Resource allocation and rationing in nursing care: A discussion paper.

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.

Modeling Missed Care: Implications for Evidence-Based Practice.

BACKGROUND: There is a growing nursing literature that views missed care as an inevitable consequence of work intensification associated with the rationing of nursing and material resources available to deliver care. Global studies recognize that missed care is now ubiquitous, although studies tend to be conducted in one region, rather than nationwide. This study seeks to understand the Australian context of missed care. AIMS: To explore self-reported reasons for missed care and to identify the main factors for predicting missed care within a sample of Australian nurses and midwives working in public and private hospitals in New South Wales, Victoria, Tasmania, and South Australia. METHODS: A nonexperimental, descriptive method using Kalisch's (2006) MISSCARE survey was used. Responses from 1,195 nursing and midwifery staff with differing qualifications, English language skills, and Australian employment settings were analyzed using Rasch analysis and then modeled using the Structural Equation Modeling. RESULTS: The frequency of missed care on the morning shift directly impacted on higher priority care missed during the afternoon shift. Staff skill mix imbalances and perceived inadequacy of staff numbers for the work demands further exacerbated all aspects of care during afternoon shifts. Other major factors associated with missed care were the different clinical work settings and staff to patient ratios. LINKING EVIDENCE TO ACTION: The incidences, types, and reasons behind missed care are a multidimensional construct which can be predicted when known significant factors behind missed care are simultaneously accounted for.

Missed nursing care as an 'art form': The contradictions of nurses as carers.

This article draws on the free-text commentaries from trans-Tasman studies that used the MISSCARE questionnaire to explore the reasons why nurses miss care. In this paper, we examine the idea that nurses perpetuate a self-effacing approach to care, at the expense of patient care and professional accountability, using what they describe as the art of nursing to frame their claims of both nursing care and missed nursing care. We use historical dialogue alongside a paradigmatic analysis to examine why nurses allow themselves to continue working within settings that put their professional/personal selves aside in an attempt to deliver care within constraints that make completing care an impossible task. The findings suggest an ambivalence and conflict confront nurses attempting to provide care within the New Public Management environment. This can be seen in the tensions that draw a line between care as an art, and care as a financial target, juxtaposed with the inherent clash of values arising from the way nursing care is conceptualised within two contradictory paradigms.

Nursing and the ethnographic accomplishment.

This issue of Nurse Researcher focuses on ethnographic research in nursing. The three themed papers provide an overview of the ethnographic accomplishment dealing with methodological issues in the conduct of ethnographic work and how nursing and nurses' work is represented. The authors take account of how contemporary approaches to ethnography are shaped by understandings of and approaches to nursing.

Situation awareness: when nurses decide to admit or not admit a person with mental illness as an involuntary patient.

AIM: This paper will explore the application of situation awareness in nursing to determine its suitability as a framework to study how the decision to admit or not admit a person as an involuntary patient is made. BACKGROUND: The decision by a specially qualified nurse to admit or not admit a person to a mental health facility against their will remains a central component of contemporary mental health legislation. The decision has an impact on a person's autonomy and human rights. Conversely, the decision to admit may facilitate urgent assessment and treatment and ensure the safety of the individual and others. Research highlights that decision-making in this context is challenging due to the multiple information sources and often incomplete information available to the clinician. Situation awareness is a concept used to explain how practitioners identify, use and make meaning of a multitude of factors and elements relevant to their practice. DESIGN: Discussion paper. DATA SOURCES: A search of terms related to situation awareness and mental health nursing was conducted in the period 2000 - present. IMPLICATIONS FOR NURSING: Exploring nurses decision-making using a situation awareness framework provides for a more nuanced understanding of nurses knowledge and skill when deciding to admit or not a person as an involuntary patient. CONCLUSION: The concept of situation awareness provides a framework to better understand the decision-making process associated with the involuntary admission decision.

The impact of rationing of health resources on capacity of Australian public sector nurses to deliver nursing care after-hours: a qualitative study.

Australia, along with other countries, has introduced New Public Management (NPM) into public sector hospitals in an effort to contain healthcare costs. NPM is associated with outsourcing of service provision, the meeting of government performance indicators, workforce flexibility and rationing of resources. This study explores the impact of rationing of staffing and other resources upon delivery of care outside of business hours. Data was collected through semistructured interviews conducted with 21 nurses working in 2 large Australian metropolitan hospitals. Participants identified four strategies associated with NPM which add to workload after-hours and impacted on the capacity to deliver nursing care. These were functional flexibility, vertical substitution of staff, meeting externally established performance indicators and outsourcing. We conclude that cost containment alongside of the meeting of performance indicators has extended work traditionally performed during business hours beyond those hours when less staffing and material resources are available. This adds to nursing workload and potentially contributes to incomplete nursing care.

Rounding, work intensification and new public management.

In this study, we argue that contemporary nursing care has been overtaken by new public management strategies aimed at curtailing budgets in the public hospital sector in Australia. Drawing on qualitative interviews with 15 nurses from one public acute hospital with supporting documentary evidence, we demonstrate what happens to nursing work when management imposes rounding as a risk reduction strategy. In the case study outlined rounding was introduced across all wards in response to missed care, which in turn arose as a result of work intensification produced by efficiency, productivity, effectiveness and accountability demands. Rounding is a commercially sponsored practice consistent with new public management. Our study illustrates the impact that new public management strategies such as rounding have on how nurses work, both in terms of work intensity and in who controls their labour.

Factors influencing why nursing care is missed.

AIMS AND OBJECTIVES: This study explores the reasons nurses identify missed care and what factors account for this variance in nursing practice. Second, the study seeks to understand if the identified reasons behind missed care interact with one another and form a multidimensional construct. BACKGROUND: This study draws on the results of previous research conducted by Kalisch in developing the MISSCARE research survey tool and now applies it to an Australian context. DESIGN: This study engages a nonexperimental exploratory approach where 16 latent variables are identified and estimated using structural equation modelling to determine the capacity each of these factors has in predicting the reasons for reported missed nursing care. METHODS: Data were obtained from an electronic survey sent to nursing members of the Australian Nursing and Midwifery Federation of South Australia. A self-report, Likert-type instrument was used to capture the strength and direction of consensus derived from a sample of 289 nurses and midwives. RESULTS/FINDINGS: Eight variables were identified as having direct predictor effects as to why nursing care was being missed, and included shift type, nursing resource allocation, health professional communication, workload intensity, workload predictability, the nurses' satisfaction with their current job and their intention to remain working. Additional indirect effects of other variables explained 34% of the variance of the total scores for why nursing care was reported as being missed. CONCLUSION: Historically, the MISSCARE survey has identified and quantified what types of nursing care is missed. This paper takes this concept further by producing an interactional model identifying the effects different variables have on why nursing care is missed. RELEVANCE TO CLINICAL PRACTICE: These Australian findings not only contribute to other international studies that identify why nursing care is omitted, it provides a framework for why reported episodes of missed care can be predicted and subsequently addressed.

Nurses and midwives perceptions of missed nursing care--A South Australian study.

BACKGROUND: Budgetary restrictions and shorter hospital admission times have increased demands upon nursing time leading to nurses missing or rationing care. Previous research studies involving perceptions of missed care have predominantly occurred outside of Australia. This paper reports findings from the first South Australian study to explore missed nursing care. AIM: To determine and explore nurses' perceptions of reasons for missed care within the South Australian context and across a variety of healthcare settings. METHOD: The survey was a collaborative venture between the Flinders University of South Australia, After Hours Nurse Staffing Work Intensity and Quality of Care project team and the Australian Nursing and Midwifery Federation, SA Branch. Electronic invitations using Survey Monkey were sent to randomly selected nurses and midwives and available online for two months. Three hundred and fifty-four nurses and midwives responded. This paper reports qualitative data from answers to the open questions. FINDINGS: Three main reasons for missed care were determined as: competing demands that reduce time for patient care; ineffective methods for determining staffing levels; and skill mix including inadequate staff numbers. These broad issues represented participants' perceptions of missed care. CONCLUSION: Issues around staffing levels, skill mix and the ability to predict workload play a major role in the delivery of care. This study identified the increasing work demands on nurses/midwifes. Solutions to the rationing of care need further exploration.

Mapping social processes at work in nursing knowledge development.

In this paper, we suggest a blueprint for combining bibliometrics and critical analysis as a way to review published scientific works in nursing. This new approach is neither a systematic review nor meta-analysis. Instead, it is a way for researchers and clinicians to understand how and why current nursing knowledge developed as it did. Our approach will enable consumers and producers of nursing knowledge to recognize and take into account the social processes involved in the development, evaluation, and utilization of new nursing knowledge. We offer a rationale and a strategy for examining the socially-sanctioned actions by which nurse scientists signal to readers the boundaries of their thinking about a problem, the roots of their ideas, and the significance of their work. These actions - based on social processes of authority, credibility, and prestige - have bearing on the careers of nurse scientists and on the ways the knowledge they create enters into the everyday world of nurse clinicians and determines their actions at the bedside, as well as their opportunities for advancement.

Relocating care: negotiating nursing skillmix in a mental health unit for older adults.

Mental health care in Australia in the last 20 years has moved from stand-alone psychiatric hospitals to general hospitals and the community. This paper reports an action research project exploring the experiences of nurses on an acute mental health unit for older adults staffed with a skillmix of mental health and general nurses, which recently transitioned from a psychiatric to a general hospital. The new service provides comprehensive health care, including the management of physical co-morbidity and a recovery orientation. Recovery acknowledges the role and rights of consumers and carers in planning and management of care, choice and individual strengths (Shepherd). The new ward received additional resources to establish the model of care, including a broader skillmix. The paper explores the dynamics of development of a new model of care and of bringing together staff with different professional orientations, cultures and priorities. Focus groups and interviews were conducted with 18 staff. Analysis resulted in three themes relating to the impact of competing goals and foci of care upon professional boundaries; competing organisational cultures and the impact of service change upon work practices. The findings are explored in relation to ideas about health care delivery associated with neoliberalism.

Enterprise bargaining: a case study in the de-intensification of nursing work in Australia.

This paper explores labour negotiations between nurses and government in the public health sector in Australia between 1996 and 2005. During this period, industrial negotiations between nurses and government in the public health sector moved from centralized wage determinations to agreements made at the level of the enterprise through the Workplace Relations Act 1996. Simultaneously, public sector nurses reported increased work intensification, a result of new public management strategies. This led to the Australian Nursing Federation negotiating enterprise agreements that included the introduction of highly specified workload algorithms in an attempt to de-intensify nurses' labour. The irony of this strategy is that these calculations and tools operate as both a human resource mechanism for maximizing productivity as well as an industrial relations tool for reducing work intensification.

Community mental health nursing: keeping pace with care delivery?

The National Mental Health Strategy has been associated with the movement of service delivery into the community, creating greater demand for community services. The literature suggests that the closure of psychiatric beds and earlier discharge from inpatient services, have contributed to an intensification of the workload of community mental health nurses. This paper reports findings from the first stage of an action research project to develop a workload equalization tool for community mental health nurses. The study presents data from focus groups conducted with South Australian community mental health nurses to identify issues that impact upon their workload. Four themes were identified, relating to staffing and workforce issues, clients' characteristics or needs, regional issues, and the impact of the health-care system. The data show that the workload of community mental health nurses is increased by the greater complexity of needs of community mental health clients. Service change has also resulted in poor integration between inpatient and community services and tension between generic case management and specialist roles resulting in nurses undertaking tasks for other case managers. These issues, along with difficulties in recruiting and retaining staff, have led to the intensification of community mental health work and a crisis response to care with less time for targeted interventions.

Measuring the workload of community mental health nurses: a review of the literature.

The movement away from centralised awards along with the intensification of nursing work has provided an impetus for the Australian Nursing Federation to seek the inclusion of workload measurement tools into Enterprise Bargaining Agreements. This paper reports a review of literature undertaken to identify issues relating to workload measures developed for community mental health settings. The issues addressed include:a review of approaches to measuring workload; an evaluation of how applicable these approaches are to community mental health settings; a review of issues that need to be considered in applying a workload measurement tool to community mental health; and the identification of existing workload models for this setting. The paper concludes that activity based models which measure the work undertaken retrospectively are most appropriate for community mental health as they capture the less tangible aspects of community mental health nursing practice.

Ethical elements in priority setting in nursing care: A scoping review.

BACKGROUND: Nurses are often responsible for the care of many patients at the same time and have to prioritise their daily nursing care activities. Prioritising the different assessed care needs and managing consequential conflicting expectations, challenges nurses' professional and moral values. OBJECTIVE: To explore and illustrate the key aspects of the ethical elements of the prioritisation of nursing care and its consequences for nurses. DESIGN, DATA SOURCES AND METHODS: A scoping review was used to analyse existing empirical research on the topics of priority setting, prioritisation and rationing in nursing care, including the related ethical issues. The selection of material was conducted in three stages: research identification using two data bases, CINAHL and MEDLINE. Out of 2024 citations 25 empirical research articles were analysed using inductive content analysis. RESULTS: Nurses prioritised patient care or participated in the decision-making at the bedside and at unit, organisational and at societal levels. Bedside priority setting, the main concern of nurses, focused on patients' daily care needs, prioritising work by essential tasks and participating in priority setting for patients' access to care. Unit level priority setting focused on processes and decisions about bed allocation and fairness. Nurses participated in organisational and societal level priority setting through discussion about the priorities. Studies revealed priorities set by nurses include prioritisation between patient groups, patients having specific diseases, the severity of the patient's situation, age, and the perceived good that treatment and care brings to patients. The negative consequences of priority setting activity were nurses' moral distress, missed care, which impacts on both patient outcomes and nursing professional practice and quality of care compromise. CONCLUSIONS: Analysis of the ethical elements, the causes, concerns and consequences of priority setting, need to be studied further to reveal the underlying causes of priority setting for nursing staff. Prioritising has been reported to be difficult for nurses. Therefore there is a need to study the elements and processes involved in order to determine what type of education and support nurses require to assist them in priority setting.

Evaluating the Performance of a Single-Item, Global, Estimate of Missed Nursing Care.

BACKGROUND AND PURPOSE: Current measures of missed nursing care employ inventories of tasks which are rated for the frequency with which each is missed. These lists have shortcomings for research and clinical evaluation. There is a need for measures with less response burden, wider generalizability, and greater sensitivity and specificity for identifying poor quality care. METHODS: We tested a single-item, global, measure using data from a large study of missed care in Australia. We employed traditional and innovative analysis techniques such as receiver operating characteristic curve and item response theory. RESULTS: The single-item measure had adequate concurrent and convergent validity when compared to one list-format measure of missed care and strong sensitivity and specificity for identifying poor quality care. CONCLUSIONS: A well-crafted single-item measure, such as the one tested, can be useful for measuring missed nursing care.

Nurses' perceptions of the impact of the aged care reform on services for residents in multi-purpose services and residential aged care facilities in rural Australia.

AIM: To understand nurses' perceptions of the impact of the aged care reform on care and services for residents in multi-purpose services (MPS) and residential aged care facilities (RACF) in rural South Australia. METHODS: An interpretative study using semi-structured interviews. Participants comprised registered and enrolled nurses working with aged care residents in rural South Australia. Eleven nurses were interviewed, of these seven worked in MPS and four in RACF. RESULTS: Data were analysed for similarities and differences in participants' experiences of care delivery between MPS and RACF. Common issues were identified relating to funding and resource shortfalls, staffing levels, skill mix and knowledge deficits. Funding and staffing shortfalls in MPS were related by participants to the lower priority given to aged care in allocating resources within MPS. Nurses in these services identified limited specialist knowledge of aged care and care deficits around basic nursing care. Nurses in RACF identified funding and staffing shortfalls arising from empty beds due to the introduction of the accommodation payment. Dependence upon care workers was associated with care deficits in complex care such as pain management, medication review and wound care. CONCLUSION: Further research is needed into the impact of recent reforms on the capacity to deliver quality aged care in rural regions.

Calculating nurse staffing in community mental health and community health settings in South Australia.

AIM: The article reports the development of and data from a preliminary evaluation of a staffing methodology equalization tool (SMET) designed for the South Australian Department of Health to equalize the workload of community mental health and community health nurses working within multidisciplinary teams. BACKGROUND: Shorter admissions, increasing patient acuity, and shortages of beds have intensified the work of community nurses. Existing workload models have limitations for community nursing settings. METHOD: A workload tool for community mental health and community nurses was developed in consultation with a reference group of nurses. A trial was conducted at six sites, and the tool was evaluated using qualitative and quantitative data. RESULTS: The tool increased transparency and equity of workloads in community teams and provided a means of reducing workload through demonstration of a capacity to take new clients, however, further work is required to factor the intensity of caseload into the tool. CONCLUSIONS: The tool needs further evaluation to determine its applicability to a range of clinical settings.

Organizational predicaments: ethical conditions for nursing research.

AIM: This paper highlights the sometimes problematic matter of access to the field in clinical ethnographic research by discussing a hypothetical scenario of an instance of change in the terms of access. BACKGROUND: A review of the methodological literature about research access revealed that there was little in the nursing literature about this issue, although anecdotally many nurse researchers reveal that access is not unproblematic and requires active maintenance to ensure smooth operation of a project. However, in returning to literature in sociology and anthropology, where gaining access for fieldwork is not considered so routine, we found much in the literature about dilemmas, predicaments and conflicts over access, confidentiality and anonymity that were not mentioned in nursing research about access to clinical areas. We returned also to the ethical and legal framework guiding access practices so as to explore the issues in fieldwork situations. DISCUSSION: In exploring the problems arising from maintaining confidentiality, safety of participants and researchers, it is clear that the much-vaunted insider status is both a boon and a burden. Intimate and inquisitive research using ethnographic techniques has the potential to unsettle organizations and workers through the very processes used to undertake the research. CONCLUSION: Ethical comportment is not enough to protect a study. A more overt and less naïve approach to access for fieldwork is required to better inform future nurse researchers how to maintain access to the field and the requirement of constant negotiation and adjustment.