Rationed or missed nursing care: Report to the ANMF (Victorian Branch)
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Date
2015
Authors
Willis, Eileen Mary
Blackman, Ian Robert
Henderson, Julie Anne
Xiao, Lily Dongxia
Toffoli, Luisa Patrizia
Journal Title
Journal ISSN
Volume Title
Publisher
Flinders University
Rights
Copyright 2015 The authors
Rights Holder
The authors
Abstract
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.
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Citation
Willis, E.M., Blackman, I.R., Henderson, J.A., Xiao, D. and Toffoli, L.P. (2015). Rationed or missed nursing care: Report to the ANMF (Victorian Branch). Bedford Park, South Australia: Flinders University