EXPLORATION OF INTENSIVE CARE UNIT NURSES’ OPINION AND BARRIERS EXPERIENCED TOWARD COSTING IN A CENTRAL HOSPITAL IN GAUTENG Cindy D. Veran A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfilment of the requirements for the degree of Master of Science in Nursing Johannesburg, 2019 ii DECLARATION I, Cindy D. Veran, hereby declare that this research report is as a result of my own work. It is being submitted for the degree of Master of Science (Nursing) at the University of the Witwatersrand, Johannesburg. It has not been submitted anywhere else for candidature for any degree programme or examination at the university. Signature…………………………………………………………… Date…………………………………………………………………. Protocol Number M170861 iii DEDICATION Om Nama Sivaya, To my late parents, for teaching me the importance of education and perseverance. To my children, for their patience, love and support. To all the earth bound Angels that provided the encouragement and positive reinforcement when I needed it. iv ACKNOWLEDGEMENTS I would like to Thank the following people for all their support:- To Ms. Viv Herbert, my heart-felt appreciation, for picking me up when I was down. To Prof. Shelley Schmollgruber for all the support and guidance. To all the nurses who volunteered their time and effort to be interviewed. To all my friends and colleagues that supported me during my studies. v ABSTRACT Background: The cost of healthcare is rising worldwide and placing a heavy financial burden on health systems and populations globally, nationally and locally. In 2007, the Gauteng Health Department introduced the “Uniformed Patient Fee Scheduled Charge Sheet” (UPFS) for tertiary, regional and district hospitals, whereby every health-service activity rendered to the patient is costed daily by the nursing personnel. However, since the introduction of the UPFS in the government sector hospitals, no studies have been done in South Africa, on the opinion of Intensive Care Unit (ICU) nurses in public hospitals with regard to costing for the healthcare rendered. Aim: The purpose of this study was to explore the opinion of ICU nurses and the barriers experienced towards costing in a Central Hospital in Gauteng. Design: An exploratory qualitative design. Methods: Professional nursing staff was chosen from the nursing staff working in ICUs. A purposive sample was selected as determined by data saturation. Semi- structured interviews were conducted on twelve (N=12) participants, over four months. Data analysis was done using Clarke and Braun’s (2013) thematic analysis. Lincoln and Guba’s (1985) method of trustworthiness was applied. Findings: The study demonstrated that ICU nurses focus is quality, safe patient care. ICU nurses have negative and positive feelings associated with costing whilst understanding the reasons for costing. Despite being overloaded with work, ICU nurses are prepared to assist with the costing but felt that the multidisciplinary team should be responsible for costing for activity-based costing and not just the ICU nurse. Factors that influenced costing negatively were identified as ethical dilemmas, workload issues, continuity of care, lack of consultation, lack of support and inappropriate use of resources. Facilitators of costing were identified to be role clarity and responsibility, the costing process, review of the costing document and system review. Recommendations: Role clarification and responsibility is vital. Review and standardization of the costing document, costing process and system needs to be done. Management support is vital for changing attitudes towards costing and setting up and implementing evidenced-based accurate costing using a resource specialist in the ward. The multidisciplinary team’s responsibility and accountability to resource costing will lighten the work load for ICU nurses with. Further research would be beneficial in developing a source document, testing its applicability in the broader population with further testing of its efficacy. Conclusion: ICU nurses feel that the successful control of activity-based costing at the patient’s bedside is vital as this affects the budget and resource allocation. This is, however, dependent on multidisciplinary teamwork and management support. Key words: hospital costing, intensive care units, nurses, South Africa vi TABLE OF CONTENTS Page DECLARATION ii DEDICATION iii ACKNOWLEDGEMENTS iv ABSTRACT v TABLE OF CONTENTS vii LIST OF FIGURES xi LIST OF TABLES xii LIST OF ABBREVIATIONS xiii CHAPTER ONE: OVERVIEW OF THE STUDY 1.0 INTRODUCTION 1 1.1 BACKGROUND OF THE STUDY 1 1.2 PROBLEM STATEMENT 3 1.3 PURPOSE OF THE STUDY 5 1.4 OBJECTIVES 5 1.5 SIGNIFICANCE OF THE STUDY 5 1.6 RESEARCHER’S ASSUMPTIONS 5 1.6.1 Meta-theoretical Assumptions 6 1.6.2 Theoretical Assumptions 6 1.6.2.1 Operational Definitions 8 1.6.3 Methodological Assumptions 11 1.7 OVERVIEW OF THE RESEARCH METHODS 11 1.8 OUTLINE OF THE STUDY 12 1.9 SUMMARY 12 CHAPTER TWO: LITERATURE REVIEW 2.1 INTRODUCTION 13 2.2 COSTING AND RELATED CONCEPTS 13 2.2.1 Costing 13 2.2.2 Activity Based Costing (ABC) 14 2.2.3 Application of ABC in ICU 15 2.2.4 Application of ABC in healthcare 15 vii 2.3 LEGISLATION, POLICY AND STANDARDS 16 2.4 REASONS FOR INTENSIVE CARE UNIT COSTS RESEARCH 18 2.5 FACTORS IMPEDING COST CONTAINMENT 19 2.5.1 Workload issues 19 2.5.2 ICU cost drivers 20 2.5.3 Ethical dilemmas 20 2.6 FACTORS FACILITATING COST CONTAINMENT 21 2.6.1 Teamwork 21 2.6.2 Process of change 21 2.7 STRENGTHS AND WEAKNESSES OF LITERATURE 22 REVIEWED ABOUT COSTING 2.8 SUMMARY 23 CHAPTER THREE: RESEARCH DESIGN AND METHODS 3.1 INTRODUCTION 24 3.2 RESEARCH DESIGN 24 3.3 RESEARCH METHODS 25 3.3.1 Population 26 3.3.2 Sample and sampling 26 3.3.3 Data collection 27 3.3.3.1 Instrument 28 3.3.3.2 Procedure 28 3.3.4 Data Analysis 29 3.4 ETHICAL CONSIDERATIONS 31 3.4.1 Permission to conduct study 31 3.4.2 Informed consent 32 3.4.3 Confidentiality 32 3.4.4 Anonymity 32 3.4.5 Storage of data 32 3.5 MEASURES OF TRUSTWORTHINESS 33 3.6 SUMMARY 35 CHAPTER FOUR: FINDINGS 4.1 INTRODUCTION 36 4.2 RESEARCH PARTICIPANTS 36 4.3 DEMOGRAPHIC PROFILE OF PARTICIPANTS 36 4.4 THEMES EMERGING FROM THE INTERVIEWS 37 viii 4.4.1 Theme 1: Understanding of costing 39 4.4.1.1 Sub-theme: Reasons for costing 39 4.4.1.2 Subtheme: Feelings associated with costing 40 4.4.1.3 Sub-theme: Teamwork 43 4.4.2 Theme 2: Factors that influence costing negatively 44 4.4.2.1 Sub-theme: Ethical dilemma 44 4.4.2.2 Sub-theme: Workload issues 46 4.4.2.3 Sub-theme: Continuity of Care 49 4.4.2.4 Sub-theme: Consultation 51 4.4.2.5 Sub-theme: Lack of support 54 4.4.2.6 Sub-theme: Appropriate use of resources 58 4.4.3 Theme 3:- Facilitators of costing 63 4.4.3.1 Sub-theme: Role clarity and responsibility 63 4.4.3.2 Sub-theme: Costing Process 69 4.4.3.3 Sub-theme: Review of document 72 4.4.3.4 Sub-theme: System review 75 4.5 SUMMARY OF MAIN FINDINGS 78 4.6 SUMMARY 79 CHAPTER FIVE: DISCUSSION OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS 5.1 INTRODUCTION 79 5.2 DISCUSSION OF FINDINGS 79 5.2.1 Understanding of costing 79 5.2.1.1 Reasons for costing 79 5.2.1.2 Feelings associated with costing 81 5.2.1.3 Teamwork 84 5.2.2 Factors that influence costing negatively 86 5.2.2.1 Ethical dilemma 86 5.2.2.2 Workload issues 88 5.2.2.3 Continuity of Care 89 5.2.2.4 Consultation 91 5.2.2.5 Lack of support 92 5.2.2.6 Appropriate use of resources 93 5.2.3 Facilitators of costing 93 5.2.3.1 Role clarity and responsibility 94 ix 5.2.3.2 The Costing Process 95 5.2.3.3 Review of document 96 5.2.3.4 System review 97 5.3 LIMITATIONS 99 5.4 RECOMMENDATIONS 100 5.4.1 Management 100 5.4.2 Clinical Practice 102 5.4.3 Education 103 5.4.4 Further Research 103 5.5 CONCLUSION 103 LIST OF REFERENCES 107 APPENDICES Appendix A Information letter to participant in research study 111 Appendix B Consent form to participate in study 112 Appendix C Consent form for recording of interview 113 Appendix D Demographic Sheet 114 Appendix E Semi-structured interview process 115 Appendix F Semi-structured interview guide and probes 116 Appendix G Example of Interview 118 Appendix H Ethical clearance certificate 132 Appendix I Hospital approval letter 133 Appendix J Language editing and proofing 134 x LIST OF FIGURES Figure 2.1 Activity based costing (ABC) versus traditional cost accounting (TCA) Systems 14 Figure 3.1 Six Phases of Thematic Analysis 29 xi LIST OF TABLES Table 4.1 Qualifications and experience of ICU nurses 37 Table 4.2 Themes, sub-themes and categories from the semi-structured interviews 39 xii LIST OF ABBREVIATIONS ABC Activity Based Costing CCN Critical care nurse CNS Clinical nurse specialist DRG Diagnostic related grouping ICN Intensive care nursing ICU Intensive Care Unit NHI National Health Insurance PFMA Public Finance Management Act SANC South African Nursing Council TCA Traditional cost accounting UPFS Uniform Patient Fee Structure WHO World Health Organisation CHAPTER ONE OVERVIEW OF STUDY 1.0 INTRODUCTION This chapter will provide an overview of the importance of this study by looking at the background, problem statement, purpose, objectives, significance, researcher assumptions, and overview of methodology, trustworthiness and ethical considerations.