Article

Self-Leadership in a Critical Care Outreach Service

for Quality Patient Care
Carine Prinsloo
https://orcid.org/0000-0001-7435-6788
University of South Africa
[email protected]

Abstract
The deterioration of patients in general wards could go unnoticed owing to the
intermittent monitoring of vital data. The delayed or missed recognition of
deteriorating patients results in serious adverse events in general wards. These
challenges have resulted in the development of a critical care outreach service.
Australia was the first country to establish critical care outreach services in
1990. In South Africa, critical care outreach services were implemented in 2005
at a private hospital in Pretoria. The researcher has noticed certain phenomena
supported by literature such as the hesitancy of nurses working in general wards
to escalate a patient to a critical care outreach service, and incorrect
interpretation of modified early warning scores which could cause delays in
patients being referred to outreach nurse experts. In this study, nurses’
(professional, staff and auxiliary nurses) experiences in respect of their self-
leadership in critical care outreach services were explored. To this end, a
qualitative phenomenological research approach was followed. Focus groups
were held with the nurses (all nurse categories) working in a South African
private hospital which provides critical care outreach services. It is
recommended that nurses be granted access to training sessions, workshops and
information to provide appropriate nursing care. Nurses should be encouraged
to focus on the positive outcomes of providing nursing care and to “applaud
themselves mentally” when they have successfully assisted or cared for their
patients. Nurses also need to identify and correct negative assumptions about
their competence.

Keywords: critical care outreach, patient deterioration, quality patient care, self-
leadership

Africa Journal of Nursing and Midwifery https://doi.org/10.25159/2520-5293/7542

https://upjournals.co.za/index.php/AJNM/index ISSN 2520-5293 (Online), ISSN 1682-5055 (Print)
Volume 22 | Number 2 | 2020 | #7542 | 19 pages © Unisa Press 2020
 Prinsloo

Introduction and Background

The monitoring of vital data of patients admitted to general wards is generally limited
to the intermittent measuring of observations and several hours can pass between
measurements, resulting in patient deterioration going unnoticed (Vincent et al.
2018, 325). The effective observation of ward patients is key in identifying any
deterioration in patients (Van Galen et al. 2016, 7). There is increasing support for the
notion that early detection and response to physiological deterioration can improve
patient outcomes (Adam, Osborne, and Welch 2017, 5). By contrast, the delayed or
missed recognition of deteriorating patients contributes to serious adverse events in
general wards, given that abnormal vital signs are observable up to 48 hours before such
adverse events (Preece et al. 2012). McQuillan et al. (1998, 1857) conclude that most
patients receive suboptimal care before their unexpected admission to intensive care,
which increases patient mortality. This resulted in the development of critical care
outreach services (CCOS).

A diversity of CCOS models has been developed around the world to optimise patient
care. Australia was the first country to establish CCOS in 1990 and named them medical
emergency teams (Baxter 2006, 613). America followed with the implementation of
rapid response teams in 1996 and England introduced patient-at-risk teams in 1997
(Marsh and Pittard 2012, 78). Canada introduced CCOS in 2006 (Upadhye, Rivers, and
Worster 2007, 34) and New Zealand in 2009 (Manchester 2015, 12). These CCOS
models were known under different names, varied in size and scope and were nurse-led
or physician-led. These diversity models all contain common elements that enable the
tracking of vital observations using an early warning score (for example, the modified
early warning score (MEWS)) as a referral algorithm which enables nursing staff in
general wards to undertake timely, suitable and personalised interventions. Globally,
several studies were done about CCOS on patient outcomes, but these studies lack
quality research on the effectiveness of CCOS (McNeill and Bryden 2013, 1662). Carter
(2008, 52) did a study in one of KwaZulu-Natal’s hospitals on the feasibility of a CCOS
service and concluded that such a service could create an opportunity to improve the
quality of care rendered to patients in general wards.

CCOS was introduced to general wards at a private hospital in Pretoria in 2005, and in
2007, the researcher joined the CCOS as an outreach nurse expert. The CCOS consisted
of professional nurses who were ICU-trained and were called by nurses (all nurse
categories) working in general wards when these nurses were concerned about a patient
or if the patient’s vital data fit the calling criteria. Initially, the CCOS (one outreach
nurse expert) was only available from 07:00–19:00 every day and in 2010 the service
was extended to a 24/7 service resulting in one outreach nurse expert available during
the day and the night shift. Nurses working in general wards were trained on the vital
data calling criteria, initially called quick response parameters that focused on the
identification of abnormal vital data to call the outreach nurse expert.

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In November 2012, the calling criteria were changed to MEWS, which aimed at the
early detection of a patient’s deterioration. After patients’ vital data were measured a
score was allocated according to the MEWS algorithm which indicated what actions the
nurse needs to take. In this hospital, if the patient’s MEWS were higher than three, the
nurse needed to call the outreach nurse expert. The outreach nurse expert with her ICU
knowledge and skills assesses the patient, guide the nurse in the ward by providing
appropriate nursing interventions to be implemented to prevent the patient from further
deteriorating, and enlighten the patient treating doctor. If needed, the outreach nurse
expert escalates the deteriorating patient to the resuscitation team if the patients’
condition requires such action. CCOS support and empower nurses in general wards
when caring for their patients.

Nurses’ performance is directly linked to a healthcare facility’s organisational

performance (Lee and Ko 2010, 840). Kim et al. (2016) confirm that nurses’ personal
leadership skills affect the quality of the nursing care they deliver, and to improve this,
they strongly recommend education in self-leadership. Neck and Houghton (2006, 270)
define self-leadership as a process through which individuals control their own
behaviour, in effect influencing and leading themselves by using specific sets of
strategies. Among these are strategies which are behaviour-focused, involve natural
rewards and revolve around constructive thought patterns (Neck and Houghton
2006, 270). Behaviour-focused strategies consist of self-observation, self-goal setting,
self-cueing, self-reward and self-correcting feedback – all of which are aimed at
promoting constructive behaviour and discouraging actions which can be deemed
unconstructive (Neck, Manz, and Houghton 2017). Natural reward strategies refer to
employees’ positive views of tasks that need to be completed, which usually involve a
belief in, commitment to, or enjoyment of, their work for its own value (Shek et al.
2015, 346). Constructive thought patterns identify dysfunctional beliefs and attitudes
among employees, and the need to replace them with positive beliefs, self-talk or mental
imagery, which involves visualising success (Neck and Manz 2013).

Leaders in organisations are expected to continuously improve their skills by practising

self-awareness, self-confidence, self-regulation and self-motivation (Hollenbeck,
McCall, and Silzer 2006). Several scholars claim that leadership also requires self-
leadership (Manz and Sims 1991, 18; Pearce 2007, 357; Reichard and Johnson
2011, 34; Rosenbach, Taylor, and Youndt 2018, 55).

For Neck and Houghton (2006, 283), self-leadership has a positive impact on individual
and organisational outcomes, which is supported by, and evident in, increased
commitment, job satisfaction, creativity and positive affect. Prussia, Anderson and
Manz (1998, 535) state that self-leadership creates a heightened sense of competence,
self-control, meaningfulness and task-related responsibility.

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Research Problem
The researcher, who was an outreach nurse expert at the time of the study on which this
article is based, took note of certain phenomena, which were supported by the literature:
(1) where CCOS systems were implemented in hospitals, there was still a marked
hesitancy on the part of ward staff to refer patients to the outreach nurse expert
(Radeschi et al. 2015, 92); (2) as Sandroni and Cavallaro (2011, 797) mention, ward
staff referred only 30 per cent of patients who were admitted to ICU without prior
planning for such an eventuality to the outreach nurse expert; (3) Van Galen et al.
(2016, 8) identify difficulties in respect of the way in which vital data observations are
taken, with staff not using early warning scoring tools correctly, nurses being uncertain
about referring patients to outreach nurse experts, and staff’s non-compliance with
protocols – all factors which cause delays in patients being referred to outreach nurse
experts.

Jeddian et al. (2017, 258) highlight two of the negative outcomes (in a CCOS) for nurses
as factors associated with an increased workload and the unwillingness of nurses
working in general wards to take responsibility for patient care. The nurses working in
the ward, and their ability to respond timeously and to refer patients who are at risk of
deteriorating (or are already deteriorating) according to the MEWS referral algorithm
to outreach nurse experts, confirms the importance of self-leadership in a CCOS
scenario.

Research Purpose
The purpose of the research on which this article focuses was to understand nurses’
experiences of their self-leadership in a private hospital in Pretoria, South Africa, in
which a CCOS is currently implemented.

Definition of Terms
Critical care outreach service: the Intensive Care Society (2015) defines CCOS as an
approach that functions at hospital level to manage patients who are at risk of
deteriorating or who are already deteriorating. It provides for their timely admission to
an ICU when needed, and offers guidance on patient nursing care and follow-up, and
the teaching and sharing of critical care skills among nurses in general wards. In this
research, the CCOS is described as an ICU-trained nurse-led service in which patients
in general wards who are at risk of deteriorating or who are starting to deteriorate are
identified by nurses (all nurse categories) working in general wards. These nurses use
the MEWS, with personalised interventions subsequently being applied according to the
needs of the patient in question, in combination with the teaching of nurses working in
general wards by outreach nurse experts.

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Outreach nurse expert: The South African Nursing Council (SANC 2012) defines a
clinical nurse specialist (CNS) as a person with a specialised qualification, in-depth
knowledge and expertise that enables her/him to focus on facility care and to work
closely with medical officers on a consultative basis. In this research, an outreach nurse
expert is a CNS with critical care skills who guides nurses to attend to patients who are
at risk of deteriorating or who are already deteriorating in the general wards of a
hospital.

Research Design
A qualitative, exploratory, descriptive contextual design was deemed appropriate for
this research. The experiences of nurses in the CCOS were explored and described to
obtain insight into the self-leadership they exercise within this context. A semi-
structured interview guide was used to conduct a total of eight focus group discussions
(FGDs) with 50 participants that lasted between 45 and 75 minutes. The coding of the
transcribed data, as obtained from the participants, was guided by open coding on
Atlas.Ti, using the computer-assisted NCT (noticing things, collecting things, and
thinking about things) analysis approach (Friese 2019, 108).

Study Setting
The research took place at a private hospital in Pretoria, with a bed capacity of
approximately 500, 6 ICU units, 2 high-care units, and a level-2 emergency department.
The CCOS was established in 2005 at this hospital to serve patients in 9 general wards
(medical (2), orthopaedic (2), surgical (3), oncology (1), and paediatric (1)).

Study Sample
The accessible population in this study consisted of 203 nurses working in general wards
at the hospital in question. For the focus groups, the inclusion criteria were as follows:
nurses from all three levels of nursing qualifications who worked in general wards and
that referred patients to an outreach nurse expert. Excluded were nurses who were not
permanently employed at the private hospital as they were not familiar with the CCOS,
ward managers, and also nurses working in ICU, high care and the emergency
department because they did not make use of the CCOS as it was implemented in
general wards.

Sample Selection
After obtaining permission to conduct research from the ethics committee of the
university, the private hospital group and the hospital management, homogenous
purposive sampling (Gray 2017, 227) was done according to each level of nursing

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qualification, as defined in the Nursing Act (RSA 2005). The participants were
approached by the unit managers and invited to participate in the study; this allows
participants to stay anonymous if they refuse to participate. Verbal and written
information was disseminated regarding the research, and all the participants had to sign
consent forms before participating. All the participants were informed of their ethical
rights, including the right to withdraw at any time without fear of repercussions.

Data Collection
The researcher made use of a highly recommended independent moderator to lead the
FGDs as most of the participants were known to the researcher and the researcher
wanted to prevent the participants from feeling uneasy if the researcher leads the FGDs.
The researcher found the moderator suitable to conduct FGDs as she had a PhD degree
in research methodology and is an expert in qualitative research. A preliminary focus
discussion (pilot) was held with the professional nurses to provide the moderator with
an opportunity to confirm the wording of the questions. This was done to advance
discussions about self-leadership in such a way as to achieve the objective of the
research. The pilot focus group reported that the questions were easy to understand, and
indicated the time required for the discussions. The FGDs were held in English as the
hospital communication policy indicated that all communication had to be in English
thus ensuring no communication barrier during the FGDs. After that, one participant
from each of the nine generals wards was invited to participate in an FGD (notably, all
of them had the same level of qualification). Table 1 provides a breakdown of the
nursing qualification levels and the number of participants in the eight FGDs.

Table 1: Focus group sample

Focus group Nursing qualification level Number of participants

1 (pilot) Professional nurses 5
2 Staff nurses 6
3 Auxiliary nurses 6
4 Auxiliary nurses 5
5 Professional nurses 6
6 Staff nurses 7
7 Staff nurses 9
8 Auxiliary nurses 6
Total 50

The FGDs were held separately for the participants from each qualification level to
make such groups homogenous – the reason being that each nursing qualification level
has a unique scope of practice. The FGDs were held during both the day and night shifts
to ensure that the experiences of both groups would be reflected in the data. The semi-
structured FGDs started with one open-ended question, namely, “How is it for you to
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lead yourself in the current CCOS in the ward where you are placed?” and followed
with probing questions. The FGDs lasted between 45 and 75 minutes. Audio recordings
of the FGDs were made, and the researcher observed participants and made field notes
during the FGDs.

Data Analysis
After each FGD the data were transcribed verbatim; any personal data that could
identify a participant were removed to preserve his/her anonymity (Hennink, Hutter,
and Bailey 2011, 215). The pilot FGD data were useful and were included in the data
analysis. The data analysis was done using the computer-assisted NCT analysis
approach (Friese 2019, 108). It is a systematic method for preparing data, creating a
project file, coding the data and sorting and structuring them to discover patterns and
relationships (Friese 2019, 108). During the data analysis, the researcher made
observations when reading through the transcribed data and field notes, and these
observations were subsequently captured by making notes or assigning preliminary
codes to them. Collecting things was done by undertaking repeated readings of the data
collected, and highlighting similarities. Next, the identified items were allocated
preliminary codes, or codes were renamed in instances in which an item did not fit under
a particular heading. The thinking process involved considering the items that had been
noted and coded to find patterns and relationships in the data from which to create
categories and subcategories (Friese 2019, 108). After that, the credibility of the coding
was checked by an experienced coder.

Ethical Considerations
Ethical clearance for this research was obtained from the Higher Degrees Committee of
the Faculty of Community and Health Sciences and the Senate Research Committee of
the University of the Western Cape (ethical clearance number 12/7/6) and the Research
Operational Committee of the private hospital group (approval number UNIV-2013-
007B).

Trustworthiness
To support the trustworthiness of this undertaking, the techniques listed by Tappen
(2016, 155) were followed. Credibility was obtained through the prolonged engagement
and persistent observation during the in-depth FGDs. Persistent observation enabled the
researcher to watch, listen, question and record the participants’ behaviours, expressions
and interactions, and to take into consideration the social setting, location and context
in which they were situated (Hennink, Hutter, and Bailey 2011, 17). During these
interactions, the researcher spent time answering any pertinent questions which the
participants had. Dependability was enhanced by digitally recording the FGDs. The
researcher adhered to the interview guide (piloted during an FGD) to confirm that the
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participants understood the questions and that the questions provoked suitable
discussions.

An audit trail (Tappen 2016, 160) was compiled of the research process, the researcher’s
thoughts and any related decisions made. Confirmability was achieved through member
checking the accuracy of the identified themes, and the researcher’s interpretations and
conclusions. A thick description of the research setting observed processes and FGDs
was done to achieve transferability. The participants and research setting were
thoroughly described, so that the effectiveness of the researcher’s reporting on the
evidence could be established for others.

Discussion of Results
Three categories, each with subcategories, emerged from the data analysis: an outreach
service as essential to delivering care to at-risk patients, the assistance or support and
guidance received from the patient outreach service team, and the challenges when
calling on patient outreach experts (see Table 2).

Table 2: Categories and subcategories

Category Subcategory
An outreach service as essential to Viewing positive outcomes/quality of
delivering care to at-risk patients patient care/patient satisfaction as
essential
Knowledge of patients’ health
conditions
Assistance and guidance received from Management of the MEWS
patient outreach nurse experts Support for nurses who ask for
assistance
Teamwork as a critical component of
healthcare
Challenges when calling on patient The role of ward nurses as part of the
outreach experts team
A need for outreach experts to
facilitate a positive outcome for a
deteriorating patient

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Category 1: An outreach service as essential to delivering care to at-risk patients

Subcategory: Viewing positive outcomes/quality of patient care/patient satisfaction as

essential

A CCOS facilitates the early detection and management of ward patients who are
deteriorating. When the study participants were asked about CCOS, they expressed the
way in which that approach, along with the outreach nurse experts, helped them to
provide nursing care to deteriorating and high-risk patients that was beneficial to
patients. As four of the participants stated:

I think the patients . . . they also feel that comfort, when they know there is someone
else that can assist them as well. (FG2; P1)

. . . we want the patient to be stable, so that is why we are monitoring all the
observations, everything, and then – if the patient is stable – then we no longer do the
outreach. The focus is on the patient [being] stable. (FG5; P2)

We [do] not hav[e] more deaths, because of the outreach services; we rarely see death[s]
in the wards. [From] what I have seen, I can say the outreach service is very good. They
improve life, really. (FG6; P4)

My concern is to take care of the patient, to make sure that the patient’s condition is
okay. If I see the patient is complicating and [his/her] condition is [. . .] unstable, then I
have to report to the sister. (FG8; P1)

The participants showed self-leadership when they acted on their impulse to call the
outreach nurse expert to help with a deteriorating or at-risk patient. This involved the
outreach nurse expert offering advice and assisting the nurses with patient management.
The outreach nurse expert thus empowered the ward nurses by supporting them in
managing the patients, thereby creating feelings of self-efficacy in those nurses and
enabling them to experience nursing care as more satisfying – this constituted a natural
reward for their efforts. Natural reward strategies, which encompass positive
experiences and views that can be linked to an employee’s responsibilities, manifest
themselves as that individual believing in, is committed to, or enjoying the actual work
(Shek et al. 2015, 346). In addition to natural rewards strategies, the participants
reported behaviour-focused strategies involving goal setting, such as taking care of
patients and calling on the outreach nurse experts – these actions positively influenced
their behaviours.

The achievement of goals provides immense personal satisfaction (Neck, Manz, and
Houghton 2017). The participants reported seeing CCOS as a beneficial service, helping
to improve patient outcomes. Arguably, the nurses “applauded themselves mentally” as
a form of self-reward for achieving goals in delivering quality nursing care. Self-reward
as a behaviour-focused strategy was apparent when the nurses successfully assisted or

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cared for their patients, and, as a result, experienced feelings of satisfaction. Hendijani
et al. (2016, 252) and Neck, Manz, and Houghton (2017) confirm that self-reward
positively influences self-motivation.

Subcategory: Knowledge of patients’ health conditions

The participants reported that they needed to take responsibility for their patients, and
to have the requisite knowledge to provide adequate nursing care.

I think we must take responsibility; we must make sure; we must know our patient.
Whatever condition changes, you must know, and even the medication you give the
patient, you must also explain, know it. We learn from our actions. (FG1; P4)

You need to know about your patients, you need to know about blood tests. If you read
[a blood test result], what does it say? If you see a doctor doesn’t want to read [it], you
see the patient looking queasy [. . .], nauseous, you make all the observations, then
you’ve got to be clever and awake enough with the blood tests. At least pick them up,
then you [will] see ‘the potassium is high’ [. . .] ‘the CRP is high’. (FG3; P5)

I think you have to know your patient and know their diagnosis because if you know
your patient, for example, let me say you are working from 1 to 4, and then there are 10
patients . . . (FG4; P7)

Neck, Manz, and Houghton (2017) view natural reward strategies as helping to create
feelings of competence and self-determination, which in turn strengthen performance-
enhancing, task-related behaviours. Nurses use self-determination as a dimension of the
natural reward strategy by taking responsibility for providing adequate nursing care to
their patients and being knowledgeable of a patient’s diagnosis and the nursing care
needed. Having the appropriate knowledge to provide adequate nursing care creates
feelings of competency and self-efficacy among nurses. Natural reward strategies are
perceived as a means of attaining those positive feelings that come from knowing you
have what it takes to understand a patient’s condition and can do something to help
him/her (Amundsen and Martinsen 2015, 317; Neck, Manz, and Houghton 2017).

Category 2: Assistance and guidance received from patient outreach nurse experts

Subcategory: Management of the MEWS

Vital data monitoring is the core of any nursing care being offered to patients. The
MEWS, which is a track-and-trigger tool that uses a patient’s vital data, was developed
to identify patients who are at risk of deteriorating or who are deteriorating. When the
participants were asked about the MEWS, they explained the way in which the scoring
system guided them when selecting the appropriate nursing behaviour in a specific
scenario:

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The MEWS score, it tells you what to do. You must call the outreach and, to be safe, on
the safety side – for yourself, for the patient . . . especially the patient. (FG1; P2)

. . . the MEWS score? It makes our life [. . .] easier. [. . .] you can see at the chart that
when the patient’s MEWS score is [. . .] 5, you can see that this patient is really in serious
trouble, so you need to activate an outreach sister so she can come. (FG5; P1)

. . . now we [have] the MEWS, the MEWS score chart, they have done the chart for our
MEWS. If the observations are like this, you can call the outreach. If [they are] like this,
you have to inform the doctors. So that chart help[s] us a lot. The MEWS chart, because
you can see if the observation is like this, it means it is abnormal, so the outreach must
be informed or the doctor must be informed. (FG6; P1)

Nurses demonstrate self-leadership through self-determination when assessing patients.

They use the MEWS as a cue to determine their next action when providing nursing
care. They set behaviour-altering goals for themselves, using concrete tools such as the
MEWS to help focus their attention on goal attainment (Ross 2015, 77). In this case, the
participants reported being able to provide appropriate nursing care to prevent
deterioration among their patients. According to Neck, Manz, and Houghton (2017),
goals are effective when used in combination with self-rewarding and self-cueing
strategies which motivate individuals to achieve those goals.

Subcategory: Support for nurses who ask for assistance

Outreach nurse experts empower nurses by providing guidance, support and assistance
when caring for patients. The study participants voiced their need for support from
outreach nurse experts:

There is somebody that you can call if you really need help or support for a patient,
because we all are RNs [registered nurses], and most of us actually know, really. We
know what to do when we are worried about a patient, but it is always nice to have
somebody that you can call, that has a little bit more knowledge and can support you.
(FG1; P4)

So it is very, very important for [the] outreach sister to be there and to guide [us],
because if you don’t know what signs to look for, the outreach sister can always say,
‘Look out for this, look out for that.’ So, she is a very important guide for us. (FG4; P1)

We have to call an outreach sister so that she can guide us here if we can do this. (FG4;
P7)

If nurses focus on the pleasant aspects of their work, such as seeing a patient recover
from illness and discharged to go home, tasks will be naturally rewarding. Neck and
Houghton (2006) believe natural reward strategies involve building pleasurable aspects
into any given task. Such strategies can include positive insights into and practices
associated with tasks which need to be accomplished. Nurses can apply these strategies

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by seeking out enjoyable tasks, or by modifying their insights into certain tasks so that
they increase their levels of self-control, motivation and fulfilment (Shek et al.
2015, 346). Besides, nurses can make use of an intrinsic reward system to help them
find something positive in even routine tasks. Empowering activities, such as the
guidance nurses receive from outreach nurse experts, create intrinsic rewards, and
feelings and thoughts of self-competence. In turn, such feelings increase motivation
(Stewart, Courtright, and Manz 2011, 189).

Subcategory: Teamwork as a critical component of healthcare

Teamwork is regarded as a complex social activity in which a group of people work

supportively to achieve a task or goal and this creates an environment for nurses to
explore current or different work practices and to confront their own beliefs and
attitudes that strengthen their practice (Nelsey and Brownie 2012, 199). The literature
links effective teamwork in nursing with high-quality patient care (Marguet and Ogaz
2019, 172). Nurses working in the wards and outreach nurse experts can work together
as a critical care outreach team to care for their patients. The participants viewed such
teamwork as follows:

It’s teamwork, it’s all about teamwork. Immediately when you work [and] you hear [the]
emergency bell . . . (P5: ‘You run!’) . . . we attend [to] that emergency bell. (FG1; P3)

So, if you make your colleagues happy and you help them [. . .] you can ask them. I very
seldom sit. You know, I always help them, and then they trust you. If something goes
wrong or they think something [is going] wrong, they go to you and they ask [for help].
(FG3; P4)

In many ways, teamwork is in itself naturally rewarding but dysfunctional teams that
lack unity hinders work performance, increase group conflict and decrease job
satisfaction (Carver and Candela 2008). Nelsey and Brownie (2012, 199) argue that
team effectiveness could be limited owing to the lack of knowledge of individuals’ roles
and responsibilities in the team. On the other hand, Rosengarten (2019, 36) mentions
that successful working in teams can be instrumental in turning unmanageable situations
for one person into a positive experience for a team. Working as a team to provide
nursing care for patients generates an enjoyable working atmosphere (Maryville
University 2018) and teamwork is associated with higher levels of job satisfaction, a
higher quality of care and improvements in patient safety (Marguet and Ogaz
2019, 172). The support, guidance and advice that nurses receive during teamwork are
naturally rewarding and keep them motivated.

Category 3: Challenges when calling on patient outreach experts

Subcategory: The role of ward nurses as part of the team

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Nurses need to be equipped with knowledge so that they have a detailed understanding
of the nursing care their patients need (James and Ella 2016, 181). Some participants
admitted that they did not always have the necessary knowledge:

. . . but the people who are doing the observations, who are reporting, they don’t have
enough information about what they are doing. (FG1; P2)

Some of the nurses, they don’t do the score right, they know they [are] going to call
outreach, so if you saw the score is 4 . . . some, they reduce it. (FG8; P7)

I can’t deny that [the] outreach sister always [. . .] sometimes I [got] the MEWS score
right, but she [corrected] me [on] some of the MEWS scores. Sometimes I do
neurological, and then I [don’t] count the MEWS score of [the] neurological
observations. [If] you find that the score is 14, [. . .] then you have to count it. [You
might get a] patient who is confused and then it is another point, it must be added there.
(FG6; P2)

Through self-observation as a behaviour-focused strategy (Neck, Manz, and Houghton

2017), the participating nurses confirmed that they sometimes lack the necessary
knowledge to manage deteriorating patients. By calling the outreach expert nurse to help
them with a deteriorating patient, nurses gain knowledge through observing the outreach
expert as a role model and taking part in providing the nursing care needed for the
deteriorating patients. When working as a team with the outreach expert nurse, the
experience and personal understanding of nurses working in general wards when taking
care of deteriorating patients are enhanced. Moule, Aveyard and Goodman (2016) claim
that nurses develop knowledge through experience and personal understanding. Nurses
need to change their behaviour and motivate themselves to call the outreach expert
nurse, to equip themselves with knowledge which is appropriate for understanding
exactly what nursing care their patients require.

Another challenge in respect of the role of some ward nurses, as part of the team, is their
lack of confidence to be assertive and to use their knowledge. This was confirmed by
one of the participants:

I think it is also a question of assertiveness. A lot of the ENs [enrolled nurses] and ENAs
[enrolled nursing assistants] come over as not be[ing] assertive and not knowing. [. . .]
It’s not that they [don’t] know what they are doing, they are so scared of the doctors and
they are not assertive. They don’t tell him, ‘Doctor, this is my name. I am going to walk
with you. Tell me what you need, tell me what I must do for the patient.’ They are not
like that. They tend to withdraw and avoid the situation. (FG2; P2)

The study participants identified a need to make use of constructive thought pattern
strategies, by employing positive self-talk to identify and replace dysfunctional
assumptions. Nurses need to be empowered so that they can substitute incorrect
assumptions and learn the way in which to be assertive and confident when performing
certain activities in a team.
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Subcategory: A need for outreach nurse experts to facilitate positive outcomes for
deteriorating patients

Outreach nurse experts support ward nurses concerning the nursing care they offer to
patients who are at risk of deteriorating. The participants regarded the availability of an
outreach nurse expert as a safety net, noting:

We really need outreach sisters as well. Sometimes there are two professional nurses in
the ward, there [are] 38 patients and we get, say, seven or eight outreaches – we can
quite cope with that. But I think, especially at night, you’ve got one professional nurse
and the ward is full and, as you say, five or six patients, then [. . .] it is very difficult to
make sure that all those patients are okay. It helps if you know the outreach sister will
come and just assess them as well. (FG2; P3)

I think one outreach in this big hospital is really not enough. An example: they are
calling her for outreach, it’s in high care . . . I mean, code blue in high care. Another
code blue is activated in the ward, but she is still busy with that code blue. What is
happening with that other [second] code blue? At this stage, must she leave the first code
blue and go to the second code blue? Must she leave the second code blue and continue
with the first code blue? I think, really, we need a second one. (FG4; P6)

The participants were positive about the availability of an outreach nurse expert to
provide support when faced with a patient with an elevated MEWS. Arguably, the
nurses thus built uplifting or confidence-boosting elements into the task of caring for
patients. Applying natural reward strategies and identifying the pleasant aspects of any
task, therefore, help the nurses to focus, and this gives rise to stronger intrinsic
motivation and self-determination (Furtner, Rauthmann, and Sachse 2015, 107).
Routine or challenging tasks, therefore, become naturally rewarding, because of the
positive aspects associated with such tasks.

Conclusion and Recommendations

The results of this research indicate that CCOS nurses mainly use natural reward
strategies in addition to focusing on the pleasant aspects of their work. Empowering
activities create feelings of self-efficacy and thoughts of competence in them, which
serve to increase their motivation. The participating nurses also reported making use of
behaviour-focused strategies such as goal setting. The MEWS is used as a cue to
determine the nursing activity (behaviour) needed to accomplish the goal of providing
appropriate nursing care and preventing patients from deteriorating. Another
behavioural focus strategy which the nurses used was self-observation, as they realised
that they sometimes lack the knowledge to provide patients with the appropriate nursing
care. It is recommended that nurses have access to training and workshops, and be
granted the necessary means to gather information on what nursing care diverse patients
need. Nurses should be encouraged to focus on the positive outcomes of providing
nursing care and to “applaud themselves mentally” when they have successfully assisted
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or cared for their patients. Nurses also need to strive to identify and replace any negative
assumptions about themselves and their tasks, to boost morale.

Limitations of the Research

This research was conducted at a private hospital in Pretoria that has a CCOS, thereby
limiting its application to other public and private hospitals in South Africa that do not
have a CCOS.

Acknowledgements
The author acknowledges the financial assistance of the National Research Foundation,
along with the academic support for obtaining the PhD degree that she received from
the University of the Western Cape.

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