Rationed or missed nursing care: Report to the ANMF (Victorian Branch)
Blackman, Ian Robert
Toffoli, Luisa Patrizia
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In May to July 2015, 1683 nurses, midwives and personal care workers (PCW) and Assistants in Nursing (AiN) employed in public and private health facilities in Victoria completed the MISSCARE survey. This represents around 3 percent of the total number of nurses and midwives employed in the state of Victoria. The survey was administered via Survey Monkey by a research team from Flinders University in collaboration with the Victorian branch of the Australian Nursing and Midwifery Federation (ANMF Vic Branch). The Victorian MISSCARE survey is a modification on the original design developed by Beatrice Kalisch (2006). It contains eleven demographic questions, 23 questions dealing with working conditions including questions on staffing tools, 21 questions concerning missed care (care that is omitted, postponed, or incomplete) and 20 questions addressing reasons why care is omitted in the settings in which the nurse/midwives practice. Victoria is the only state in Australia to have mandated nurse-patient ratios. The state of Victoria is experiencing rapid growth in population. Missed nursing care is a global phenomena linked to the rationing of health care. Nurse researchers around the world are recording the levels of missed, delayed or rationed care. Nurses have always rationed care tasks, or prioritised them when work intensifies. Nursing assistants known as health assistants in nursing, have been employed in some public hospitals in Victoria since 2009. Patient satisfaction surveys conducted by the public hospitals in Victoria show high rates of satisfaction with nursing care, and the courtesy of nurses, and low scores for organisational issues such as food, restfulness of hospitals and waiting times. There is some overlap between the patient satisfaction surveys conducted in the public hospital system and the MISSCARE survey such as length of time taken for nurses to respond to call bells, patient education, hand hygiene and medication requests. Sixty-seven percent of nurses in Victoria are employed on a permanent part-time basis. This is higher than NSW where 48.3 percent of nurses are employed part-time permanent. Fifty-six percent of nurses work 30 hours or more in Victoria. Sixty-five percent of nurses and midwives prefer to maintain their current schedule. Over 22 percent of nurses said they worked overtime greater than 20 times in the last 3 months. Thirty-four percent of nurses and midwives worked 2 to 3 shifts over the last 3 months even though they were sick or injured, with 32 percent stating they felt an obligation to their colleagues to go to work. Fifty-three percent of nurses and midwives felt that there were adequate staff between 100 and 75 percent of the time. The remaining 47 percent felt staffing was inadequate between 50 and all of the time. Seventy-three percent of nurses and midwives had less than 9 patients per shift, with eighty-six percent reporting that they had fewer than 5 admissions per shift Rounding appears to be used in 53 percent of situations, although many nurses had not heard of the term. Nursing care tasks most often missed include skin and wound care, and glucose monitoring. The care missed is consistent across all three shifts, although some tasks are more likely to be missed on a particular shift; eg afternoon shift has higher scores for missing the promotion of PRN medications, while night shift staff report the omission of managing parenteral devices. Nursing care tasks such as turning patients, oral hygiene, prompt medication administration and patient education are least missed. Missed nursing care can be categorised into low, intermediate and high treatment. Lower priority care includes emotional support, patient education and discharge planning, and high priority care includes handwashing, IV/CVC lines, call bells, BSL, vital signs. Treatment (intermediate) related care is the most likely form of care to be missed. These include nursing specific tasks such as feeding, turning/positioning, wound care, administering medication on time, ambulation, mouth hygiene, and toileting. This finding is consistent with survey results from NSW. Variables with a direct impact on missed care include the hospital location (rural hospitals report higher rates of missed care), the use of rounding impacts on missed care, and staff adequacy. Reasons for missed care include urgent patient situations and unexpected rises in patient volumes which impact upon staffing issues. While just over 50 percent of nurses thought their ward was adequately staffed 75 to 100 percent of the time, unpredictable work increases such as increased admissions and discharges contribute to missed care. Other important reasons for missed care include: ‘Inadequate skill mix for your area’, ‘an unbalanced patient assignment’ together with an ‘inadequate number of assistive and/or clerical personnel’ and ‘supplies/equipment not available when needed’. Two hundred and eighty four nurses and midwives provided qualitative comments within the survey. Responses illustrated a stronger focus on nursing the budget, with participants indicating they were more aware of financial constraints or the need for profits than previous generations of nurses. Midwives reported that early discharge of mothers curtailed adequate patient education. Nurses and midwives targeted cost constraints, lack of adequate numbers of clerical and ancillary staff, particularly on night duty, the lack of mandated nurse-patient ratios in private hospitals, poor access to medical staff, patient acuity, and competing demands placed on nurses who are at the centre of the ward or unit. Consistent with survey results from other states, lack of access to equipment including medications also impacts on missed care. Nurses in Victoria also indicated that poor communication was a factor in missed care. When nurses were asked about personal issues that impacted on missed care they reported that their capacity to deliver uninterrupted care and an inability to attend case conferences as causing missed care. This was followed by the absence of hospital policies and inability to delegate work to others. The frequencies and types of missed care are significantly influenced by both hospital/clinical unit effects including hospital location and by individual nurse/midwife factors. Missed care shows greater variation within Victorian rural hospitals. The average frequency of missed care on Victorian afternoon and night shifts is significantly less than reported in NSW however, the average frequency of missed care on the Victorian day shift is equivalent to that reported in NSW. Employer type (private or public agency) was not associated with missed care by Victorian respondents The use of rounding practices in the clinical arenas presents as contributing to and preventing missed care dependent upon context. The rate and frequency missed care is defined by the type of care missed. Intermediate treatment related care is more likely to be missed than higher priority and lower priority nursing tasks. In Victoria, the morning shift is associated with the greatest volume of missed care, followed by the then afternoon shift and then the night shift. Country of origin of nursing/midwifery qualifications is associated with significant variation in the frequencies and types of care missed in Victoria. Age of the staff providing care shows a mixed but statistically significant influence on missed care in Victoria. The gender and the level of qualifications held by the Victorian nurse/midwife is associated with significant variations in treatment-related missed care. Staff employment status (both full and part-time employment) demonstrates variance in frequencies of Victorian missed care. The complexity of staffs’ ability to manage daily work tasks shows significance variation in missed care in Victoria.. Dissatisfaction with work teams has a statistically significant influence on Victorian missed care. Current job dissatisfaction has a statistically significant influence on Victorian missed care. Staffs’ self-rated level of their current health and the number of hours they are employed for per week are not associated with Victorian missed care. In order of magnitude, the reasons why Victorian care is missed care are issues associated with the provision of resources for care, communication tensions between care providers, workload (un)predictability, (dis)satisfaction levels with members of the team and workload intensity.