Care rationing: “we can’t change what we don’t acknowledge”

1 November 2013

JO ANN WALTON* argues that the public ­­– and some health colleagues – still need to be educated on the vital role of both “essential” and “inessential” nursing care.

On two consecutive days in late August, the Dominion Post newspaper ran major stories on its front page about nursing.

The headlines read, “Nurses ration patient care” and “Rationed care cuts deep say patients”. Below the headlines, the stories both reported that across the country nursing shortages were resulting in nurses having to prioritise the care they give to patients.

Reference is made to ‘essential care’, such as giving medication, dressing wounds, and recording observations. ‘Comfort care’, on the other hand, is apparently an inessential kind of attention that includes things like washing patients, cleaning teeth, and rearranging pillows.

It is impossible to know exactly what prompted the news reports, but good evidence backs them up. This includes international research by a consortium that New Zealand’s Professor Jenny Carryer is a member of, and in an opinion piece, she responded to the stories by talking of both care rationing and ‘missed care’ (see News Feed Sept 4 www.nursingreview.co.nz).

Adding to the picture, an independent analysis recently released by the Nursing Council (see story this edition and earlier online News Feed) predicts worsening nursing shortages in the years to come. While stories such as this may deepen concern among some over the safety of our health system, it is good to see them out in the public arena. As TV talkshow host Dr Phil so often says, “we can’t change what we don’t acknowledge”.

Nurses are the eyes and ears of the public health system. Patients are in hospitals for nursing, not for medical care. While the two disciplines must, and do, work closely together, the need for nursing care and assistance is the reason patients are not discharged home.

If nursing care is failing, so is the system. Is this something more people ought to understand? Do patients and their families see nurses as key health workers? Do our medical colleagues understand that patients might just as well be at home if the nursing care they need in hospital is unavailable? Do our health managers and health policy makers grasp this? Of course some do, but in my opinion, there is work to be done in explaining the vital role of nursing to the general public, and indeed, to some of our colleagues.

One way of doing this may be to explain clearly to patients and family members why the care that is ‘missed’ is essential, what is being rationed and what the consequences may be. So when we need to ask for help from patients and their carers they will understand what contribution they are making, and why it is important, not just for comfort, but also for safety’s sake.

The news stories also have me reflecting on the ‘Catch-22’ situation in which we as nurses often find ourselves. Keeping calm and carrying on is standard behaviour for us. When things must be done, we do them. When priorities must be decided, we decide them. Quite rightly we don’t want to make patients worry. Furthermore, when we are overstretched with urgent work, there is no time to think about strategising solutions to our dilemmas.

At the same time, we know that ‘comfort care’ is not inessential. Oral hygiene, skin integrity, and body positioning are basic – not in the sense that they are low priority but because they are fundamental and crucial to health and healing. Many readers will have heard the public outcry and felt professional distress at other news reports of patients left in faeces or in wet beds, or as reported on the radio recently, patients with dementia tied to chairs.

Yet speaking up is neither easy, nor in some cases, effective. Internationally, speaking up publicly about poor care has brought a nasty end to several nurses’ careers in the past decades, although new moves regarding speaking out safely are being implemented in the UK and Canada.

What to do? Learn the processes for registering concern at your workplace. Read the policies. Tell your manager. Put it in writing: calmly, accurately, and specifically. There is nothing quite so powerful in a manager’s hands as good, objective data. Help her or him gather it. Find out about the safe staffing initiatives at your place of work. See if you can work with colleagues to find solutions.

What are the speaking out policies where you work? UK Health Minister Norman Lamb has been reported as considering prosecuting nursing directors of institutions guilty of poor care or neglect. Could that happen here? Your nursing director needs your support to maintain excellent standards of care. We cannot change what we do not acknowledge…

Incidentally, sharing the front page of the Dominion Post with one of those stories about nurses rationing care was a front page article about 18 Wellington buses failing safety checks. They were taken off the road. “We are left with little choice when public safety is at stake,” said police.

What choices do we have? I would love to hear what you think.

*Jo Ann Walton is Professor of Nursing at Victoria University of Wellington and an elected member of the Nursing Council.