Rationed time leads to rationed care?

1 January 2014

Missed care, rushed care, and tick box care plans … Researcher BERT TEEKMAN set out to find out was happening to bedside nursing and decided your average ‘med/surg’ nurse was definitely more sinned against than sinning under today’s managerial-focused health system. FIONA CASSIE finds out more.

Bert Teekman (pictured) was puzzled.

Student nurses kept coming back to his class reporting they weren’t seeing the nursing assessments they were taught actually being done by busy nurses on the ward.

Patient’s vital signs were being taken, of course, but beyond this, nursing assessment was usually limited to a quick “how are you this morning?” Missing in action at the bedside was the in-depth and holistic health assessments the students were being taught as best practice.

After doing a one-year stint on the wards as a clinical lecturer, Teekman started to think maybe they weren’t exaggerating. He began his PhD research with the aim of observing and analysing the use of health assessment in bedside practice and its impact on nursing interventions in medical and surgical wards.

Fairly quickly, he observed that holistic health assessment was rarely happening, with nurses instead rushing from one task to another. Seeing a nurse sitting at the bedside chatting to a patient was hardly ever observed. The nurses kept telling him the main obstacle to doing more was lack of time.

Due to circumstances, he had to pause his research for three years. On starting again, he re-interviewed some of the nurses and it was apparent staffing levels had improved, workloads were more manageable, and stress levels reduced. But the nurses also said that despite this, their nursing practice had little changed. He was even more puzzled and wondered why.

“It’s easy from the outside to blame the nurse, and to a certain degree, and I hate to admit this, that’s how I started out as well … why aren’t they doing this?” recalls Teekman.

His research focus shifted to what was really happening on wards. Why did nursing rhetoric talk about being “patient-centred” but in reality nursing on the ward floor was “task oriented” and focused on getting the job done?

Why – despite improved staffing levels and an influx of new graduates with new ways of thinking – were ward routines and nursing practice remaining largely the same, despite nurses he talked to expressing frustration and distress with that way of working?

“They look inwards and feel that they are failing, that they are failing their patients by not giving them the care you are supposed to give … and they look at themselves and their own time management.” But Teekman believed something else was amiss.

He spent 41 days observing the bedside practice of 12 staff nurses working in busy medical and surgical wards and interviewing them afterwards. He also did an extensive literature review and decided to additionally interview seven senior nurses including charge nurses, clinical nurse educators, and clinical nurse specialists.

He concluded the failure to do in-depth health assessment and the inertia to break away from set ward routine was the symptom of a “deeper malaise” in the high-churn, high-acuity medical and surgical wards of today.

“In the reality, it’s not so much what nurses do or not do – instead, it is the context in which they work which makes it really, really hard for them to nurse the way they think is appropriate.”

Teekman looked to the British sociologist Anthony Giddens’ structuration theory to get an understanding of why nurses struggle to change ward culture and routines.

Giddens concept of ‘structure’ is based on the idea that rules and resources make up the framework of social systems that both enable and constrain social activities like work.

“Giddens says social environments, like workplaces, are developed by us, maintained by us, but are also imprisoning us,” says Teekman.

“You can see that so nicely with nursing and ward routines but also in other professions with strong routine cultures. Nurses are more or less forced to comply with those routines, and if you don’t, colleagues will tell you ‘that’s not the way we do things here’.

“Which makes it really difficult for nurses to stand up and say ‘well I’m sorry, I’m going to do this differently’,” says Teekman.

A number of nurses in his research endorsed this by telling him ‘this is just the way things are’ and they didn’t have the freedom to make changes.

Management style and TrendCare takes toll on autonomy

The 1990s introduction of generic management principles to the New Zealand health sector took its toll on nursing autonomy, believes Teekman. Along with dismantling nurse leadership, the 90s brought a new focus on productivity and technical advances that saw patient length of stay shorten and shorten, which meant that patient acuity got higher and higher.

He says managerial rationalism is reflected in the new vocabulary that has infiltrated nursing practice since the 90s; language like ‘patient management’, ‘patient outcomes’, ‘bed management’, ‘patient turn-around targets’, ‘hot bedding’, and ‘cost effectiveness’.

Teekman says the advent of the acuity-based nursing workload measurement tool TrendCare* (see box) followed nurse staffing levels being heavily reduced in the 1990s and attempts were made to better understand how to calculate a safe staffing level.

TrendCare requires the nurse to fill in an acuity computer checklist for each of their patients based on their level of dependence – for instance, whether they are incontinent or have an IV. The software tool then calculates a workload in hours and minutes for their patient caseload.

Teekman says on the face of it TrendCare is an excellent system for putting some rationale behind staffing levels and staffing deployment, but he got a mixed response to TrendCare from nurses on the wards during his research.

“I have yet to come across one nurse who tells me that it is an accurate tool and that it is a true reflection of a nurses’ workload. I have spoken to a large number of nurses, many more than directly involved in the research, and they all have the same message; it is not an accurate tool, yet their workload is based on it.

“Once it is introduced and becomes part of the routine, that system starts to dictate how much time you can spend on each patient. It also means that if you spend ten minutes more on one patient, then those ten minutes have to be taken from somewhere else as otherwise you wouldn’t be able to fit your workload in.”

Missing care

“Many patients now in a med/surg ward used to be in intensive care 25 years ago,” says Teekman. “They are now being looked after by nurses on the floor.”

The high acuity, high patient turnover, and the administration demands of the modern med/surg ward mean nurses are “continuously struggling” to try and ensure that patients get the care that they require, says Teekman.

“At the same time, they have to do that within the time calculated by TrendCare. What my research showed is that nurses start to manipulate what they do for patients and what they don’t do for patients. So they start to miss out some aspects of care …”

Teekman says there is increasing discussion about ‘missed care’ in the nursing literature, but he argues that such cares have not been overlooked but deliberately left out as nurses ensure that they prioritise the ‘essential’ cares within the allowable time.

Hence, it is more a case of care rationing, with nurses now adept at making calls about what is critical for patient survival, like medication and IV care, and what is not, like mobilising a patient or taking them for a walk. Sometimes even hygiene care is reduced or dropped when nurses are pushed for time.

Then there is the “one size fits all” approach to nursing or “a nurse is a nurse is a nurse”.

Teekman says flexibility of bed use to increase hospital efficiency has resulted in increased case mix, a term used to indicate the placement of patients with different medical conditions into one ward.

He believes the spread of patients over different wards means that nurses do not build up the same level of expertise as they could in the past.

“Expertise is not something you can get from education alone, rather it is gained from education plus actual clinical practice and being confronted by similar cases time and time again,” he says.

“Lack of frequent exposure makes it is more difficult for a nurse to quickly see whether a patient follows the expected trajectory towards recovery or whether there are early warning signs of complications.”

Failing to pick up complications can lead to adverse events going to the coroner or health and disability commissioner’s office.

The interruptible health profession

It is colleagues not call bells that continuously interrupt nurses’ workflow, says Teekman, after closely observing general ward life for his research.

Patients told him they “felt sorry” for busy nurses, so they held off using their call-button or waited until a nurse happened to come into a room. But other members of the multi-disciplinary team (which has expanded significantly), nursing colleagues, and visitors felt less compunction at interrupting nurses, which along with phone calls and missing equipment and files, constantly broke up the workflow. He says because so many services have been outsourced in the drive for efficiency, nurses have become the default team member who spends hours searching for missing pharmaceuticals, unavailable dressings or equipment, insufficient linen, and many other essentials.

Nurses were seen as an ‘interruptible workforce’ to the point that Teekman observed on more than one occasion a nurse setting out medication for a patient only to be disrupted by a doctor asking for, and then walking away with, the patient’s drug chart for a ward round.

“What does this say about the value of nurses’ work?”

“If a doctor can’t find a file or something they need for a patient, they go to a nurse,” says Teekman. Standing in a corridor one day, he watched a physio and a doctor bypass a group of talking doctors to find a nurse to answer their question.

“I think nursing has always answered to the medical profession to a degree … but the health reforms of the 1990s have placed another layer on top of it, and that’s management. So nursing now in effect has a new master – the general manager – who says this is the way nurses have to work. As a result of that, nurses have lost their autonomy.

“Now in general wards nurses are ruled by the routines that have been placed upon them by generic management principles, and by ‘keeping to these rules’, the nurses themselves are continuously reinforcing work practices even if they are undesirable (Giddens’ structuration theory in action).

“Nurses in the interviews would suddenly say: ‘Oh, yes, now I come to think of it, I can’t remember the last time I saw a nurse sitting at a patient’s bedside’.

“Now, if you are a nurse, you know that is something nurses frequently used to do, particularly with a patient who was anxious or a patient who wanted to ask questions … now it’s more likely they would give the patient a pamphlet … and there’s an assumption that the patient will read it or that they can read it and understand it.”

Focus on patients lost

Teekman believes that while the rhetoric of modern health care is all “patient-centred” the managerial culture introduced from the 1990s onwards means the reality is “very, very different”.

He says you could crudely sum it up that the ward nurses’ focus is now directed to looking after the organisation’s needs and routines rather than the patients. Including plugging the gaps left by other members of the multi-disciplinary team – so senior nurses support junior doctors and nurses pick-up drugs that pharmacists can’t deliver. All of these activities impact on the actual time nurses need to do their own nursing role.

“It’s worryingly different. It concerns me a great deal when I talk to a student who cries, ‘I wanted to do all these things for my patient, and I’m frustrated because I’ve not been able to give the care I wanted to give’. When you hear these things you really wonder what are we doing, and why is this continuing?”

Teekman says he has come to the conclusion that autonomy is not something nurses will be given – it is something that nurses need to claim back. He stresses that his research and focus is on nurses caught in the routines of generalist med/surg wards. Clinical nurse specialists that came into the wards did have the autonomy and the time to focus on their patients. These nurses were able to carry out a complete assessment and used that information to write an individualised care plan. Teekman says ward nurses also have the knowledge and the skills to do that kind of work – what they don’t have is the time or the required level of autonomy.

“As long as nurses don’t claim it, they will not have autonomy over the profession of nursing.”

Bert Teekman RN PhD is the Programme Director for Massey University’s Bachelor of Nursing programme

TrendCare: the building block for Care Capacity Demand Management (CCDM)

The TrendCare patient acuity and workload management system was developed in Australia nearly two decades ago.

It is being used as the main building block for the care capacity demand management (CCDM) system developed by the Safe Staffing Healthy Workplaces (SSHW) unit. The unit is a joint venture between the 20 district health boards and the New Zealand Nurses Organisation and grew out of a safe staffing inquiry report in 2006.

CCDM was tested and evolved in three demonstration DHBs during 2010–11. It is now used in 13 DHBs and is soon to be rolled out to 16 DHBs.

It uses TrendCare data to not only retrospectively measure and analyse workload – both core nursing and non-core administration – on a ward but in real time recognise when a ward is understaffed or predict ahead when more staff need to be added to a roster.

The recent NZNO Employment Survey 2013 (see also other box) sought comments from respondents in workplaces with CCDM/TrendCare. About 25 per cent were aware of having a CCDM system and the survey authors say there was “evidence of a feeling of patchy implementation and variable benefit.”

“Nearly half of those who knew about CCDM in their workplace felt uninformed about TrendCare and around a third used it.”

About a third believed CCDM/TrendCare had had no impact on their workload and only 3.5 per cent believed CCDM was improving their workload management.

The authors added that additional comments were made about TrendCare, none of them were positive and the following comment was representative of comments.

“….trend care (sic) is an absolute waste of time it does not work in real life …//… it is a joke the management is really fast to remove staff when they feel that we are overstaffed but never seem to replace staff when we need it.”

TrendCare’s electronic tool calculates an estimate of the hours required for nursing care (based on patient acuity information and average care times) and how many actual nursing hours are available that shift (after subtracting the non-core hours required for other activities like training and orientation).

A nurse fills in the acuity profile for each patient under their care using one of the 110 different patient type profiles.

TrendCare says it should take 10–15 seconds for a nurse to use their clinical judgement to fill in an acuity profile by selecting the appropriate variable for each acuity indicator – i.e. whether they can feed themselves or not, have continence issues, need extra emotional support, and their mobility level.

The tool then calculates the nursing hours requirement for that patient based on data built on timing studies of patient care.

Reviewed and upgraded

Cherrie Lowe says the acuity system is “constantly reviewed and upgraded” through ongoing timing studies across a wide range of user sites.

“They are reasonable averages considering an average skill mix of nursing,” says Lowe.

She says TrendCare is based on 20 years of research and development, the first decade in Australia but the last decade also in New Zealand and Asia.

Lowe agrees that patient acuity is increasing due to an ageing population, increasing co-morbidities, shorter length of stay, and increased surgery for high-risk patients, and this was reflected in TrendCare data.

“Nurses as a profession need evidence of increasing workloads and this requires a scientific approach to measuring nursing workloads on a daily basis,” says Lowe.

“Adequate funding for nursing services in New Zealand can only be achieved if nurses provide this evidence in an organised and uniform way.”

She says like any tool, its benefits to nurses are determined by their skill and accuracy and recommends that “inter-rate reliability testing” of TrendCare users needs to be done annually to maintain skills and confidence in the system.

“Nurses can become discontent with the system when they are not appropriately trained and/or competency based.”


What do nurses think about nursing today?

Some findings from NZNO Employment Survey 2013

  • 46.4 per cent felt there were enough nurses where they worked to meet patient needs (public hospital nurses were least likely to report enough nurses).
  • Two-thirds reported that having “too few nurses to provide safe care” was the most common unsafe event.
  • Patient load, throughput, and acuity were all cited as having risen.
  • Nearly one in five nurses were currently job-hunting, with half of those looking to nurse overseas or leave nursing altogether.
  • 24 per cent had been affected by significant restructuring in their main employment in the past two years, including loss of senior leadership positions and reduction in nursing skill mix.
  • 44 per cent said the restructuring had damaged their feelings about their employer.
  • 82 per cent were positive about nursing as a career, 81 per cent were positive about their job satisfaction, and nearly 93 per cent believed the quality of care provided at their workplace was good.
  • Half felt their workload was too heavy, about 60 per cent did not believe they were well paid for the work they did, and about 45 per cent felt under too much pressure at work.

*Our Nursing Workforce: “For Close Observation”, NZ Employment Survey 2013, authors Dr Leonie Walker and Dr Jill Clendon, NZNO.

**The 3rd biennial web-based survey of NZNO members was sent out to a ten per cent random sample (4571) of the NZNO’s RN and EN membership in February 2013. There were 1448 responses, which was a 32 per cent response rate.