VOL: 97, ISSUE: 30, PAGE NO: 36
Maurice Madeo, BSc, RN, is an infection control nurse, Hull Royal Infirmary
Maurice Madeo, BSc, RN, is an infection control nurse, Hull Royal Infirmary
This study describes the experiences of patients with methicillin-resistant Staphylococcus aureus (MRSA) being nursed in isolation and uses a phenomenological approach to identify strategies to improve their time in hospital.
Patients with MRSA are often nursed in isolation, which can result in loneliness and depression as well as stigmatization (Oldman, 1998; Knowles, 1993). Most feel infected and deprived of normal relationships, and think they are a danger to themselves and their families.
Kennedy and Hamilton (1997) studied the impact of MRSA on patients with spinal cord injury and found that they were most likely to be affected psychologically by their MRSA status and believed that it had set back their rehabilitation.
Gammon (1998) suggests that patients feel stigmatized because of their infection and that nurses who avoid contact with them may make things worse. They also believe that their medical care is affected by the fact that they have MRSA - not always for the better.
What is phenomenology?
Phenomenology focuses on perception in the study of experience and is rooted in philosophy, psychology and sociology. The phenomenological approach values the subjectivity of the experience. It demands a method of data collection and analysis that will present the participants’ experience precisely from their particular perspective (Crotty, 1996).
Seven patients aged between 19 and 72 were recruited - three women and four men. All had MRSA for at least two weeks and were nursed in isolation. They had been admitted to hospital for a range of reasons, from coronary artery bypass grafts to general surgery, orthopaedic surgery, chest infection and cardiac arrest. Those who had undergone surgery were well into their recovery phase at the time of the interview.
Ethical approval and informed consent were obtained. After the patients had been interviewed, data was collected by applying Colaizzi’s (1978) seven-step process of analysis (Box 1).
Six categories emerged from the transcripts describing the essential structure of the lived experiences of patients with MRSA (Box 2). Four of the six categories were broadly similar so two pairs were merged, leaving four main categories.
A) Understanding and the impact on visitors:
The participants’ knowledge and understanding of MRSA appeared to vary, possibly depending on whether they knew someone who had had it. One participant made the following comment, which suggested that this was the case:
‘I know someone on this ward had it before, but I couldn’t understand how he could walk about the hospital. I think he just took it upon himself.’
Some participants understood the implications of MRSA and knew that their discharge would be delayed:
‘I wouldn’t be here now if I hadn’t got MRSA.’
‘I certainly think if I didn’t have it, I would be ready for off by now. I can’t see what reason there would be for me staying in hospital if I didn’t have it.’
This would suggest that the information given to patients about MRSA sometimes fails to meet all their needs. For example, two participants made the following comments:
‘To be honest, nobody explained to you how long it would take to clear up.’
‘I can’t understand how I got it in the first place because nobody has explained it to me.’
Gammon (1999) identified the benefits of giving patients with communicable disorders adequate information to reduce their stress and anxiety and help them to cope with isolation. But this study indicates that this is not always the case in practice. For example, one participant said:
‘My daughter-in-law got information about MRSA from the internet, which reassured my wife.’
B) Hotel or prison
The participants were divided into those who preferred being on their own in a single room and those who did not like it at all. It was evident that isolation was a traumatic experience, particularly for those whose diagnosis was unexpected. Two patients alluded to this:
‘I was just laid in bed and on the ward with the rest of the patients. A nurse came and said: ‘You’ve got MRSA. We’re moving you.’ The next thing I know, the bed’s on the move and my stuff is taken out of the ward and plonked in an isolation room.
‘I was then told it was thought to be MRSA and they were going to isolate me.’
Many patients expressed their feelings about the imposed isolation. For example, two were surprised by how quickly they were cut off from everyone. Oldman (1998) found this allowed them little time to adapt to the diagnosis. Three of the participants also commented on their inability to interact with other patients, which they found troubling:
‘I can’t talk to other patients. When you’re on a normal ward you can talk to other patients and I’d much rather do that than have the TV on all day.
‘Everybody else is walking about and you’re stuck in your room.’
‘I’m not allowed to go down to the dayroom yet, so I’m waiting for the day I can.’
‘It’s just that you feel isolated, that’s all.’
Some of the participants did not mind the solitude of isolation during the early days, when their physical condition was weak. But they did feel that the days passed slowly, which they found frustrating (Gaskill et al, 1997; Collins et al, 1989).
‘I know that I have to be on my own, but it doesn’t bother me because I live on my own. I’m used to being on my own, day in, day out.’
Most participants preferred a single room as it allowed them privacy, enabling them to sleep. Four of them made the following comments:
‘I’m pleased I have a room on my own because it’s like a pantomime watching me get out of bed. So I don’t mind the room because I get some privacy.’
‘I prefer to stay in a room on my own because of my injury, not because I’m antisocial.’
‘It’s been like a five-star hotel in here.’
‘The fact is you don’t hear them all snoring and moaning all through the night.’
One of the participants equated having MRSA with being unclean:
‘It makes me feel like I am a dirty, unclean person when I see the doctors and nurses coming into the room wearing aprons and touching me with gloves.’
One of the most obvious examples of a patient’s diagnosis is the isolation sign attached to the door. Although patients have a right to confidentiality concerning their diagnoses, nurses and hospitals have a duty of care to protect other patients and visitors from exposure to infection. This creates a difficult dilemma in terms of meeting the needs of all involved. If care is not taken, patients may see the sign on the door as a breach of confidentiality:
‘I can have that door open and they all walk past and nobody walks near because there’s that sign on the door. It’s like being in bloody prison.’
Participants expressed some concerns about their treatment regimes. One made specific reference to the topical antimicrobial agents used to decolonise him, saying:
‘To be honest, it scared me having this cream up your nose.’
Nasal mupirocin is generally associated with few side-effects but it can cause erythema, burning or stinging, pruritis and dryness (Bertino, 1997). These side-effects should be mentioned to the patient to prevent non-compliance.
Patients and their families do not always receive sufficient or appropriate information on MRSA (Perry and Gore, 1997). Failing to meet patients’ needs by supplying them with adequate information could be related to the ignorance of staff on the effect of the infection on patients’ lives, specifically when they are physically isolated. Isolation may be less traumatic if patients are given time to adjust to the idea and adequate provision is in place to make it bearable.
Frequent visits from staff during the day help to relieve the boredom and prevent patients from feelings neglected. Visitors should be encouraged to visit at different times spread out through the day so that they break the monotony.
Patients who are isolated for long periods are more susceptible to altered mood states that manifest as depression and withdrawal.
Patients generally feel that the stigma of diagnosis affects the attitudes of staff and the quality of their care (Knowles, 1993; Oldman, 1998).
Health care staff need to be made aware of how patients feel when they are isolated with MRSA so that strategies can be implemented to make their stay in hospital as pleasant as possible. Effective communication, including information on treatment, unrestricted visiting and staff being accessible to patients and visitors, will improve the quality of care delivered and make the patient’s stay a more pleasurable one.