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Nurses Voice Concerns on Missed Care

December 19, 2014
EIT research team leader Dr Clare Harvey

EIT research team leader Dr Clare Harvey

Nurses working in hospitals, aged care and New Zealand’s primary health care sector have raised concerns about missed patient care in a survey undertaken by academics at EIT’s Faculty of Education, Humanities and Health Science.

Led by Dr Clare Harvey, a team of seven researchers evaluated the responses of 199 registered nurses to an online survey which sought information about their working conditions and invited responses to questions around elements of missed nursing care and possible reasons for that occurring.

A third of the nurses worked in medical or surgical wards, 15 percent in critical or intensive care, 13 percent in aged care and 12 percent in primary health care.

Although international research suggests that missing care occurs mainly after hours, the New Zealand study indicates that care is missed across all shifts.

Missing care reflected variations in what was considered missed. Some care was considered acceptable to ration rather than to term it missed. Care handed over to the next shift was considered rationed, for example, without suggesting it was compromised care.

Other care that could not be completed or handed over was missed and was considered unavoidable given the environment in which the nurses were working.

More than half of the respondents flagged three significant factors in missing nursing care – a more acute patient workload over their shift, urgent clinical situations and inadequate staff numbers.

A “possible slight anomaly” was that while 60 percent considered their unit adequately staffed for 75 to 100 percent of the time, just over 50 percent cited an inadequate number of staff and incorrect skill mix for the level of care needs of the patient as reasons for care being missed. A third felt that an inadequate number of assistant or administrative staff was a significant reason for missed care.
Just under half considered an unexpected rise in patient volume and heavy discharge, transfer and admission activity were also significant.

Although 75 percent said they were happy with their work schedules, the researchers say the commentaries suggest a workforce that is stressed because the nurses are tired, unable to meet all their patient cares and are feeling somewhat undervalued.

Most (88 percent) said they had worked more than their scheduled working hours over the preceding three months. The research team says “it is clear from the comments that nurses are having to work beyond their shift finish time to complete their workload and that much of this work is unacknowledged and unpaid.”

A large majority (69 percent) also reported working when they were sick, injured, stressed or fatigued. The two main reasons given for doing so were feeling obligated to work or because the unit was short staffed.

The researchers said “the responses suggest that there is an untold agreement that nurses should not let their colleagues down by going off duty when sick. More importantly, however, the information presented suggests that managers are not enforcing the rule of sending staff home when sick.”

The sense of duty and obligation was misplaced and likely to put further strain on already stretched nursing teams.

Asked if they planned on leaving their job, more than 70 percent said they had no plans to do so.

The research team points out that nurses who are not able to use their knowledge and skills become frustrated and are forced to prioritise care, and whatever aspect of care is missed – in part or in whole or delayed – has emotional, professional and legal implications.

The researchers are urging an international approach to achieve a balance in care that is patient centred, managed appropriately and is cost effective.

“Although international research suggests that missing care occurs mainly after hours, the New Zealand study indicates that care is missed across all shifts.”