"One nurse … six bells ... maths doesn't work" – New Zealand's first missed care research finds, not surprisingly, that missing patient care is a reality in Kiwi nursing, although relatively rare. FIONA CASSIE talks to research leader Dr Clare Harvey about the trends found, including the high level of 'working-when-sick' reported and its link to increased missed care.
Nurses turning up for work despite being sick or injured are more likely to miss or delay patient care, finds recent research.The missed care survey found nearly 70 per cent of nurses surveyed reported recently working while sick, injured, stressed, or fatigued, which the research found was linked to increased likelihood of missed patient care.
Lead researcher Dr Clare Harvey says the working-when-sick phenomenon (presenteeism) findings prompt questions about why nurses feel such a sense of duty to work when apparently unfit. It also asks, "Why do nurses and nurse managers allow this to happen when patient care is clearly compromised?"
With about 200 respondents – and just over half of those in hospital settings – Harvey acknowledges that the small sample size is a major limitation of New Zealand's first missed care study. However, she believes the findings provide a "very insightful overview" of the issues around managing care in an "environment of cost constraint".
Harvey was first involved in the South Australian missed care research survey and is a member of an international research consortium working on the topic. After she moved to Hawke's Bay's EIT nursing school, she and a team of EIT researchers replicated the South Australian study. The research uses the MISSCARE survey tool developed by the field's leading US nurse researcher, Professor Beatrice Kalisch, and has also been used in the US, Turkey, and Lebanon.
Study participants were invited via an email sent out to a random sample of 2345 New Zealand Nurses Organisation registered nurse members; 845 respondents opened the email and 199 (8.5 per cent of the total sample or 23.6 per cent of those who opened the email) went on to complete the survey.
One finding where New Zealand differed from the other countries surveyed to date was that rather than missed care being more common after-hours – when there are fewer nurses, doctors, admin, and other support staff on duty – the levels of missed care were similar across all shifts.
The nurses were asked to rate on a scale of one to five (one = never, 2 = rarely and then up to 5 = always) how often they missed 25 different types of nursing care, from toileting to emotional support (see sample of results in sidebar). The average score across all shifts varied from 1.9 to 2.05, so hovering around the ‘rarely’ level and the most likely care to be missed was ambulation of patients on night shift, which had an average score of 3 (= sometimes).
Of concern when the findings were broken down further was that glucose monitoring was reported as being missed ‘rarely, occasionally, or frequently’ by nearly 50 per cent of the respondents to whom it was applicable.
"While the overall mean score for this element of missed care was low (1.6) … the immediate implications of this care being missed at all are possibly both deleterious and far-reaching."
One of the most significant findings of the New Zealand survey, and the one which Harvey and her research team are to follow up in more depth, was the high levels of presenteeism reported by respondents. Nearly 90 per cent of respondents reported working more than their scheduled hours. 70 per cent reported working while "sick, injured, stressed, or fatigued", with nearly 20 per cent reporting working unwell for more than six shifts in the previous three months and the remainder between one and six shifts.
Harvey says the two main reasons given for working when apparently unfit were feeling obligated to work or because the unit was short-staffed – which included concerns about skill mix and staff experience.
She says missed care coupled with tired staff – who may be working when sick or injured – has implications for patient outcomes, the quality of care, and nurses' own professional practice.
"The risk of creating the potential for adverse clinical events remains unacceptably high when nursing care is missed."
NZ MISSED CARE SURVEY
Five cares MOST likely to be missed or delayed
- Ambulating patients
- Attending ward rounds etc.
- Mouth care
- Fluids monitoring
- Patient washes.
Five cares LEAST likely to be missed or delayed
- Documentation
- Focused re-assessments
- Patient assessments
- Glucose monitoring
- Feeding.
Some key findings
The nurses least likely to report missing patient care worked in the private sector, primary care settings, were full-time and worked 'office hours'.
The nurses most likely to report missing patient care were working in public hospitals or aged care settings, were part-time and worked shifts.
The higher the number of presenteeism or working-when-sick shifts worked, the more likely the nurse was to report missed care.
The older the nurse, the less likely they were to report missing patient cares.
Definitions
Missed care is “any aspect of required patient care that is omitted (either in part or in whole) or delayed” (As defined in the MISSCARE survey tool).
Care rationing is defined as any time that a patient does not receive an aspect of care that professional consensus judged to be in their interests. Care may be delayed, performed to a sub-optimal level, omitted or inappropriately delegated (as defined by Safe Staffing Healthy Workplaces Unit).
Source: Aberrant Work Environments – Rationed Care As System Failure Or Missed Care As Skills Failure? Clare Harvey, Clare Buckley et al., Eastern Institute of Technology, presented at the 2nd Worldwide Nursing Conference in Singapore, June 2014.
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