Paper Title (use style: paper title)

What nurses miss most: International Network for the Study of Rationalized Nursing Care-Multi-study results Eileen Willis School of Health Sciences, Flinders University Adelaide, Australia [email protected] Patti Hamilton College of Nursing Texas Woman’s University Denton, Texas, United States of America [email protected]. Julie Henderson School of Nursing & Midwifery Flinders University Adelaide, Australia [email protected] Ian Blackman School of Nursing & Midwifery Flinders University Adelaide, Australia [email protected]

Abstract— This paper reports on a study that extended Kalisch’s work on missed nursing care to the South Australian context. Data were collected through the administration of the MISSCARE Survey with permission to administer the Survey obtained from Beatrice Kalisch. Our Australian-based international team modified the demographic section of the survey to better fit with local terminology and work environments and added separate questions to capture differences in missed care across all three shifts. The survey was administered using the online survey tool, Survey Monkey. Recruitment occurred through the Australian Nursing and Midwifery Federation (SA Branch) [ANMFSA]. Participants were asked to indicate on a five point scale where 1 is never omitted and 5 is always omitted, the frequency in which different aspects of care were missed. The tasks that are most frequently reported as being omitted are ambulation of patients (3.26) and mouth care (2.84). At the other end of the scale the tasks reported as least often omitted are blood glucose monitoring (1.99); hand washing (2.14); and IV/central line care (2.29) and providing PRN medication within 15 minutes (2.32). Given that bathing patients (2.30) and providing PRN medication within 15 minutes (2.32) are reported as being missed less frequently suggests that when nursing time is rationed priority is given to clinical and basic nursing care over tasks which may be less immediately important for patient well-being. Nurses were also

Luisa Toffoli School of Nursing & Midwifery University of South Australia Adelaide, Australia [email protected] Clare Harvey School of Nursing & Midwifery Eastern Institute of Technology Hawkes Bay, New Zealand [email protected] Elizabeth Abery School of Health Sciences Flinders University Adelaide, Australia [email protected] Claire Verrall School of Nursing & Midwifery Flinders University Adelaide, Australia [email protected]

asked to provide explanations for why care might be missed. ‘Unexpected rise in patient volume or acuity’ (54.2%), ‘heavy admission and discharge activity’ (44.8%); ‘inadequate numbers of staff’ (43.4%), ‘urgent patient situation’ (39.8%), and ‘inadequate number of assistive and/or clerical personnel’ (40.2%) were identified as significant reasons for missed care. A path analysis indicated a strong relationship between these four reasons and a lack of human and physical resources that compounds work intensification and missed care. This paper is the base line study for the International Network for the Study of Rationalisation of Nursing Care (INSRNC) and points to increasing work intensification for nurses. Keywords-Australia, missed nursing care, nursing, Path analysis, workforce

I.

INTRODUCTION

Over the last three decades in advanced Western economies there has been a move to curtail health care costs as a result of shifting patient demographics, increased costs of medical technology and rising consumer expectations. Strategies employed to rein in these costs have included 1) rigorous use of evidence-based medicine, 2) advances in medical technology and procedures allowing for shorter hospital stays

and 3) more emphasis on efficient processes 1 2 3 . Human resource strategies have included the creation of new occupational groups to manage an increase in the division of labour enabling some tasks to be assigned to less expensive care attendants, nurse practitioners and physician assistants 4 . In Australia and New Zealand industrial agreements have sought to increase productivity and workforce efficiencies of all health professionals. These industrial strategies have include functional flexibility models of care redesign that have up-skilled the work of particular occupational groups enabling less costly professionals to do the work, e.g. extended care paramedics taking up the roles of doctors, or reduced costs through further divisions of labour 5. The outsourcing of nonclinical tasks such as cleaning and food services once done by nurses, to lower skilled and less costly occupational groups is another example. A further strategy has been numerical flexibility whereby staffing numbers have been reduced or reassigned to meet the peaks and troughs of throughput, resulting in workers taking up temporal flexibility schedules (part-time, split shifts and casual forms of employment) to meet productivity demands 6 7 . In this paper the focus is on the impact of work intensification whereby the pace of work is accelerated to meet productivity demands impacting on missed nursing care. This paper reports on nurse’s views of what care is missed and how they explain omitted care in this context. We argue that missed care is an unforseen, but logical outcome of work intensification. II.

MISSED CARE

8

Kalisch’s qualitative study of missed nursing care marked the beginning of the general use of that term, although she 1

Alameddine, M., Baumann, A., Laporte, A., & Deber, R. (2012) A narrative review on the effect of economic downturns on the nursing labour market: implications for policy and planning. Human Resources for Health, 10:23 doi:10.1186/1478-4491-10-23 Retrieved January 20, 2014, from http://www.human-resources-health.com/content/pdf/1478-4491-10-23.pdf.

2

Duffield C., Gardner G., & Catling-Paull, C. (2008) Nursing work and the use of nursing time, Journal of Clinical Nursing 17(4): 3269-3274. 3

Willis, E. (2009) Purgatorial time in hospitals. LAP Lambert Academic Publishing AG & Co. KG, Germany.

drew on work by Sochalski 9 . Using focus groups, she identified nine key areas of regularly missed nursing care. These were ambulation, turning, delayed or missed feedings, patient teaching, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance 10. Kalisch 11 labelled missed care as an error of omission. Seven reasons for missed care were also identified: too few staff, time required for a nursing intervention, poor use of existing staff resources, ‘it’s not my job’ syndrome, ineffective delegation, habit, and denial. She subsequently went on to develop an instrument to quantitatively measure missed nursing care, the MISSCARE Survey – a two part tool measuring missed nursing care (Part A) and reasons for missed care (Part B). 12

Using the MISSCARE Survey, Kalisch and her colleagues then studied a large sample of nursing staff over three hospital sites, reporting a significant occurrence of missed nursing care. They established the antecedents to missed care as being labour resources, material resources, and communication, and found consistency in these antecedents across all sites 13 . To substantiate these findings, the MISSCARE Survey was administered to nursing staff in 10 acute care hospitals, examining possible variation of missed care across hospitals. A pattern of missed nursing care was found across all hospitals with common reasons for missed care cited at all sites 14. In 2009, Kalisch and colleagues argued that missed care was a global phenomenon 15 and her subsequent work has confirmed this claim. To date, she and her associates have conducted two large scale studies across 13 hospitals in the United States, along with international studies in Turkey, Iceland, Lebanon, Chile 16 and Brazil. 17 These and other

9 Sochalski J. (2004) Is more better? The relationship between nurse staffing and the quality of nursing care in hospitals. Medical Care. 42(2):II-67-73. doi: 10.1097/01.mlr.0000109127.76128.aa 10

Kalisch, B. (2006) Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.

11


12

Kalisch, B.J, & Williams, R.A. (2009) Development and psychometric testing of a tool to measure missed nursing care. Journal of Nursing Administration, 39(5), 211-219.

13

Kalisch, B.J, & Williams, R.A. (2009) Development and psychometric testing of a tool to measure missed nursing care. Journal of Nursing Administration, 39(5), 211-219.

4

Nancarrow, S.A. & Borthwick, A.M. (2005). Dynamic professional boundaries in the healthcare workforce. Sociology of Health & Illness, 27(7), 897-919. 5

Willis, E., Henderson, J., Walter, B & Toffoli, L. (2008) Development of a staffing methodology equalisation tool for community mental health and community health nurses. South Australia: Final Report, SA Department of Health, Adelaide. Retrieved January 20, 2014, from http://www.nursingsa.com/pdf/Office/doh-2624%20final_report_FA.pdf 6


14 Kalisch, B.J., Tschannen, D., Lee, H., & Friese, C.R. (2011) Hospital variation in missed nursing care, American Journal of Medical Quality, 26 (4), 291-299. doi: 10.1177/1062860610395929.

7

Toffoli, L., Rudge, T. & Barnes, L. (2011) The work of nurses in private health: accounting for the intangibles in care delivery. Health Sociology Review 20(3): 338–351.

15 Kalisch B.J., Landstrom G.L., & Hindshaw, A.S. (2009) Missed nursing care: a concept analysis. Journal of Advanced Nursing 65(7), 1509-1517 doi: 10.1111/j.1365-2648.2009.05027.x

8


16 Kalisch, B. (2012) Caring about a better outcome. Nursing Standard, 26(44), 62-63.

studies published by Kalisch identify a relationship between missed care and lack of teamwork, 18 appropriate leadership interventions for dealing with missed care and teamwork, 19 the impact of nursing staff turnover on missed care 20 and nurse staffing levels. 21 22 Kalisch has also extended her investigations to oncology units, 23 staff satisfaction 24 and to differences between Magnet and non-Magnet hospitals. 25 Independently of Kalisch and her colleagues, in 2008, Schubert, Glass, Clarke, Aiken, Schaffert-Witliet, Sloane and DeGeest 26 reported results of a multi-hospital, international project studying the association between implicit rationing of nursing care and patient outcomes. In contrast to Kalisch’s proposition that missed care is an error of omission, Schubert et al. 27 defined it as care that needs to be rationed due to scarce resources, including human resources. In defining the issue as rationed, rather than missed, they shifted the concept away from seeing the problem as one where the nurse is held responsible for missed care, to recognizing that nurses and 17

Siqueira, L.D., Caliri, M.H., Kalisch, B, & Dantas, R.A (2013). Cultural adaptation and internal consistency analysis of the MISSCARE Survey for use in Brazil. Revista Latino - Americana de Enfermagem, 21(2), 610-617. 18 Kalisch, B.J, & Lee, K.H. (2010) The impact of teamwork on missed nursing care. Nursing Outlook, 58(5), 233-241. doi:10.1016/j.outlook.2010.06.004. 19

Kalisch, B.J, Gosselin, K., & Choi, S.H. (2012) A comparison of patient care units with high versus low levels of missed nursing care, Health Care Management Review 37(4), 320-328. doi: 10.1097/HMR.0b013e318249727e. 20

Tschannen, D., Kalisch, B.J., & Lee, K.H., (2010) Missed nursing care: the impact on intention to leave and turnover. Canadian Journal of Nursing Research, 42(4), 22-39.

21 Kalisch, B.J., Tschannen, D., & Lee, K.H., (2011) (b.) Do staffing levels predict missed nursing care?, International Journal for Quality in Health Care, 23(3), 302-308. doi: 10.1093/intqhc/mzr009. 22 Kalisch, B., Tschannen, D., & Lee, K.H. (2012) Missed nursing care, staffing, and patient falls. Journal of Nursing Care Quality, 27(1), 6-12. doi: 10.1097/NCQ.0b013e318225aa23.

other health professionals have always prioritized and rationed care. Part of their hypothesis is that with increasing rationalization of funding and demands for increased productivity and efficiency, rationing is inevitable and increasing. In a recent systematic literature review of research in this area Papastavrou, Andreou, and Efstathiou 28 argue that the dominant rationale for this research direction in the early part of the 21st century is that there are insufficient human resources necessary for nurses to care for patients and that this phenomena is now global. This impacts on negative patient outcomes and is a major challenge to quality assurance, risk management and nurse satisfaction. Whether Kalisch’s model of omitted care or Schubert et al. 29 model of rationed care is supported, there is considerable evidence that work intensification in nursing has led to missed care.

III.

METHOD

Following permission to administer the survey from Beatrice Kalisch, data for this study were collected through administering the MISSCARE Survey using the online tool, Survey Monkey and the membership list provided by the Australian Nursing and Midwifery Federation (SA Branch) [ANMFSA]. Prior to administering the survey modifications were made particularly to the demographic questions and those dealing with nursing work where the terminology in Australia differed from that used by Kalisch. Additional questions were also added to capture the differences in missed care during day, evening, night, and weekend shifts, although the results of these differences are not reported in this paper. Approval to conduct the study was obtained from the Flinders University Social and Behavioural Research Ethics Committee (SBREC). The ANMFSA is the local branch of the major nursing union in Australia with approximately 16 000 registered and enrolled nurses as well as care workers in its South Australian branch. Initially the survey was sent to 10% of the membership and then via a newsletter link to all members during the months of November and December 2012. Approximately 289

23 Kalisch, B.J., Tschannen, D., & Lee, K.H., (2011) (b.) Do staffing levels predict missed nursing care?, International Journal for Quality in Health Care, 23(3), 302-308. doi: 10.1093/intqhc/mzr009.

TABLE I.

DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

N

24

Kalisch, B.J. Doumit, M., ,Lee K.H., Zein, J.E. (2013) Missed nursing care, level of staffing, and job satisfaction: Lebanon versus the United States. Journal of Nursing Administration, 43(5), 274-279. 25

Kalisch, B.J, & Lee, K.H. (2012) Missed nursing care: magnet versus nonmagnet hospitals. Nursing Outlook, 60(5) e32-e39 doi: 10.1016/j.outlook.2012.04.006.

%

Gender Female Male

261 28

90 10

Age Under 25 25-34 35-44

6 34 57

2 12 20

26 Schubert, M., Glass, T.R., Clarke, S.P., Aiken, L.H., Schaffert-Witvliet, B., Sloane, D.M., & De Geest, S. (2008).Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study. International Journal for Quality of Health Care, 20(4), 227-37. doi: 10.1093/intqhc/mzn017

Papastavrou, E., Andreou, P., & Efstathiou, G. (2013) Rationing of nursing care and nurse-patient outcomes: a systematic review of quantitative studies, International Journal of Health Planning and Management, doi: 10.1002/hpm.2160



28

45-54 55-64 65 and above

108 80 6

37 27 2

Years of Experience as a Nurse Less than 2 years 2-5 years 5-10 years More than 10 years

38 42 45 166

13 14 16 57

Location Metropolitan Rural

197 93

68 32

Setting Public Private Agency

218 54 18

75 19 6

Number of hours worked Less than 30 hours/week 30 hours or more /week

95 195

33 67

Length of shift 5-8 hours 9-12 hours Greater than 12 hours

199 76 2

69 30 1

nurses/midwives completed the survey with 843 qualitative comments listed at various points in the survey. Some of these comments are reported below in the discussion section.

IV.

RESULTS

Demographic and work profile The response profile closely resembled ANMFSA membership. The majority of respondents were female (90% as against 89% membership) with 73% reporting more than five years nursing experience. Consistent with this, 66% were aged 45 years and above (ANMFSA membership reports 51% aged above 45 years). These nurses represented rural (32%), metropolitan (68%), public (75%) and private sectors (19%) with only 6% employed by nursing agencies. Sixty-seven percent worked 30 or more hours per week, and 69% reported working 5-8 hours/shifts. The majority of nurses worked in either medical or surgical wards (42%) with 15% in aged care, and 12% in midwifery. Table 1 provides a summary of the demographic data. A small percentage (6%) believed staffing was adequate, with the majority (n=135, 46%) believing staffing was adequate around 75% of the time, and 13 respondents (4%) noting that it was never adequate. Most respondents indicated that overtime (temporal flexibility) work was either paid or they were given time off in lieu. For part time staff additional hours worked were often not considered overtime. We asked the participants to indicate the number of shifts they missed as a result of sickness, fatigue or injury in the previous three months. This is referred to as absenteeism.

Approximately 83% of the respondents had missed less than three shifts, with 31% not missing any at all. Conversely, we asked respondents to identify the number of times they had worked when they were fatigued, sick or injured. This is referred to as presenteeism. 30 Up to 35% had worked four or more shifts when they were not well, and another 35% had worked up to 2-3 shifts while not well. One of the major reasons for working while sick was a sense of commitment to colleagues given the work intensity on their ward or unit. This was expressed either as an obligation to colleagues (43.5%) or being short staffed (36%). The remainder worked for financial reasons either because they were casual or part-time, or had no sick leave days left. One of the assumptions we made was that these nurses might not be satisfied with their work due to its increasing intensity. Interestingly, respondents reported high levels of satisfaction with nursing as a profession. Sixty-seven percent indicated they were satisfied or very satisfied with nursing as a profession, and 52% were satisfied with their own current position. A significant percentage (62%) thought teamwork on their unit was high, and a further 64% had no intention to leave the profession. Work intensification: length and pace There are a range of approaches to increasing productivity. As noted these include redesigning the workplace, role substitution and increasing the pace and length of hours worked, or work intensification. 31 In this study respondents were firstly asked questions to do with length of hours worked as one proxy for work intensification, as well as what tasks were regularly missed as a proxy for pace or speed of work. In order to ascertain length of hours worked, respondents were asked how often and how many hours they had worked overtime in the last three months. Around 22.8% of nurses indicated that they had worked overtime less than five times, 28.7% nominated between five and 10 times, while 17.6% reported more than 20 overtime shifts within the last three months. In terms of hours this resulted in 25% who reported no overtime, 29% who reported between 0-10 hours of overtime and 17% between 11 – 15 hours. Added to this, 14% had worked more than 20 hours overtime. TABLE II.

COMPARATIVE MEAN SCORES FOR MISSED CARE All shifts

Ambulate patient

3.26

Mouth care

2.84

Respond to bell in 5 minutes

2.82

30 Letvak, S.A., Ruhm, C. J.. & Gupta, S.N. (2012) Nurses' presenteeism and its effects on self-reported quality of care and costs. American Journal of Nursing, 112(2), 30-38 31


Turn patient 2 hrly

2.80

Monitoring input/output

2.78

Patient education

2.78

Feed patient while food is warm

2.77

Give medications within 30 mins from schedule

2.76

Full documentation

2.68

Toileting within 5 mins

2.67

Assess effectiveness of medications

2.63

Emotional support

2.53

Patient discharge planning

2.51

Patient assessed every shift

2.49

Set patients up for meals

2.41

Vital signs assessed

2.41

Skin & wound care

2.40

Reassessment according to condition

2.39

PRN medication in 15 minutes

2.32

Patient bathing/ skincare

2.30

IV/Central line site care and assessments

2.29

Hand washing

2.14

Bedside glucose monitoring

1.99

Extending work hours enables nurses to pick up on some tasks, but not all. Many tasks need to be done within the hours allocated to a particular shift. In order to successfully manage these tasks, nurses develop efficient and systematic processes. This includes employing a systematic approach to the required work, such as use of clinical pathways, as well as prioritising tasks. In some instances tasks will be omitted that are considered marginal to patient well-being, or not necessary for a specific patient. 32 In cases where work becomes intensified, tasks will be omitted because they cannot be done in the allotted time. A key argument put forward by Kalisch33 and Schubert 34 and their colleagues is that nurses are increasingly omitting or rationalising care in response to work intensification. Table 2 provides a list of comparative mean scores for tasks respondents in our study identified as missed within the last three months where 1 is never omitted and 5 is always omitted.

32 Patterson, E.S., Ebright, P.R., Saleem, & Jason J.J. (2011) Investigating stacking: How do registered nurses prioritize their activities in real-time? International Journal of Industrial Ergonomics, 41(4), 389-393. doi:10.1016/j.ergon.2011.01.012 33 Kalisch, B. (2006) Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313. 34 Schubert, M., Glass, T.R., Clarke, S.P., Aiken, L.H., Schaffert-Witvliet, B., Sloane, D.M., & De Geest, S. (2008).Rationing of nursing care and its relationship to patient outcomes: the Swiss extension of the International Hospital Outcomes Study. International Journal for Quality of Health Care, 20(4), 227-37. doi: 10.1093/intqhc/mzn017

In summary nurses identified a range of tasks that they either saw as not necessary given the circumstances, or omitted as a result of a number of factors that give rise to work intensification. At the extreme end two missed tasks were ambulation of patients (3.26) and mouth care (2.84). Tasks that were omitted less often were blood glucose monitoring (1.99); hand washing (2.14); and IV/central line care (2.29), bathing patients (2.30), and providing PRN medication within 15 minutes (2.32). This list suggests that nurses deal with work intensification by prioritising basic clinical tasks over interdisciplinary care activities or those less obviously associated with patient recovery. V.

WHY CARE IS MISSED

In Kalisch and William’s 35 study they identified the following five situations as key to understanding why care was omitted. These were i) ‘inadequate numbers of staff’, ii) ‘inadequate numbers of assistive or clerical personnel’, iii) ‘unexpected rise in patient volume, or acuity’, vi) ‘heavy admissions and discharge activity’ and v) ‘urgent patient situations’. They also noted that lack of access to resources such as equipment to mobilise or treat patients, or medications, were significant factors in missed care. In our study we also asked nurses why care was omitted. As Table 3 illustrates over half of the respondents identified an ‘unexpected rise in patient volume or acuity’ as significant. Other significant factors included ‘heavy admission and discharge activity’ (44.8%); ‘inadequate numbers of staff’ (43.4%); ‘urgent patient situations’ (39.8%) and ‘inadequate number of assistive and/or clerical personnel’ (40.2%). These five factors can be summarised as directly intensifying the work. Communication between health professionals was not seen as overly problematic, although we note that interdisciplinary care is one of the first tasks to be omitted when work is intensified for nurses suggesting that in the long term this may be problematic.

The complexity of missed care The first five most often cited reasons identified by respondents indicate either lack of adequate staff, or an unexpected increase in work intensity directly linked to patient load or acuity, as contributing to missed care. These are predictable contributors to work intensification and possible missed care. However, as Kalisch36 has demonstrated missed care is a complex phenomenon. An intriguing finding in this study was the relationship between resource deficits, work intensity and missed care. We performed a path analysis using the data from the cohort of 46 nurses working in general and ICU wards during the day shift. This sample was chosen as being comparable to the samples used in previous research 35 Kalisch, B.J, & Williams, R.A. (2009) Development and psychometric testing of a tool to measure missed nursing care. Journal of Nursing Administration, 39(5), 211-219. doi: 10.1097/NNA.0b013e3181a23cf5. 36 Kalisch, B. (2006) Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.

using this tool. The results suggested that ‘lack of physical and human resources’ is the most significant variable in work intensification and missed care with a co-efficient of +0.61. (See Fig. 1). We explore two features of this variable; lack of assistive and administrative support (human) and lack of or faulty physical resources. Work intensity was not directly associated with missed care however it influenced workload predictability with a path co-efficient of +0.48. This demonstrates that work intensity in combination with workload predictability have a conjoint impact on the frequency of reported missed nursing care. VI.

DISCUSSION

Lack of human and physical resources is part of managerial reforms in hospitals that are often well outside nursing control. Shortages and deficits in these areas suggest a lack of understanding of the interrelatedness of the tasks done by the various occupational groups or the way in which nurses depend on the work done by ward clerks, hospital administrators, cleaners and other ancillary staff. While many nurses respondents reported that the computerised nursing workload measurement/rostering tool, ExcelCare, failed to make adequate predictions for the number of staff needed per shift, or the complexity of patient needs, others pointed to the fact that ancillary and administrative staff were not available particularly after hours or during off peak times, so that nurses were left to do their work. The employment of ancillary staff such as ward clerks, on a 9am to 5pm roster assumes the bulk of the work required to support nurses still occurs within this time frame; surgery times and patient admissions and discharges being the obvious examples. This is no longer the case given the significant increases in patient throughput that has occurred partly in response to funding reforms such as activity based funding. For example between 2009 and 2011, ‘separations increased overall by 3.8% (4.2% in public hospitals and 3.2% in private hospitals)’ in Australia and ‘Patient days increased by 2.0% overall, by 2.1% in public hospitals and 1.8% in private hospitals’. 37 Allied health staff are only employed between the hours of 9am to 5pm, on a five day a week roster in most Australian public hospitals. If patient throughput has increased, and presumably patient acuity, some of the care required is outside the standard working hours of 9am to 5pm and as a consequence is left to nursing staff. Even where additional nurses are rostered, the failure to also roster ancillary and allied health staff after hours assumes the work intensity tapers off. In the Australian context this assumption flies in the face of the fact that procedural aspects of patient care, such as surgery, and diagnostic tests are not confined to the early shift, but bleed into those shifts outside the standard working hours. 38 39 40 41 Further to this,

37 Australian Institute of Health and Welfare (2013) Admitted patient care: overview Retrieved January 20, 2014 from http://www.aihw.gov.au/haag1011/admitted-patient-care-overview/ 38 Willis, E. (2009) Purgatorial time in hospitals. LAP Lambert Academic Publishing AG & Co. KG, Germany. 39 O’Loughlin, E., Smithies, W. & Corcoran, T. (2010) Out of hours surgery – a snapshot in time. Anaesthesia and Intensive Care, 38(6), 1059-1063.

fewer primary care services such as access to general practitioners are available after hours leading to higher numbers of after-hours presentations at Emergency Departments which in turn places pressure on admission and discharge activity across many wards in large tertiary hospitals. 42 The second component of resource deficits noted by nurse respondents as a major issue was lack of physical resources, equipment, beds, and medications needed to provide efficient and timely care. In some cases these resources could be sourced, but the time taken to do this impacted on work intensification and missed care. In any given shift the rostered staff might be (in)adequate, but if a piece of equipment is broken, or missing, the time taken to replace, retrieve or borrow it from another ward or unit resulted in intensifying work and possible missed care. Interestingly this was most evident for nurses in rural and aged care settings, although nurses across the public, acute and private sectors also noted resource deficits. As one respondent noted: There seems to be a lot of time these days looking for things or chasing things up ie: medication running out, trying to find equipment that is available and working. Things are not being ordered in advance. In aged care settings nurses noted the difficulties and time taken in obtaining adequate medications after hours given their reliance on visiting medical officers. It would appear that the move to improve efficiency and productivity within healthcare has not necessarily resulted in providing staff with sufficient supplies or work tools. This is not a new phenomenon, although it is surprising for health care systems in advanced economies. In previous research conducted in community health centres in South Australia we found nurses and allied health professionals were often forced to delay completing their work as a result of lack of access to transport to visit patients, too few mobile phones to ensure staff safety, or there was often only one or two computers available to complete reports on time. 43 More recent research from the 40 Tobin, A. & Santamaria, J. (2006) After-hours discharges from intensive care are associated with increased mortality. Medical Journal of Australia, 184(7), 334-337. 41 Toffoli, L. ‘Nursing hours’ or ‘nursing’ hours – a discourse analysis. Unpublished PhD Thesis, University of Sydney. Retrieved January 20, 2014, from http://ses.library.usyd.edu.au/handle/2123/8367 42

Parry, Y. & Willis, E. (2012) Are the new General Practitioner Plus Centres the correct government response to a lack of pediatric after-hours care for patients? Leadership and policy quarterly, 1(2), 77-94

43 Willis, E., Henderson, J., Walter, B & Toffoli, L. (2008) Development of a staffing methodology equalisation tool for community mental health and community health nurses. South Australia: Final Report, SA Department of Health, Adelaide. Retrieved January 20, 2014, from http://www.nursingsa.com/pdf/Office/doh-2624%20final_report_FA.pdf

British National Health Service suggests that ‘significant organizational and resource differences exist between highmortality and low-mortality outlier hospitals’ (p.1323) pointing to equipment deficits as a factor in variability in care. 44 We would suggest that resource deficits as a factor in work intensification and missed nursing care are areas requiring further investigation. These deficits point to wider problems in care design and re-organisation. Some of the current approaches to missed care in vogue, such as hourly rounding, that situate the problem as a nursing deficit, may not be the most effective strategy. 45

A second challenge arising from these resource deficits, point to inefficiencies in the division of labour in the Australian health care system. In the example taken from aged care provided above, a simple efficiency measure that would reduce work intensification and missed care would be to extend the nurse’s span of control to authority to prescribe routine medications for residents in aged care settings through the employment of nurse practitioners. VII. CONCLUSION

As our results indicate the causes of missed nursing care are complex. It is not simply a matter of nurse staffing levels, but is a dynamic in which issues such as interdisciplinary communication and staffing, lack of availability of administrative and ancillary staff, especially during off peak times, as well as resource deficits, play a role. It would appear that one of the contributing reasons for missed care may be the time nurses take to do the work done by administrative, and ancillary or allied health professionals during off peak times, as well as the time taken to replace faulty equipment, retrieve equipment from other wards when required, or seek out medications or other resources needed to care for patients. This was certainly a finding of research by Kaya, Kaya, Turan, Tan, Terzi and Barlas 46. Some of these can be managed and are the responsibility of nursing services, but not all. The tasks reported as least often omitted are blood glucose monitoring, hand washing and IV/central line care. Some of these tasks need to be situated historically. The Australian Commission for Quality and Safety in Hospitals current project

44

Symons, N.R., Moorthy, K., Almoudaris, A.M., ,Bottle, A., Aylin, P., Vincent, C.A., & Faiz, O.D. (2013) Mortality in high-risk emergency general surgical admissions. British Journal of Surgery, 100(10), 1318–1325. doi: 10.1002/bjs.9208

is hand washing. 47 This is one of the items reported on the My Hospital website. 48 It is a task currently being strongly promoted across the health sector in Australia. We suspect that if we had performed the survey at another time the results on this task may have been different. Bathing patients and providing PRN medication within 15 minutes were also reported as missed less frequently. This suggests that when nursing time is rationed priority is given to clinical and basic nursing care tasks including patient comfort, over other tasks which may be less immediately important for patient wellbeing. One of the problematic issues with surveys is to ascertain how generalizable the findings are to the total population. As we noted above the survey respondent profile closely mirrored the ANMFSA membership. However, not all nurses are union members and questions remain as to whether or not they represent a unique group who may have higher rates of dissatisfaction. We would suggest that this is not borne out. Union density for nurses in Australia has sat at approximately 70% over the last decade with numbers increasing, rather than decreasing as in the trend for other occupational and professional groups. The number of nurses employed in Australia in 2011 was around 320,000 49 with the ANMF reporting nationally over 230,000 members. 50 This would suggest the survey respondents numbers, while small, were representative of the overall nursing population. Added to this, those nurses who responded to this survey were not overly dissatisfied with the profession, nor were they an atypical group. Our results also suggest that the various productivity and efficiency measures introduced into hospitals around Australia that have seen increases in patient throughput and acuity have come at a cost. Increases in numerical and functional flexibility can increase productivity, but it is also possible that workers are required to take short cuts, ration certain tasks, or omit them all together. While nurses have always prioritised care and will continue to do so, work intensification risks nurses omitting optimum care for patients. Limitations There were three major limitations to the study: •

The small sample size (especially small for path model of such a complex phenomenon)

47 Australian Commission for Quality and Safety in Hospitals (2014) National Hand Hygiene initiative. Retrieved January 20, 2014 from http://www.hha.org.au 48 Commonwealth of Australia (2014) My hospitals. Retrieved January 20, 2014 from http://www.myhospitals.gov.au/

45

Rondinelli, J., Ecker, M., Crawford, C., Seelinger, C., & Omery, A. (2012) Hourly rounding implementation: a multisite description of structures, processes, and outcomes. Journal of Nursing Administration 42(6), 326-332 doi: 10.1097/NNA.0b013e31824ccd43. 46

Kaya, H., Kaya, N., Turan, Y., Tan, Y. M., Terzi, B. & Barlas, D. B. (2011) Nursing activities in intensive care units in Turkey. International Journal of Nursing Practice, 17(3): 304–314. doi: 10.1111/j.1440-172X.2011.01941.x

49 Australian Institute of Health and Welfare (2012) Nursing and Midwifery workforce 2011, AIHW, Canberra. 50 Thomas, L., & Chaperon, Y. (2013) Australian Nursing and Midwifery Federation submission to the Australian Nursing and Midwifery Accreditation Council (ANMAC) consultation on the review of the midwifery accreditation standards, ANMF. Canberra ACT. Retrieved January 20, 2014, from http://anmf.org.au/documents/submissions/ANMF_submission_Review_of_th e_Midwifery_Accreditation_Standards_July_2013_final.pdf

•

The large amount of missing data-likely due to having to respond to each item four times (once for each of four shifts)

•

The items were appropriate for ICU and medical surgical units. Some of our respondents indicated the items did not pertain to their patient population or their type of unit

Kalisch has published more on the topic of missed care than any other single researcher. However, another team of researchers, Schubert, et al. 51 has done extensive work on a concept they refer to as, rationed care. Exploration of the overlap or distinctiveness of these seemingly related concepts would be of benefit to those who are studying the phenomenon of missed, rationed, omitted, incomplete, or significantly delayed nursing care. As it stands, it is not clear whether missed and rationed care is actually the same construct. Thus, it is questionable whether the results of Kalisch and her team can be compared to those of Schubert and her team. One of the aims of our International Network for the Study of Rationalized Nursing Care (INSRNC) members is to answer this very question. ACKNOWLEDGMENT Flinders University Faculty of Health Sciences, Seeding Grant, and a Robert Wood Johnson Foundation Grant provided funding for this study. The authors wish to thank the Australian Nursing and Midwifery Federation (SA Branch) executive and participating members for their support.


TABLE III.

REASONS FOR MISSED CAREABLE

Unexpected rise in patient volume and/or acuity on the ward/Unit

Not a reason

Minor reason

3.2% (8)

8.8% (22)

Inadequate number of staff

3.2% (8)

Urgent patient situations (e.g. worsening patient condition)

4.4% (11)

Heavy admission and discharge activity

6.0% (15)

Inadequate number of assistive and/or clerical personnel (e.g. care assistants, ward clerks, porters)

10.4% (26)

Unbalanced patient assignment

7.7% (19)

Medications not available when needed

8.4% (21)

Supplies/equipment not available when needed Lack of back up support from team members Supplies/equipment not functioning properly when needed Tension or communication breakdowns with the Medical staff Inadequate handover from previous shift or patient transfers into ward/Unit Tension or communication breakdowns within the Nursing team Tension or communication breakdowns with other ancillary/support departments Other departments did not provide the care needed (e.g. physiotherapy did not ambulate) Nurse/carer assigned to patient off ward/Unit or unavailable Nursing assistant/carer did not communicate that care was not provided

10.8% (27) 11.6% (29) 14.8% (37) 14.6% (36) 12.7% (32) 18.4% (46) 19.6% (49) 16.5% (41) 22.6% (56) 17.3% (43)

21.9% (55) 17.3% (43) 12.4% (31) 18.3% (46) 23.4% (58) 27.1% (68) 28.5% (71) 31.2% (78) 33.6% (84) 31.2% (77) 33.9% (85) 33.2% (83) 36.8% (92) 31.3% (78) 29.8% (74) 29.4% (73)

Mod. reason 26.3% (66) 26.7% (67) 30.5% (76) 22.4% (56) 22.3% (56) 25.0% (62) 25.5% (64) 27.3% (68) 27.6% (69) 20.8% (52) 26.7% (66) 29.5% (74) 26.4% (66) 21.2% (53) 21.7% (54) 16.5% (41) 19.4% (48)

Signif. Reason 54.2% (136) 43.4% (109)

N/A

N

7.6% (19)

251

4.8% (12)

251

39.8% (99)

8.0% (20)

249

44.8% (112) 40.2% (101)

14.4% (36)

250

8.8% (22)

251

33.9% (84)

10.1% (25)

248

31.5% (79)

7.6% (19)

251

25.7% (64)

7.6% (19)

249

23.6% (59)

6.0% (15)

250

22.4% (56)

8.4% (21)

250

18.6% (46)

8.9% (22)

247

15.5% (39)

8.4% (21)

251

14.0% (35)

8.0% (20)

250

10.8% (27) 12.4% (31) 13.3% (33) 12.5% (31)

11.6% (29) 18.1% (45) 17.7% (44) 21.4% (53)

250 249 248 248

Figure 1: Final path model identifying factors that influence frequency of missed nursing care for general & ICU qualified nurses who work only during day shift(s)