Missed nursing care: Report to the Australian Nursing and Midwifery Federation: Tasmanian Branch
Blackman, Ian Robert
Toffoli, Luisa Patrizia
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Executive Summary • From June through to the end of July 2015, the missed care survey was run through the Australian Nursing and Midwifery Federation Tasmanian Branch. Six hundred and forty eight nurses, midwives and four personal care workers completed the survey. These figures mirror state numbers in terms of gender, and number of RNs to ENs and midwives. • The survey was made up of ten demographic questions, 22 questions that explored working conditions including questions to do with how workload is measured and staff assigned to the ward or unit, 21 questions concerning missed care (care that is omitted, postponed, or not completed) and 19 questions that asked the participants why they believed care was missed. • The survey also included questions on staffing tools, rounding and whether or not nurses considered they worked within their scope of practice. Kalisch defines missed care as “required patient care that is omitted (either in part or in whole) or delayed” and acknowledges that it is a response to “multiple demands and inadequate resources” (Kalisch & Williams 2009, p. 1510). • The proliferation of research on missed care, including the work on rationed care is ensuring that researchers are exploring underlying causation in more depth. To date analysis by the Australian team have focused on the relationship between missed care and work intensification linked to new public management. • Recent research published by Kalisch (2006; 2009; 2012) makes a distinction between missed care as an error of omission (care not given) and missed care as an error of commission (incorrect care). In tracking omitted care, Debney and Kalisch (2015a) have developed a missed care survey for patients which demonstrated considerable consistency with nurses’ perception of missed care. • A significant finding of the patient surveys is the impact of skill mix on missed care. Registered nurses are less likely to miss care than lower grades of care workers. This is attributed to their knowledge and deeper understanding of the importance of timeliness in providing care. • Recently published research by Kalisch et al. (2012), showed that skill mix, leadership and team work are also factors strongly associated with missed care. • Castner et al. (2014) explored missed care during times of hospital merger. Their research demonstrates that unit level factors and individual nurse factors are both contributors to missed care and there is ample evidence of related factors during hospital merger such as re-admissions following early discharge and reduced staffing levels that point to missed care. • Both the Castner et al. (2014) and the Blackman et al. (2015a) studies confirm Kalisch et al. (2015) observation that nurse skill mix and nurse communication are key to reducing missed care. • Studies suggest that highly experienced nurses report more missed care than younger nurses with less years of expereince and these same nurses report major issues with supply and communication problems. It is not clear whether this is because these nurses are more reflective than younger less experienced nurses; intuitively this would seem a reasonable assumption. • One of the managerial responses to missed care is to introduce mandatory rounding. Rounding involves nurses carrying out regular and standardised checks on all patients at set intervals to assess and manage their fundamental care needs. This is usually done on an hourly basis and is promoted as an opportunity for the nurses to involve the patient in their own care, and for them to ensure all is well (Tea, Ellison & Feghali, 2008). • Tasmania is a small state with low population and a resource base limited by low revenue. • Tasmanian health care like the rest of Australia it is a mixed system. There are 27 public and 14 private hospitals in the State. Four of the public hospitals are major providers, the other 23 are rural or community based. These smaller hospitals offer varying services from residential aged care, emergency, primary care and sub-acute and same day surgery. • Health outcomes for Tasmanians are below Australian national averages. This is reflected in lower life expectancy rates for both males and females, and the percentages of the population who smoke, are obese or overweight, as well as prevalence of chronic conditions - all of which are higher than national average. • Health system performance in Tasmania is also below peer hospitals in other states, with outcomes for patients influenced by where they live. • The major reform direction for 2015 and beyond is to organise the sector into one system, rather than three health organisations with specific hospitals operating as centres of excellence. • The concept of universal health care equity and access, the corner stone of the 1983 Medicare agreements has given way to quality and risk reduction, and a stronger focus on medical expertise. • Similar to mainland Australia, people living in Tasmania have access to private health care services. There are 14 private hospitals in Tasmania. However, the number of people with private health insurance in below the national average. • According to the Australian Health Practitioner Regulation Authority Nursing and Midwifery (AHPRA) statistics (March 2015) there are 7989 registered [6429 - 792 male] and enrolled nurses [1426- 127 male] plus 47 with dual qualifications in Tasmania with around 87 of these not practicing. There are 647 nurse/midwives with 7 not practicing and 17 midwives with a single qualification. • One of the confounding issues for Tasmania is remoteness. New South Wales has the highest average available beds per 1,000 population in Remote areas (5.0 beds per 1,000 population) and Tasmania had the lowest (1.5 beds per 1,000 population). • The NEAT target for Tasmania for 2015 is 90 per cent of patients to be attended to in Accident & Emergency (A&E) within the four hour time allocation. Current performance is between 65 and 70 per cent (AIHW 2015; DHHS 2015b). Meeting this target will impact on missed care. Tasmania also has long waits for elective surgery. • Participants reported a broad range of beliefs about the frequency of missed care with the bulk of staff indicating that missed care is occasionally to frequently missed. Staff did not indicate whether that care is always missed or never missed at all. • Missed nursing care can be categorised into treatment related, lower priority (emotional support, patient education and discharge planning) and high priority care (handwashing, IV/CV lines, call bells, BSL, vital signs). Treatment (intermediate) related care is the most likely form of care to be missed. These are nursing specific tasks such as feeding, turning, wound care, medications given on time, ambulation, mouth hygiene, and toileting. This finding is consistent with survey results from NSW and Victoria. • The frequency of missed care across the three shifts does not deviate significantly from each other, in terms of not only missed care frequency but also the different aspects of missed care. • Focused reassessment according to patient condition is missed the most frequently across all shifts, whereas staff hand-washing is missed the least frequently for the same corresponding time periods. • Staffs’ perception of how effective they are in managing their daily work tasks are strong predictors underlying the frequency of and types of missed care • Hospital or unit characteristics including the location of the health care service (regional or city based) and whether the health unit is publicly or privately owned has no effect on missed care during any shift. • Increased day shift missed care is associated with two factors: staff effectiveness in self-managing their work, and the staffs’ level of (dis)satisfaction with being a member of a team in their own workplace. • Nurses/Midwives who experience difficulty managing their daily work, who are not satisfied with their current job, nor their current work rosters, or who are working less than thirty hours per week and believe their clinical areas are not adequately staffed for long periods of time, indicate greater incidences of day treatment-related missed care. • Current job (dis)satisfaction remains a significant influence on missed care during the afternoon shift, particularly with staff employed on a part-time basis. • Staff age, particularly younger staff, are more likely to miss lower priority tasks during afternoon shifts than older staff. • Afternoon and night shift staff link missed treatment-related care to consequence of work rosters and would prefer to change these. • Staff holding a Bachelor’s degree (or above) indicate a greater likelihood for missing higher-priority care tasks during the night shift than staff with hospital qualifications or at diploma level. Length of clinical experience is a factor in missed care; staff with less experience are more likely to miss higher-priority care at night. • Reasons for missed care identified by nurses in order of magnitude are; the provision of resources for care (+0.51), communication tensions between the care providers (+ 0.34), workload predictability (+0.19), issues related to workload intensity (+0.14), and finally satisfaction levels of staff in their role as a team member (-0.15). • Hospital location is a significant factor behind why care is missed. Tasmanian regional sector venues are more likely to be identified as contributing to missed care compared to city based health care venues. • The average frequency of missed care is approximately the same for both morning and afternoon shifts, and is significantly less overall in all shifts compared to NSW and Victorian. • Employer type (private of public agency) was not a factor associated with missed care in Tasmania. • The use of rounding practices in the clinical arenas has produced (a small) negative result in both the frequencies and types of missed care.