acute care hospital beds for the last 2 decades, which increase the number of patients in ICU for more than 250%, which accounts for more or less 10% of the entire hospital beds (Lustbader and Fein, 2000). In addition, it is also expected to increase due to the increase in the age of the entire population (Groeger and Strosberg , 1992). This is for the case of American alone. In other countries, they are experiencing shortage of nurses and doctors, particularly in developing countries, because of most of their nurses and doctors
  • 68. are going to other countries in order to acquire higher salary. On the other hand, there are other developed countries, wherein people are not that interested in entering the said profession. As a result, the number of people who are willing and capable in entering the healthcare is declining, therefore, it can add up to the problems related to stress and overload inside the ICU environment. There are different factors inside the ICU which affect the mentality, physical activities, feelings and emotions of the staffs – the doctors, specially the nurses. This include those factors that are related to their working environment, co-workers, subordinates, superiors, management, their patients and their respective families, the facilities, etc. These factors have a vital influence on the overall feeling, ambiance and condition of the ICU, which can greatly influence the performance of the medical staffs, particularly the nurses, who are doing variety of jobs. With all these work-related factors, together with the personal factors which the nurses and doctors experienced and encountered outside the hospital, inside their homes – with their spouses, children, families and friends, stress is considered as inevitable. This is important, for there are different studies which show that patient safety and medical errors, together with the different adverse impact from those errors are commonly found inside the ICU (Donchin and Gopher, 1995). Medical errors are important issue in any hospital or medical institution, for it can greatly influence the overall image of that hospital, at the same time, it has a vital influence over the individual performance and position of medical professionals. 5.2 Workload in ICU
  • 69. Based on the review and reflection, it had showed that nurses play different roles inside the ICU. They are considered as the busiest medical professionals inside the ICU environment, for they cater for different needs and focus on helping other medical professionals, such as the doctors, at the same time support the patients and their families. According to the study of Oates and Oates (1996), ICU is filled with high workload situations. This is because nurses have to continuously respondent to the needs of the patients and their families, at the same time routinely connect with the most intense emotional aspect of life. As a result, workload is considered as one of the most, if not the most, vital determinants of safety of the patients and the quality of services and care in ICUs (Carayon and Gurses, 2005). In my experience as a nurse in my working environment, one of the most common sources or reasons of over workload is the shortage of staffs. First, some of the head nurses have been promoted in other position, as a result, we have to focus on training and mentoring the newly hired and inexperienced nurses, which again will add up to our burden. In addition, because the new nurses are inexperienced and not that knowledgeable, we have to continuously guide them, because we will be blamed for their mistakes. Therefore, we have to cater most of the critical and difficult tasks inside the ICU. In connection, the study of the Australian Incident Monitoring Study, showed that the shortage of nursing staff in ICU can lead to compromised quality of care (Beckmann and Baldwin, 1998). The two main reasons of shortage of nursing staffs are: inappropriate staffing for current patient load and the inability of the management
  • 70. to respondent in the increasing unit activity (Carayon and Gurses, 2005). These two factors can be found in our working environment, for the management is somewhat blind and not that open for change, in spite of the fact that they are continuously opening new beds for the said unit. The issue of understaff of the ICU is very important for it can cause to different medical errors and problems, such as drug administration or documentation problems, inadequate or insufficient patient supervision, incorrect ventilator or equipment setup as well as self-extubation (Carayon and Gurses, 2005). Furthermore, undesirable patient outcomes connected with the inadequate nursing staff include major physiological change, patient or relative dissatisfaction as well as physical injury. This is because nurses will have to handle to do different tasks of different types in short period of time. Furthermore, the study of Tarnow-Mordi and Hau (2000) focus on the connection of mortality rates and the workload of hospital staff in one adult ICU in the UK. The measures of workload for a given patient’s stay include the occupancy per shift, peak occupancy, ICU nursing requirement per shift, ICU nursing requirement during the first shift of the patient, the ratio of the occupied to appropriately staffed beds per shift, and the ICU nursing requirement per occupied bed per shift. The result of the study showed that those patients who are exposed to high ICU workload were more likely to die than those who are exposed to low workload. The three measures of workload most strongly connected with mortality were peak occupancy, average nursing requirement per occupied bed per shift, and the ratio of occupied to appropriately staffed beds.
  • 71. Some of the explanations for the connections between high workload and mortality include: inadequate time for clinical procedures to be done in appropriate manner, inadequate training or supervision, errors, overcrowding and consequently nosocomial infections, limited availability of equipment and premature discharge from the ICU. Some of these factors can be observed in my current working environment. The best example is the inadequate training or supervision given to the new nurses. This is because, we have to train them, and at the same time do our tasks. In addition, we are also experiencing some overcrowding, particularly when VIP patients will come, they are not following orders regarding the visits and other important factors. As a result, we are having difficulties in doing our jobs, particularly when there are number of people who are watching us and asking questions while doing our jobs. 5.3 Relationship between Workload and Stress in ICU Different studies, including Crickmore (1987), Malacrida and Bomio (1991) and Oates and Oates (1996) showed the relationship between stress and workload. According to their studies, workload is considered as one of the most vital job stressors among the nurses of ICU. The practice of medicine alone is already considered as stressful. For instance, the study of Malacrida and Bomio (1991) studies the quality and frequencies of stressors in an ICU environment with the use of two different data collection methods, which include Nursing Stress Scale (NSS) questionnaire and a computer-aided self-observation method development and improved by the authors for this study. The result of the computer-aided self-observation method, 17 ICU nurses were asked to record
  • 72. their experiences on a computer placed in the ICU, immediately after having stressful experiences and events. These same 16 ICU nurses and other 31 nurses working at the same hospital were asked to fill out the questionnaire. The result of both data gathering methods showed that the most vital and important stressors for nurses, where those related to death and high workload. As a result, staffing and scheduling problems, not having enough time in order to complete nursing tasks and not having vital and enough time in order to offer emotional support to patients were all connected to workload or considered as workload- related issues or problems. Again, all of these factors can be observed and experienced in my current working environment. The staffing and scheduling problems due to the inconsistency and inability of the management to connect with the nurses regarding the different changes as well as the different actions to be implemented in the hospital, greatly influence the grievances and the roles of the nurses inside the hospital. Having the enough or sufficient time catering the demands and needs of the patients, together with doing the jobs inside the ICU environment is another factor. This is because of the fact that we are experiencing shortage of the medical professionals, particularly those related to the experienced nurses in the environment. Even though, there are new nurses inside the ICU environment, experience is always an important factor. This is particularly because of the fact that ICU is different from other units of the hospital or the medical institutions. This is because there are different emotional, psychological and physical factors that can be faced or encountered by the nurses, which are unavailable or cannot be encountered in other units of the
  • 73. hospital, particularly those related to the deaths of the patients and grievances, agony and pain of their families. In addition, it is important to consider that nurses also have their lives outside the ICU and outside the hospital. This pertains on their responsibilities and roles inside their homes and their families, their friends, their clubs and organizations, their religions and their society they are included in. In my case, I have my own family, my husband and my children, to whom I have a responsibility to be done. I have to be there in order to support my husband and my children. Help my husband to fix his wardrobe for his work, to prepare my family’s breakfast and dinner, at the same time, to go out with them even once a month for bonding moment or time. However, the time that I am spending inside the ICU and in the hospital, together with pile of tasks that I have to do inside the ICU, most often than not I have no more energy to be spent in order to communicate and help my husband and support my children about their work or their studies. This commonly cause problems with my husband, because there are times that I am bringing some of the emotional burden from ICU, particularly related to those patients whom I have already created a certain connection. These emotional and physical stresses affect my relationship with my family at certain level. Furthermore, the study of Bratt and Broome (2000) and Darvas and Hawkins (2002), shows that in terms of working conditions and stress, there are different evidences which shows the connections between nursing working conditions and the job satisfactions. Behavioral consequences of job
  • 74. dissatisfaction in nursing, which include low morale, absenteeism, turnover as well as poor job performance, can potentially threaten and affect the care quality of the patient as well as the overall effectiveness of the organization (Cavanagh, 1992). There are different nursing studies which analyzed and assessed the results or outcomes of job satisfaction. Study of McCloskey and McCain (1987) showed a positive connection between job satisfaction and job performance, while the study of Tarnowski-Goodell and Van Ess Coeling (1994) showed a positive connection between job satisfaction and patient satisfaction and quality of care. In addition, the study of Keijsers and Schaufeli (1995) and Aiken and Clarke (2002) showed that high workloads is connected to sub-optimal patient care, which can influence the decision of the care providers and nurses towards the different medical procedures (Griffith and Wilson, 1999), which will consequently lead to the reduced satisfaction of the patients (Anderson and Maloney, 1998). In addition, high workload is also expected to lead to poor nurse-patient communication (Llenore and Ogle, 1999), impaired nurse-physician collaboration (Braggs and Schmitt, 1999), nurse burnout and dissatisfaction to the job (Aiken and Clarke, 2002). All of these factors can directly and indirectly influence the individual performance of the nurses, including the quality of care that they are tendering towards their patients, then will affect the overall image of the hospital or medical organization or institution that they are in.
  • 75. As a result, it is important to focus on the workload in order to lessen the stress of the nurses inside the ICU. This can be done by focus on the improvement of the working conditions, together with the improvement of the communication, collaboration and connection between the nurse and the physician or the doctors. This can help in order for the nurses to know their roles and responsibilities, which will help them in order to know what are the tasks that they must perform towards their co-workers, their subordinates, the physicians or doctors, towards their patients and their patients’ families (Evans and Carlson, 1992). References Abramson, N. A. and Wald, K. S. (1980). ‘Adverse occurences in intensive care units’. Journal of American Medical Association. 244, 1582 – 1584. Ahot. Using a model of reflection. Retrieved 23rd November, 2010, from Ahot.utu.fyi website. Aiken, L. H. and Clarke, S. P. (2002). ‘Hospital nurse staffing and patient mortality, nurse burnout and job satisfaction’. Journal of American Medical Association. 288(16), 1987 – 1993. Anderson, F. D. and Maloney, J. P. (1998). ‘A descriptive, correlational study of patient satisfaction, provider satisfaction and provider workload’. Mil Medical. 163, 90 – 94.
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  • 81. Appendix 1 John’s Model of Reflection (1994) 1. Description of the experience · Phenomenon – describe the here and now experience · Casual – what essential factors contributed to this experience? · Context - what are the significant background factors to this experience? · Clarifying – what are the key processes for reflection in this experience? 2. Reflection · What was I trying to achieve? · Why did I intervene as I did? · What were the consequences of my actions for: Myself? The patient / family? The people I work with?
  • 82. · How did I feel about this experience when it was happening? · How did the patient feel about it? · How do I know how the patient felt about it? 3. Influencing factors · What internal factors influenced my decision – making? · What external factors influenced my decision – making? · What sources of knowledge did / should have influenced my decision – making? 4. Could I have dealt with the situation better? · What other choices did I have? · What would be the consequences of these choices? 5. Learning · How do I now feel about this experience? · How have I made sense of this experience in light of past experiences and future practice? · How has this experience changed my ways of knowing Empirics – scientific Ethics – moral knowledge Personal – self awareness Aesthetics – the art of what we do, our own experiences
  • 83. Source: (http://www.communityhealthcarebolton.co.uk/SHA/LLL/resources/reflectiv e/JOHNS.doc) 1.4 Review of Literature Intensive Care Unit (ICU) is considered as an area of a hospital which offer aggressive and insistent therapy, with the use of state-of-the-art and high-end technology, together with invasive and non-invasive monitoring for critically ill and high-risk patients. In these units, the physiological variables and factors of the patients are reported to the practitioner on continuous and unbroken manner, in order to offer and provide titrated care (Varon and
  • 84. Acosta, 2010). With this, it shows that the main objective or purpose of ICU is simple, but the practice and standards being implemented inside is complex. Healthcare professionals who are working in the ICU rotate their shift in order to offer around-the-clock intensive monitoring and treatment of patients all throughout the week. Patients are commonly and normally admitted to an ICU if they are expected to take advantage and be benefited from the high level of care to be offered. Thus, it benefits those patients who are strictly and severely ill and unstable in terms of medical and physical condition – with life- threatening disease or illness (ENotes.com, n.d.). According to Garland (2005) ICUs are considered as vital but troubled component or aspect of the health-care systems (p. 2153). It is considered as the area within the hospital which constitutes extensive and large risk of morbidity and mortality (Berenholtz et al., 2002). In the United States alone, ICU constitutes a vital portion of the entire health care system. According to the study of Angus and Kelly (2000) the number of ICUs in the US is more or less 6,000. Thus, it is considered as important aspect of the entire health care system. Different researches and studies about ICU patient and medical staffs problems shows that unpleasant events frequently happening in Intensive Care Unit (ICU) (Abramson and Wald, 1980). The study of Bracco and Favre (2000) which was conducted as a prospective observational study of consecutive patients admited over 1 year to an 11-bed multidisciplinary ICU in a non-university teaching hospital to know critical incidents and associated risk factors. The study included
  • 85. 1024 patients in 2801 days treatment in the ICU. A total of 777 incidents were detected during the 1 year study period: 31% were human-related, 2% were equipment-related and 67% were patient related, the study concluded that human-related errors prolonged ICU stay by 425 patient days over 1-year period (Carayon and Gürses, 2004). The observational study of Giraud and Dhainaut (1993) examined the iatrogeniche connections relationship showed that workloads of nurses are considered as one of the most important factors which causes stress in the ICU environment. Thus, one of the major challenges for ICUs is improving the quality and safety of nursing care. The study of Kopp et al. (2006) shows that there was one error for every five medication doses administered in a medical surgical ICU, therefore, it shows that medication administration stage is very susceptible for different errors. In connection, nurses play a vital role in the care being offered in ICUs (Rogers et al., 2008). This is because they are responsible in the different procedures and processes related with the medical care towards the patient. Therefore, nurses can influence the process of healing or the other way around of the patients.