Designing Job Descriptions for Toxicology Nurses

This study aimed at designing job descriptions (JDs) for toxicology nurses at NECTR Cairo University Hospitals. The Center composed of ICUs (24beds) and ER (4beds).Throughout the “developing of JDs" the methodological design was used. The Sample composed of all Nursing Staff at NECTR (N=30). The Nursing Activity Checklist and Job Analysis Questionnaire tools were developed, with 12 dimensions and 123 items and had an excellent reliability and validity. The Nurses’ roles were described and identified for the highest and lowest tasks, to examine the frequency, importance, and difficulty of each task. Thus each category had various duties and tasks. Based on the Jury/ experts' opinions, the investigator developed validated JDs for Toxicology Nurses (DON, Deputy DON, Charge Nurse and Staff Nurse). The educational sessions were successful in increasing the nurse's knowledge about the newly designed JDs. This study concluded that it is necessary to implement the designed JDs and develop educational programs to improve the nurses' disabilities at NECTR.


Introduction
In the most basic sense, a lack of a job description (JD) may make it difficult for an employee to have an accurate and complete understanding of his or her role.JD is a structure standard that should outline the required knowledge, skills, abilities, duties, responsibilities, performance and scope of authority for specific position to ensure that the correct people are hired for the job (Brannick, Levine, & Morgeson, 2013;Sullivian, & Decker, 2013).Nevertheless, some JDs are completely separate from the standards of practice with no indication of the expected job behavior related to each position defined in the standard (Jernigan, & young, 2010).
JD involves also establishing rational basis for the salary structure, clarifying relationship between jobs, analyzing employees duties, evaluating job performance, orienting new employees, assisting in hiring and placement, establishment lines of promotion, identifying potential training needs, critically reviewing existing work practices, providing data as to proper channels of communication, developing job specification, serving as a basis for planning staffing levels, all are the most vital requirements and responsibilities are the part of the job and directly linked to the achievement of the goals of the organization (Brannick et al., 2013;Sullivian, & Decker, 2013).
In fact, job analyses is used to identify the differences and similarities among different positions, achieve knowledge and requirements on jobs to prepare a JD and job evaluation (Palmer, 2010;Royer, et al., 2010;Vati, 2013).According to Cucina, Martin, Vasilopoulos, and Thibodeuax (2013), there are two broad categories of job analysis elements, job oriented and worker oriented.Job-oriented elements focus on the job itself and the work or tasks performed by incumbents, whereas worker-oriented elements focus on collecting information regarding the competencies required in performing a job.
The American Nurses Association (ANA), (2010), was the first association to design the standard of nursing practice for all areas including emergency nursing practice and intensive care nursing practice.As stated by Hardingham and Lorine (2009); Mamseri and Mc Bezuidenhout (2012), these standards were divided into four phases related to the steps of nursing process to meet the needs of nursing services.The standards provide a method to ensure that patients are receiving high quality of care and that the nurse knows the essentials to provide nursing care (Youngjin et al., 2014).

Statistical Analysis
The data pertinent to job analyses were scored, tabulated and analyzed by computer using the statistical package for the social sciences (SPSS) Program version 21.

Results
In this chapter the results and analysis for this study are presented as follows: Part one.Characteristics of the participants (table 1).
Part two.Descriptive analysis of participants tasks according to its importance and frequency from table 2.1 to 2.12.
Part three: Statistical distribution of participants' knowledge Pre/posttest (table 5.2).

Discussion
As previously outlined, the present study found that more than Two-Thirds of the considered sample were females, this result is congruent with many researchers in Egypt; Abudahi, Fekry and Elwahab (2012); Rushdy, Youssef, Morsy, and Elfeky (2014).Concerning to the age group, Two-Thirds of the sample were in the age group between 20 to 40.This finding is in agreement with that of El Feky, and Ali (2013), who found that participant' ages ranged from 20 to 40 years.Regarding qualifications 83.4% of the considered sample had the secondary school of nursing diploma (SSND) and 13.3% were Technical Institute Diploma, only one (DON) with Master Degree in Pediatrics (DON) and no nurses with BSN degree.This was not surprising because nursing syndicate registered 240,000 nurses (95%) of them were SSND and 5 % were BSN (Egypt Nursing Profile, 2012).
The study result found that almost half of the nurses had no training courses in toxicology field.According to the nurses who attended previously, the provided courses were conducted in English, it was beyond their level of education and was difficult for them to understand.These findings were supported by; El.Sayed, et al. (2015), who found that critical care and emergency nurses dealing with poisoned patients in the same place at NECTR had an inadequate practice and knowledge, about detection and management of poisoning patients.Most of the nurses verbalized that they acquired the work experience at the setting and no need to attend further training, because they are the source of information.
As presented by Taha (2004), who studied the effect of the training program provided for 36 nurses assigned in critical care units.The study was successful with highly significant statistical differences in improving the knowledge of the nurses after the application of the training program.Moreover One -Thirds of the nursing staff salary was less than 1500 Egyptian pound per month; the low salary could be one of the major reason for NECTR nurses doing dual work in private hospitals, to support their families.
The finding of the study indicated that the following tasks had the highest frequency: The staff nurses at NECTR make patients' assessment by getting simple information like the patient's verbal response, taking the data related to the time of administration, route and dose, but not using Glasgow Coma Scale.This finding oppose Santos et al (2016), who found that the majority of nurses (more than 80%) in ICUs has good knowledge about (GCS) Glasgow coma scale; Also taking vital signs is a simple task and considered as an essential element for decision, planning of treatment and resuscitation procedures of the toxicology patient.
Nurses usually in a hurry to finish the endorsement report and many studies suggested that leadership is vital for effective handover, the presence of the nurse in charge at a handover demonstrates a commitment to the process and provides the nurse with an overview of the clinical area (Riesenberg, Leitzsch, & Cunningham, 2010).NECTR nurses consumed a lot of time in filling different forms with redundancy of information.
Additionally, Dingley, et al (2008), found that observations and combination of knowledge sources can identify changes in the patient's clinical status, enabling fast interventions to prevent further deterioration if detected and reported quickly to the treating physician for action.Medical rounds also, provide a huge opportunity for interprofessional learning for the whole multidisciplinary team and for review of patients pre-discharge; and progress (Royal College of Physicians, 2012).
The nurses at NECTR used to leave the unit to collect the medication from pharmacy, some medications were out of stock and requested from the family to purchase.While medication administration has to be given according to the physician instructions, it happened on several occasions that the ER nurses, administered medication to the patient without prescribed order.The last incident happened when the doctor was not around and according to the participants, "if the assigned nurses asked the family to wait for the physician, they will be attacked by them".Although this action could be interpreted as practicing medicine by nurses and possibly lead to a serious penalty.In this respect, NECTR nurses need to stay within their scope of practice and at the same time to be supported by protocol and policy to avoid medication errors and being accused of exceeding the scope of practice (Buppert, 2015).
In line with the protection of the patient privacy and confidentiality; It is amazing about the restricted role at NECTR, nobody can release any information without the permission of the Director.Furthermore, wearing uniforms with identification card was strictly followed by the nursing staff with absence of policy.The nursing uniform support the specialized uniqueness in healthcare, it raises a positive self-image, and considered as a clue to self-confidence and better presentation of nursing profession in the hospital (Desta, Gebrie, & Dachew, 2015).
Concerning, lifting and transferring the patient from department to another considering safety precaution.Waters, Hughes, and Menzel (2009) stated that nurses should be engaged with the risk assessments in the workplace, selection, and use of the suitable lifting devices and apply evidence-based practices for handling patients.Also, the tasks of delivery of samples to the laboratory, and equipment and supplies to the relevant units, have to be delegated to the nursing assistant to free NECTR nurses for patient care.
The purpose of performance evaluation of nursing personnel is to identify the areas of strengths and weaknesses.The DON at NECTR mentioned that the incentives of nursing staff are connected with their annual appraisal.It was a surprise that the DON at NECTR had no official responsibilities in her performance appraisal form, to be accountable for developing nursing policies and procedures, ensures its availability and implementation.
The finding of the study indicated that the following tasks had the least frequency: Regarding the assessment of injury prevention measures like suicidal attempt the NECTR administration installed windows protection in the second floor to protect patients with suicidal attempt, after an incident happened to a female patient jumped from the window (two years ago).The third floor, still without windows protection.It was noticed by the research investigator that most of the ICU beds had no side rails to protect the patients from falls.Some of the factors involved in these falls were: communication failures, lack of adherence to protocols and safety practices, inadequate staff orientation, and lack of leadership (JC, 2015;Viernes, 2016).
For certain circumstances related to the poisoning patients, the nurses were not able to involve the family in their care.According to Fateel and O'Neill (2015), who presented that; nurses are responsible to ensure patient' centered care is practiced, the international standards of practice for role clarification to be followed, and to involve the family and patient' in the care.
Additionally, NECTR nurses need to give priority to the toxicology center in responding to an emergency.Some of the nurses verbalized that, they had no time to respond to the emergency call.While the CPR certificates were expired, nurses must update their CPR and also the absence of record at NECTR about, whether the previously performed CPR was successful or not as an assessment of the team performance to plan for better practice.
Nurses at NECTR were blamed for several incidents related to the absconded patients.The administration used locked door instruction without written policy to prevent such incidents and give more responsibilities to nurses to control the traffic.The nurses verbalized, that they were not happy to do the job of the security guard and had no time to do other people work.According to many authors, the physical violence against nurses was experienced more frequently in Egypt (62%) (Pinar & Ucmak, 2011).
Nurses at NECTR used to give antitoxin medication to the poisoning patient without skin test and also ignoring to monitor the patient under observation.Such behavior could jeopardize the patient safety (Saminathan, et al., 2015).Some nurses said that this item is the duty of the physician to make the skin test, due to their disabilities to perform the task.Few senior nurses justified the reasons because of the float system, the floated nurse to ER had no idea about skin test and gastric lavage.Tsang, et al (2014), stated that an effective supervision system is required with regular training.
Nevertheless, the participants at NECTR verbalized that the information given as intragroup communication were lacking of transparently and team work, mainly between the groups of nursing staff.Teamwork is frequently considered as the best way to deliver higher performance; increase communication and innovation, continuous progress, increased work satisfaction, improve service quality, lower level of absenteeism, promote staff retention and increase workplace productivity (Kaya, et al., 2013).
Regarding responding to call and inquiries from patients and families.The finding is congruent with the study of Loghmani, Borhani, and Abbaszadeh (2014), who found poor attitudes toward the patients and their families and strictly recommended about the application of the nursing code of ethics and the manager to use corrective action as required, in order for nursing staff to realize, that patient and his family are the center of care in the organization.
Furthermore, the hand wash is well known to be one of the key modes of decreasing health care associated infection and improving patient safety (WHO, 2009).The nurses at NECTR were reluctance to wash their hands between patients.The finding of this study indicated the absence of infection control manual at NECTR.Moreover, the task of food distributing is the responsibility of the dietary department.Schubert, et al. (2008), stated that patients have the rights to be well nourished in clean environment with good personal hygiene.
Though, most of the nurses raised their concern about the dysfunction equipment, the delivery of unfitting spare parts and misplaced equipment.Also, no available computer for nursing staff, to facilitate their work in relation to statistics, lab request, admission, discharge.It is cost effective in the long run, the center can start gradually, to save the nurse' time.
While the NECTR nurses had unsolved conflicts within the groups of nurses in different shifts and between nurses and physicians due to the absence of JDs for the role clarification, policies, procedures and standard of care to control the staff behavior.Such conflicts can arise from the individual's inability to accept various roles, which can lead to stress.Effective negotiation skills resolve conflicts and encourage collaboration, therefore producing a favorable work environment (Nayeri & Negarandeh, 2009).
Hence, all nursing and personnel policies and procedures including vacation policy are necessary to be communicated, and implemented, detailing how much time of each staff member gets and how far in advance they need to request it (Desuyo, 2009).Vacation plan will never function at NECTR with; high absenteeism, abuse of sick leave, maternity leave, emergency leave, and so on… the inability of the nursing administration to replace the staff.Also, the absence of delegation policy, creating a role of ambiguity, when the nurses and general assistance did not know their roles and responsibilities with the big picture of the absence of JDs.
Additionally, no fixed schedule, agenda, and meeting minutes as a record keeping for DON meetings with the staff nurses at NECTR.Also, the absence of a periodic report.The nursing staff at NECTR had high absenteeism and poor attendance rate, some nurses said: "they have to stay more hours waiting for the nurses' arrival of next shift, so they have to compensate by doing the same".Cohen and Golan (2007), found that absenteeism worsens the difficulty of care delivery in many nations, where the number of nurses available is inadequate to meet all the healthcare difficulties of the population and the health care organization.
The finding of the study indicated the absence of nursing policies related to quality management, infection control, and the safety rules.The role of the leader is to establish the clinical practice policies to guide and motivate nurses -follow the standard of practice, for the organizational control.The DON had no authority to participate in the annual budget at NECTR.According to Gealan, and Patricia (2013), the operating budget is the main budget for the nurse managers and leader to maintain an active role in controlling personnel and supply costs, with the collaboration of nursing staff in all units.Also, the nurses at NECTR had no knowledge regarding disaster plan, this result is similar to the study done by Paganini, et al (2016), who found the staff on duty had poor knowledge of disaster plan.Thus, the leader responsibilities to develop a disaster plan, train and educate the staff, give feedback and ensure, that the plans are known to all nurses.
The responsibility of DON to work on nurses satisfaction includes measures to reduce work-related stress, opportunities for training and development, mentoring, orientation programs, social support, feedback and positive staff motivation by an acknowledgment from the nurse managers and experienced colleagues (Flinkman, et al. 2014).Effective leadership is critical in generating opportunities which create the potential for professional self-development for junior staff (Allan, et al, 2008).Furthermore, the DON has to recognize the importance for the nurses to participate in scientific research and studies to improve their performance.

Conclusion:
In this study, the validated tool of 12 dimensions and 123 items were utilized as a base for designing JDs for Toxicology Nurses (DON, Deputy DON, Charge Nurse and Staff Nurse) at NECTR.General Systems Theory (GST) was used as a process to follow and facilitate the understanding of the sequence for developing JDs.The duties and tasks of toxicology nurses were identified and extracted from the analyzed tools (JAQ& NAC), grouped and organized according to the variance of the nurses' levels of professional category.The nurses' roles were adjusted and described by focusing on these tasks that NECTR Nurses considered as the most importantly, with the highest in frequency.The nurses' knowledge, skills and disabilities were observed by the research investigator.This study proposed that educational programs in Arabic are mandatory to improve nurses disabilities and unnecessary tasks not related to nursing should be assigned to other non-nursing staff.Thus the toxicology nurses at NECTR will be able to concentrate on their essential tasks corresponding to the newly designed JDs.The most important area required improvement opportunities as previously discussed is to expand the management and leadership roles of nursing administration at NECTR.
Therefore, the study indicated the following components of the JDs for nursing categories (table 2.1to 2.12).

Table A .
Scoring System According to the Mean Value: (Statistical institute -Cairo University, 2016).*M= mean value
(a) BSN: Bachelor Science of Nursing.(b) SSND: Secondary school of nursing diploma.

Table 2 .
2 Descriptive Analysis of "Nursing Care Plan' Tasks".(N=30).Administer IV fluids and use scientific, correct ways in mixing solutions.4.73 0.58 4.13 1.25 10 Keep and give narcotic medications according to the instructions and regulations of the toxicology center.Adhere to the ethics and behavior of the profession, preserves the dignity and respect for patients, and use the correct phone etiquette.Respond to call and inquiries from patients and their families.Explains the steps of patient' care, and give awareness of health to patient and his relatives.