Balancing the scales-Nurses' attempts at meeting family and employer needs in a work-intensified environment.

AIMS: This paper describes findings from a survey conducted in New Zealand exploring nurses' decision-making about when to delay care, delegate care, hand care over or leave care undone. Unanticipated findings identified processes that nurses go through when deciding to take planned/unplanned leave when wards are constrained through budget limitations. BACKGROUND: Missed/rationed care is increasingly the focus of attention in international studies, identifying a complex interplay of organisational, professional and personal factors affecting nurses' decision-making when faced with limited organisational time, human and material resources to provide care. METHODS: The survey presented nurses with Likert-scale questions with option for free text comments. This paper reports on the commentaries about work-life balance. RESULTS: Nurses described workload pressures that lead to rationing care affected them, and the long-term effect on them as individuals. Nurses verbalized the difficulties and associated guilt about taking leaving and sick leave when wards were short staffed. CONCLUSIONS: Nurses consider how their absence will affect the workspace and their home first, considering the impact on themselves last. IMPLICATIONS: The findings may provide valuable insights for nurse managers in relation to workforce allocations and resources where acknowledgement of work-life balance is considered.

Discursive practice - lean thinking, nurses' responsibilities and the cost to care.

PURPOSE: The purpose of this paper is to explore the literature regarding work intensification that is being experienced by nurses, to examine the effects this is having on their capacity to complete care. The authors contend that nurses' inability to provide all the care patients require, has negative implications on their professional responsibility. DESIGN/METHODOLOGY/APPROACH: The authors used institutional ethnography to review the discourse in the literature. This approach supports inquiry through the review of text in order to uncover activities that remain institutionally accepted but unquestioned and hidden. FINDINGS: What the authors found was that the quality and risk management forms an important part of lean thinking, with the organisational culture influencing outcomes; however, the professional cost to nurses has not been fully explored. RESEARCH LIMITATIONS/IMPLICATIONS: The text uncovered inconsistency between what organisations accepted as successful cost savings, and what nurses were experiencing in their attempts to achieve the care in the face of reduced time and human resources. Nurses' attempts at completing care were done at the risk of their own professional accountability. PRACTICAL IMPLICATIONS: Nurses are working in lean and stressful environments and are struggling to complete care within reduced resource allocations. This leads to care rationing, which negatively impacts on nurses' professional practice, and quality of care provision. ORIGINALITY/VALUE: This approach is a departure from the standard qualitative review because the focus is on the textual relationships between what is being advocated by organisations directing cost reduction and what is actioned by the nurses working at the coalface. The discordant standpoints between these two juxtapositions are identified.

Nurse practitioners in aged care settings: a study of general practitioners' and registered nurses' views.

BACKGROUND: This paper draws on a 2015 study in New Zealand that examined perceptions of registered nurses (RNs) and general practitioners (GPs) regarding the role of Nurse Practitioners (NPs) in long-term aged care facilities (LTACF). AIM: To explore the attitudes of RNs and GPs regarding the role of NPs in LTACFs. DESIGN: A descriptive, mixed methods design with a survey and invitation to interview was used. RNs and GPs who provided hospital-level care were invited to participate. FINDINGS: The findings showed RNs and GPs are open to considering the NP role in aged care. However, there remains a lack of understanding of what NPs do. CONCLUSIONS: This study suggests a shift in attitude towards accepting the NP role by RNs and GP working in LTACFs.

Understanding how nurses ration care.

Purpose The purpose of this paper is to explore how nurses make decisions to ration care or leave it undone within a clinical environment that is controlled by systems level cost containment. The authors wanted to find out what professional, personal and organisational factors contribute to that decision-making process. This work follows previous international research that explored missed nursing care using Kalisch and Williams' MISSCARE survey. Design/methodology/approach The authors drew on the care elements used by Kalisch and Williams, asking nurses to tell us how they decided what care to leave out, the conduits for which could include delaying care during a shift, delegating care to another health professional on the same shift, handing care over to staff on the next shift or leaving care undone. Findings The findings suggest that nurses do not readily consider their accountability when deciding what care to leave or delay, instead their priorities focus on the patient and the organisation, the outcomes for which are frequently achieved by completing work after a shift. Originality/value The actions of nurses implicitly rationing care is largely hidden from view, the consequences for which potentially have far reaching effects to the nurses and the patients. This paper raised awareness to hidden issues facing nurses within a cycle of implicitly rationing care, caught between wanting to provide care to their patients, meeting the organisation's directives and ensuring professional safety. Rethinking how care is measured to reflect its unpredictable nature is essential.

Work Intensification and Quality Assurance: Missed Nursing Care.

This article examines nurses' commentaries from a survey conducted in New Zealand that studied contradictions between quality assurance and work intensification in nursing care. Nurse managers were blamed for either avoiding or not recognizing work intensification affecting quality care delivery. However, the data illustrate key structural issues resulting in missed care that impact on patient safety, rather than a problem directly attributable to managers. Until these structural issues are addressed, missed care and adverse events will continue to affect the quality of care.

Technology and the issues facing nursing assessment.

This article describes an investigation into the use of technology and the issues nurses face undertaking nursing assessment. It reports qualitative, descriptive research involving interviews with ten ward nurses from three hospitals in New Zealand. Thematic analysis of the data revealed three key issues: the impact of technology, the influence of early warning systems and nurse autonomy. Results show how clinical decision making around nursing assessment is influenced by technology and the Early Warning Score. These clinical decisions may not always be informed by critical thinking in complex healthcare environments. The article concludes that nurse autonomy, while supported and endorsed in theory, is frequently in conflict with hospital risk-management policies and the use of prescriptive algorithms.

Factors Influencing Outpatient Cardiac Rehabilitation Attendance.

PURPOSE: In the current health climate, the length of stay of cardiac patients in hospital has been decreasing, and this has significantly reduced the time nurses and colleagues have for providing inpatient cardiac rehabilitation (CR). The purpose of this research was to determine if inpatient CR has an influence on outpatient cardiac rehabilitation attendance for women, Maori, and older people. METHODS: An audit of patients discharged from hospital between November 2011 and July 2012 with a diagnosis of acute coronary syndrome were sent a postal questionnaire. FINDINGS: The survey was completed by 143 people: 46% female, 12% Maori, and 70% > 65 years. Only 38% attended outpatient CR on discharge. Reasons for not attending included lack of referral to CR, and 61% understood only some/none of the information given to them while in hospital. The Cardiac Rehabilitation Coordinator most consistently recommended attendance, but this invitation was extended after discharge from hospital. CONCLUSIONS: Attendance at outpatient CR is low and may increase with an improved individualized plan of care including greater cultural considerations and attention to discharge planning. An automatic referral tool as well as following evidence-based guidelines for inpatient care may increase participation rates for CR. CLINICAL RELEVANCE: Nursing staff have the majority of contact with patients and it appears that very few nurses are discussing CR programs with their patients. The information to attend CR should be offered by all of the health professionals patients meet during their stay in hospital.

Why don't nurses consistently take patient respiratory rates?

This is an investigation into nurses' practice of when they would not take and record a patient's respiratory rate. It reports results of qualitative, descriptive research involving interviews with ten ward nurses from three hospitals in New Zealand. Results affirm that, despite it being the most sensitive vital sign for managing patients, nurses acknowledged circumstances in which respiratory rate taking was missed. Reasons were complex and, contrary to expectations, not always associated with the introduction of technology to record other vital signs. Time pressures, work interruptions and rationalised judgements made by experienced nurses all contributed to incidences of missed respiratory rate taking. It is concluded that patient respiratory rate measures do not seem to be highly valued, calling into questions nurses' level of understanding of respiratory physiology, as well as the extent to which intuitive nursing practice is supported by critical analysis.

Perceptions of key influences on effective pre-dialysis nursing care.

With the increasing burden of chronic kidney disease (CKD) in New Zealand (NZ) the number of people requiring pre-dialysis care is increasing. Pre-dialysis nurses play a central role in the delivery of this care. This paper describes and discusses what pre-dialysis nurses perceive to be key influences on effective pre-dialysis nursing care in NZ. It is based on findings from a wider qualitative study that interviewed the majority of NZ pre-dialysis nurses. Following inductive data analysis four main influences were identified. They were: having time from referral to commencement of renal replacement therapy (RRT) to provide adequate education and support; having good access to cultural and other supports and an understanding of differing cultural views of health; the importance of good inter-professional relationships; and support from nursing management and doctors to advance professionally. With the knowledge of the projected increase in patients with CKD, we argue that it is important to ensure the positive aspects of these influences are enhanced in order to ensure effective pre-dialysis nursing care, nurse satisfaction and professional advancement.

Staff beliefs about sexuality in aged residential care.

Expression of sexuality is a lifelong need and a basic human right, yet little is known about how staff in aged care facilities approach and manage the sexuality needs of residents. Fifty-two staff members from the rest home component of aged care facilities in one District Health Board completed a survey anonymously. Findings indicated that while the majority believe residents have sexual needs that should be acknowledged and supported, expression of sexuality often created discomfort and the need was not regularly assessed, or managed by a team approach. Lack of privacy, negative staff and family attitudes plus the difficulty of managing risk make responding to sexuality a complex issue. The combination of individual and institutional barriers suggest that thoughtful and creative team strategies are required to address the sexuality related needs of the older person in residential care.

What do New Zealand pre-dialysis nurses believe to be effective care?

In New Zealand, and globally, the incidence of patients developing chronic kidney disease and entering the pre-dialysis phase is increasing at approximately 6% per year. The specialist pre-dialysis nurse plays a key role in providing care to this complex group of chronically ill people, but as yet no literature indicates what constitutes effective pre-dialysis nursing care. This paper reports on qualitative research that asked a group of New Zealand specialist renal nurses what they believed comprised effective pre-dialysis nursing care. Semi-structured phone interviews were undertaken with eleven pre-dialysis nurses from throughout the country. Through inductive analysis a number of key themes were identified. These were; a strong nurse patient relationship, a comprehensive holistic nursing assessment and timely and appropriate patient education. Commonly used measurable indicators, timely initiation of dialysis and formation of dialysis access prior to treatment, were also considered important but essentially seen as out of the nurse's control. We argue that to ensure pre-dialysis care is effective it is important to not only measure quantifiable parameters but also consider the qualitative elements identified as being at the heart of effective pre-dialysis nursing practice.