Understanding the impact and causes of 'failure to attend' on continuity of care for patients with chronic conditions.

AIM: To understand the impact and causes of 'Failure to Attend' (FTA) labelling, of patients with chronic conditions. BACKGROUND: Nurse navigators are registered nurses employed by public hospitals in Queensland, Australia, to coordinate the care of patients with multiple chronic conditions, who frequently miss hospital appointments. The role of the nurse navigator is to improve care management of these patients. Evidence for this is measured through improvement in patient self-management of their conditions, a reduction in preventable hospital admissions and compliance with attendance at outpatient clinics. Failure to attend (FTA) is one measure of hospital utilisation, identifying outpatient appointments that are cancelled or not attended. METHOD: The cohort for this study was patients with multiple chronic conditions, and nurse navigators coordinating their care. Data describing the concept of FTA were thematically analysed twelve months into this three year evaluation. RESULTS: Although the patient is blamed for failing to attend appointments, the reasons appear to be a mixture of systems error/miscommunication between the patient and the health services or social reasons impacting on patient's capacity to attend. Themes emerging from the data were: access barriers; failure to recognise personal stigma of FTA; and bridging the gap. CONCLUSION: The nurse navigators demonstrate their pivotal role in engaging with outpatient services to reduce FTAs whilst helping patients to become confident in dealing with multiple appointments. There are many reasons why a patient is unable to attend a scheduled appointment. The phrase 'Failure to Attend' has distinctly negative connotations and can lead to a sense of blame and shame for those with complex chronic needs. We propose the use of the neutral phrase "appointment did not proceed" to replace FTA. IMPLICATIONS FOR NURSING MANAGEMENT: This article advocates for further consideration of collaborative models that engage the patient in their care journey and for consideration of the language used within the outpatient acute hospital setting, proposing the term 'appointment did not proceed.'

Examining the hurdles in defining the practice of Nurse Navigators.

BACKGROUND: Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care. PURPOSE: A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident. DISCUSSION: Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance. CONCLUSION: Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

Nurses' views on workload, care rationing and work environments.

AIMS: The article examines nurses' experiences to institutionally enforced choices they must make regarding what patient care will be left undone. Cognitive dissonance theory is used to discuss how missed care is reconciled with the nurses' sense of professionalism and feelings of compassion. BACKGROUND: Research into missed nursing care and care rationing is increasing, with an awareness that it impacts on nurses' coping ability. METHODS: In-depth video and telephone interviews were conducted with four experienced nurses who were asked to describe how they made choices regarding required patient care and how they managed care under workload pressures. RESULTS: Thematic analysis of interview narratives revealed four key themes describing the experiences of nurses managing their work: compromising care; incongruity between professional standards and organisational resources; emotional exhaustion; and depersonalization. CONCLUSIONS: Nurses expressed concerns that their professional values regarding patient care are being lost in a quest to achieve financial targets. It raises questions regarding ethical and psychological dilemmas created for workers by work intensification. IMPLICATIONS FOR NURSING MANAGEMENT: Financial effectiveness negatively impacts on nurses' emotional and clinical well-being cannot be easily dismissed, given that cognitive dissonance arises from attempting to provide quality care of patients whilst meeting organisational financial targets.

Exploring the nurse navigator role: A thematic analysis.

BACKGROUND: Patients with complex chronic conditions experience fragmentation of care, unnecessary hospitalization and reduced quality of life, with an increased incidence of poor health outcomes. AIM(S): The aim of this paper was to explore how nurse navigators manage client care. This was achieved through an examination of narratives provided by the nurse navigator that evaluated their scope of practice. METHOD(S): All nurse navigators employed by Queensland Health were invited to participate in a study evaluating the effectiveness of the service. Eighty-four self-reported vignettes were thematically analysed to understand the work from the nurses' perspectives. RESULTS: Two themes emerged from the vignettes. Theme 1, the layers of complexity, is comprised of three sub-themes: the complex patient, the complex system and patient outcomes. Theme 2, professional attributes, has two sub-themes: person-centred care and clinical excellence. CONCLUSION: Navigators innovatively integrate services and address the fragmented nature of the health system. They apply expert clinical and social skills, through consistent and robust communication, to meet the needs of those with multiple chronic conditions. IMPLICATIONS FOR NURSING MANAGEMENT: Results provide insight into the new role, illuminating the work they achieve, despite system complexities.

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.

The evaluation of nurse navigators in chronic and complex care.

AIM: With increasing age and chronicity in populations, the need to reduce the costs of care while enhancing quality and hospital avoidance, is important. Nurse-led co-ordination is one such model of care that supports this approach. The aim of this research was to assess the impact that newly appointed Navigators have on service provision; social and economic impact; nurses' professional quality of life and compassion fatigue; and analysis of the change that has occurred to models of care and service delivery. DESIGN: A concurrent mixed-method approach was selected to address the research aims. METHODS: The research project was funded in July 2018 and will conclude in December 2020. Several cohorts will be studied including; patients assigned to a navigator, patients not assigned to a navigator, family members of patients assigned a navigator; and a sample sized estimated at 140 navigators. DISCUSSION: This study provides a comprehensive international longitudinal and mixed method framework for evaluating the impact of nurse navigators on quality of care outcomes for patients with chronic conditions. IMPACT-WHAT PROBLEM WILL THE STUDY ADDRESS?: Even with specialty focused co-ordinated care, patients get lost in the system, increasing the incidence of non-compliance and exacerbation of condition. Navigators work with patients across service boundaries allowing for care that is patient responsive, and permitting variables in clinical, social and practical elements of care to be addressed in a timely manner. This novel nurse-led approach, supports hospital avoidance and patient self-management, while encouraging expansion and opportunity for the nursing and midwifery workforce.

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.

The information needs of patients receiving procedural sedation in a hospital emergency department.

This research investigated the information needs of patients receiving ED procedural sedation to determine the best format to consistently deliver key information in a way acceptable to all involved. Of particular interest was the question concerning patients' need for receiving written information. A descriptive exploratory study gathered qualitative data through face-to-face interviews and focus groups involving patients, nurses and medical staff. Individual interviews were conducted with eight adult patients following procedural sedation. They identified very few gaps in terms of specific information they needed pertaining to procedural sedation and rejected the need for receiving information in a written format. Their information needs related to a central concern for safety and trust. Focus groups, reflecting on the findings from patients, were conducted with five ED nurses and four emergency medicine consultants/registrars who regularly provided procedural sedation. Themes that emerged from the analysis of data from all three groups identified the issues concerning patient information needs as being: competence and efficiency of staff; explanations of procedures and progress; support person presence; and medico-legal issues. The research confirms that the quality of the patient's ED experience, specifically related to procedural sedation, is enhanced by ED staff, especially nurses, providing them with ongoing and repeated verbal information relevant to their circumstances.

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.

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.

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.

The B4 school check behaviour measures: findings from the Hawke's Bay evaluation.

The Before (B4) School Check is a free health and development check delivered by specifically trained nurses to four year old children throughout New Zealand, aimed to identify and address any health, behavioural, social or developmental concerns that could affect a child's ability to get the most benefit from school. Reported here are the results of an evaluation of the B4 School Checks in Hawke's Bay, focusing specifically on children assessed at the 84 School Check with behaviour issues as determined by the Strengths and Difficulties Questionnaire (SDQ). Health Hawke's Bay (HHB) records were reviewed to understand the number and demographics of the children assessed with behaviour issues at the B4 School Checks up to 31 August 2011, and the interventions to which they were referred. Telephone Interviews were conducted with 36 parents/caregivers of these children to address the questions, what difference did the B4 School Check make to children assessed with behaviour issues and what aspects of the B4 School Check delivery contributed to successful outcomes for these children? Results showed that child behaviour issues in Hawke's Bay were identified in more boys than girls and concentrated in more deprived families. Maori children were represented in numbers disproportional to the regional population. The majority of referrals for child behaviour directed parents/caregivers to non-governmental organisations for family support and parenting programmes. Thematic analysis was applied to the qualitative data derived from the interviews with parents/caregivers and results indicated high levels of satisfaction with the B4 School Check for behaviour and the referred outcomes. Implications for nursing practice arise from these findings in that they identify factors which contribute to what does and does not work well for achieving successful outcomes from the B4 School Check for behaviour.

The clinical nurse specialist in New Zealand: how is the role defined?

New Zealand, like many countries, is developing new advanced nursing practice roles to meet emerging needs. While much has been written about the Nurse Practitioner (NP), the role of Clinical Nurse Specialist (CNS) remains relatively unexplored and lacks national definition. This paper reports the findings from research designed to investigate the role of the CNS and how it is defined by New Zealand District Health Boards (DHBs). The study sought to identify the current requirements and expectations for the CNS role and how it is defined in practice. In 2008, 15 CNS job descriptions were collected from eight DHBs throughout the country generating data that were treated both quantitatively and qualitatively. Overall, few areas of consensus were found regarding the essential requirements for the CNS role and there were inconsistencies in how the roles were defined, most notably concerning requirements for postgraduate qualifications and Professional Development Recognition Programmes. Thematic analysis of the documents generated four key areas relevant to the CNS role. These described the CNS as a leader, a clinical expert, a co-ordinator and an educator. The findings indicate that the CNS role is inconsistently defined in New Zealand, particularly with respect to the postgraduate qualifications required and what is meant by 'expertise'.

Long-term condition management: health professionals' perspectives.

INTRODUCTION: Long-term conditions (LTCs) are the leading cause of morbidity and mortality in New Zealand. The burden upon patients and health care services to manage these conditions has prompted calls for primary care to lead the way in early diagnosis and coordination of LTC care. The purpose of this study was to investigate the perspectives of health professionals in a geographically-isolated region of New Zealand regarding current levels of LTC management to provide direction for future service development. METHODS: Semi-structured, face-to-face interviews conducted in 2009 with 10 purposively sampled health professionals in the primary care field, including four general practitioners, four nurses and two management team personnel, all practising in a regional District Health Board. The resultant data were analysed using a general inductive thematic approach. FINDINGS: Three main themes were identified by the health professionals as being key issues pertaining to the management of LTCs. These are discussed as issues pertaining to management, information and communication and leadership. CONCLUSION: The results showed that LTC management is rated as highly important by health care professionals who are aware of the need to change current delivery methods to improve client outcomes. All those interviewed highlighted issues related to funding as being a significant barrier to implementing innovations in LTC management, including nurse-led services. Plans to develop integrated family health centres, information technology systems and increased collaboration between clinicians were hailed as potential solutions to improving LTC management.