'Nursing Hours' or 'nursing' hours - a discourse analysis

This thesis is about the business of nursing; the making and remaking of nurses’ work in the context of private healthcare. Nurses in Australia, as in other countries around the world, have experienced considerable workplace changes over the past 15 years due to governments and public and private healthcare organisations seeking to reform healthcare service delivery. These reforms have significantly changed not only how private hospitals manage care, but the nursing role in practice. This ethnographic study explores the impact of these reforms on nurses’ work in one Australian acute care private hospital. It critically examines nurses’ organising practices in light of the workload measurement method used to staff the hospital, unit and ward with minimum staffing. Using Foucault’s (1972) archaeological approach and drawing upon governmentality theory as the analytical framework, I will argue that within the political rationality of neo-liberalism, ‘care’ in nursing is a technology of governance. As such, nurses’ ‘care’ transforms contemporary healthcare policy, in particular policy pertaining to private healthcare, from a macro to the micro level of everyday practice. Care is the means of producing a ‘business savvy’ nurse; someone who is not only an expert clinician with transferable skills but who knows the private health market and is able to work within a competitive business environment. Analysis reveals the contradictions and tensions that exist for nurses between the clinical and economic foci, and the economics and business of health as the nursing role is played out within the organisational imperatives of their work. This study illustrates the shifting boundaries of nurses’ work in relation to the ascendancy of business concerns in healthcare delivery. While methods of workload measurement may well represent what counts as the nursing hours in healthcare organisations, the nurses in this study spoke at length of the strategies they used to make the nursing hours ‘work’. Findings indicate that nurses employ specific discursive strategies when talking about ‘nursing hours’. When addressing their workloads, their discourses centred on the business of care delivery, of nurse-to-patient ‘allocations’ and ‘handover’, or the many instances of ‘handing over’ their work. The study challenges nurses’ professional discourses about what nursing is, what nurses actually do and the sophistication with which this is accomplished at work. Conceiving of nurses’ work in terms of ‘nursing’ hours rather than patients in the business of health service delivery provides a different way of thinking about nursing workforce issues at a time when healthcare organisations and systems worldwide grapple with the question of how many nurses and what kind of nurses they need

After hours nurse staffing, work intensity and quality of care - missed care study: New South Wales public and private sectors. Final report to the New South Wales Nurses and Midwives' Association

The MISSCARE survey was developed by Beatrice Kalisch who defines missed care as “required patient care that is omitted (either in part or in whole) or delayed” and is a response, she claims, to “multiple demands and inadequate resources”. The MISSCARE survey has three components: demographic and workplace data; missed nursing care, which consists of a list of nursing tasks which had been identified; and reasons for missed care. Core nursing tasks routinely omitted in Kalisch’ studies are discharge planning and patient education, emotional support, hygiene and mouth care, documentation of fluid intake and output, ambulation, feeding and general nursing surveillance of the patient. Nurses and midwives consistently attributed instances of missed care to inadequate staffing levels, unexpected heavy workloads, too few resources, lack of supplies, shift rosters with an inappropriate mix of nursing skills, inadequate handovers, orientation to the ward and poor teamwork.The research is funded by a Flinders University Faculty of Health Science Seeding Grant

Gendered relations to working time: enterprise bargaining outcomes in acute care and community nursing settings in Australia

In this paper we examine the outcomes of the 2001, 2004, 2007 Enterprise Bargaining Agreements between the Australian Nursing Federation (SA) and the South Australian Government with particular focus on union-based strategies for de-intensifying nurses’ labour in the acute and community sectors. Consistent with the theoretical and empirical research on time, the strategies employed in the acute sector reflect rational, linear, bureaucratic, logical and masculinist relations to time through the use of computerised time and task measures. Community sector solutions are characterised by cyclical, messy and highly relational feminised approaches to reducing work intensification. We argue that the outcomes of these two approaches are contradictory. The community-based solution of case management is less successful in reducing workload, but maintains worker control over the labour process, while in the acute sector, the highly Taylorist approach is successful in de-intensifying workload but at the cost of reduced control over the labour processes

Rationed or missed nursing care: Report to the ANMF (Victorian Branch)

In May to July 2015, 1683 nurses, midwives and personal care workers (PCW) and Assistants in Nursing (AiN) employed in public and private health facilities in Victoria completed the MISSCARE survey. This represents around 3 percent of the total number of nurses and midwives employed in the state of Victoria. The survey was administered via Survey Monkey by a research team from Flinders University in collaboration with the Victorian branch of the Australian Nursing and Midwifery Federation (ANMF Vic Branch). The Victorian MISSCARE survey is a modification on the original design developed by Beatrice Kalisch (2006). It contains eleven demographic questions, 23 questions dealing with working conditions including questions on staffing tools, 21 questions concerning missed care (care that is omitted, postponed, or incomplete) and 20 questions addressing reasons why care is omitted in the settings in which the nurse/midwives practice. Victoria is the only state in Australia to have mandated nurse-patient ratios. The state of Victoria is experiencing rapid growth in population. Missed nursing care is a global phenomena linked to the rationing of health care. Nurse researchers around the world are recording the levels of missed, delayed or rationed care. Nurses have always rationed care tasks, or prioritised them when work intensifies. Nursing assistants known as health assistants in nursing, have been employed in some public hospitals in Victoria since 2009. Patient satisfaction surveys conducted by the public hospitals in Victoria show high rates of satisfaction with nursing care, and the courtesy of nurses, and low scores for organisational issues such as food, restfulness of hospitals and waiting times. There is some overlap between the patient satisfaction surveys conducted in the public hospital system and the MISSCARE survey such as length of time taken for nurses to respond to call bells, patient education, hand hygiene and medication requests. Sixty-seven percent of nurses in Victoria are employed on a permanent part-time basis. This is higher than NSW where 48.3 percent of nurses are employed part-time permanent. Fifty-six percent of nurses work 30 hours or more in Victoria. Sixty-five percent of nurses and midwives prefer to maintain their current schedule. Over 22 percent of nurses said they worked overtime greater than 20 times in the last 3 months. Thirty-four percent of nurses and midwives worked 2 to 3 shifts over the last 3 months even though they were sick or injured, with 32 percent stating they felt an obligation to their colleagues to go to work. Fifty-three percent of nurses and midwives felt that there were adequate staff between 100 and 75 percent of the time. The remaining 47 percent felt staffing was inadequate between 50 and all of the time. Seventy-three percent of nurses and midwives had less than 9 patients per shift, with eighty-six percent reporting that they had fewer than 5 admissions per shift Rounding appears to be used in 53 percent of situations, although many nurses had not heard of the term. Nursing care tasks most often missed include skin and wound care, and glucose monitoring. The care missed is consistent across all three shifts, although some tasks are more likely to be missed on a particular shift; eg afternoon shift has higher scores for missing the promotion of PRN medications, while night shift staff report the omission of managing parenteral devices. Nursing care tasks such as turning patients, oral hygiene, prompt medication administration and patient education are least missed. Missed nursing care can be categorised into low, intermediate and high treatment. Lower priority care includes emotional support, patient education and discharge planning, and high priority care includes handwashing, IV/CVC lines, call bells, BSL, vital signs. Treatment (intermediate) related care is the most likely form of care to be missed. These include nursing specific tasks such as feeding, turning/positioning, wound care, administering medication on time, ambulation, mouth hygiene, and toileting. This finding is consistent with survey results from NSW. Variables with a direct impact on missed care include the hospital location (rural hospitals report higher rates of missed care), the use of rounding impacts on missed care, and staff adequacy. Reasons for missed care include urgent patient situations and unexpected rises in patient volumes which impact upon staffing issues. While just over 50 percent of nurses thought their ward was adequately staffed 75 to 100 percent of the time, unpredictable work increases such as increased admissions and discharges contribute to missed care. Other important reasons for missed care include: ‘Inadequate skill mix for your area’, ‘an unbalanced patient assignment’ together with an ‘inadequate number of assistive and/or clerical personnel’ and ‘supplies/equipment not available when needed’. Two hundred and eighty four nurses and midwives provided qualitative comments within the survey. Responses illustrated a stronger focus on nursing the budget, with participants indicating they were more aware of financial constraints or the need for profits than previous generations of nurses. Midwives reported that early discharge of mothers curtailed adequate patient education. Nurses and midwives targeted cost constraints, lack of adequate numbers of clerical and ancillary staff, particularly on night duty, the lack of mandated nurse-patient ratios in private hospitals, poor access to medical staff, patient acuity, and competing demands placed on nurses who are at the centre of the ward or unit. Consistent with survey results from other states, lack of access to equipment including medications also impacts on missed care. Nurses in Victoria also indicated that poor communication was a factor in missed care. When nurses were asked about personal issues that impacted on missed care they reported that their capacity to deliver uninterrupted care and an inability to attend case conferences as causing missed care. This was followed by the absence of hospital policies and inability to delegate work to others. The frequencies and types of missed care are significantly influenced by both hospital/clinical unit effects including hospital location and by individual nurse/midwife factors. Missed care shows greater variation within Victorian rural hospitals. The average frequency of missed care on Victorian afternoon and night shifts is significantly less than reported in NSW however, the average frequency of missed care on the Victorian day shift is equivalent to that reported in NSW. Employer type (private or public agency) was not associated with missed care by Victorian respondents The use of rounding practices in the clinical arenas presents as contributing to and preventing missed care dependent upon context. The rate and frequency missed care is defined by the type of care missed. Intermediate treatment related care is more likely to be missed than higher priority and lower priority nursing tasks. In Victoria, the morning shift is associated with the greatest volume of missed care, followed by the then afternoon shift and then the night shift. Country of origin of nursing/midwifery qualifications is associated with significant variation in the frequencies and types of care missed in Victoria. Age of the staff providing care shows a mixed but statistically significant influence on missed care in Victoria. The gender and the level of qualifications held by the Victorian nurse/midwife is associated with significant variations in treatment-related missed care. Staff employment status (both full and part-time employment) demonstrates variance in frequencies of Victorian missed care. The complexity of staffs’ ability to manage daily work tasks shows significance variation in missed care in Victoria.. Dissatisfaction with work teams has a statistically significant influence on Victorian missed care. Current job dissatisfaction has a statistically significant influence on Victorian missed care. Staffs’ self-rated level of their current health and the number of hours they are employed for per week are not associated with Victorian missed care. In order of magnitude, the reasons why Victorian care is missed care are issues associated with the provision of resources for care, communication tensions between care providers, workload (un)predictability, (dis)satisfaction levels with members of the team and workload intensity

Missed nursing care: Report to the Australian Nursing and Midwifery Federation: Tasmanian Branch

Executive Summary • From June through to the end of July 2015, the missed care survey was run through the Australian Nursing and Midwifery Federation Tasmanian Branch. Six hundred and forty eight nurses, midwives and four personal care workers completed the survey. These figures mirror state numbers in terms of gender, and number of RNs to ENs and midwives. • The survey was made up of ten demographic questions, 22 questions that explored working conditions including questions to do with how workload is measured and staff assigned to the ward or unit, 21 questions concerning missed care (care that is omitted, postponed, or not completed) and 19 questions that asked the participants why they believed care was missed. • The survey also included questions on staffing tools, rounding and whether or not nurses considered they worked within their scope of practice. Kalisch defines missed care as “required patient care that is omitted (either in part or in whole) or delayed” and acknowledges that it is a response to “multiple demands and inadequate resources” (Kalisch & Williams 2009, p. 1510). • The proliferation of research on missed care, including the work on rationed care is ensuring that researchers are exploring underlying causation in more depth. To date analysis by the Australian team have focused on the relationship between missed care and work intensification linked to new public management. • Recent research published by Kalisch (2006; 2009; 2012) makes a distinction between missed care as an error of omission (care not given) and missed care as an error of commission (incorrect care). In tracking omitted care, Debney and Kalisch (2015a) have developed a missed care survey for patients which demonstrated considerable consistency with nurses’ perception of missed care. • A significant finding of the patient surveys is the impact of skill mix on missed care. Registered nurses are less likely to miss care than lower grades of care workers. This is attributed to their knowledge and deeper understanding of the importance of timeliness in providing care. • Recently published research by Kalisch et al. (2012), showed that skill mix, leadership and team work are also factors strongly associated with missed care. • Castner et al. (2014) explored missed care during times of hospital merger. Their research demonstrates that unit level factors and individual nurse factors are both contributors to missed care and there is ample evidence of related factors during hospital merger such as re-admissions following early discharge and reduced staffing levels that point to missed care. • Both the Castner et al. (2014) and the Blackman et al. (2015a) studies confirm Kalisch et al. (2015) observation that nurse skill mix and nurse communication are key to reducing missed care. • Studies suggest that highly experienced nurses report more missed care than younger nurses with less years of expereince and these same nurses report major issues with supply and communication problems. It is not clear whether this is because these nurses are more reflective than younger less experienced nurses; intuitively this would seem a reasonable assumption. • One of the managerial responses to missed care is to introduce mandatory rounding. Rounding involves nurses carrying out regular and standardised checks on all patients at set intervals to assess and manage their fundamental care needs. This is usually done on an hourly basis and is promoted as an opportunity for the nurses to involve the patient in their own care, and for them to ensure all is well (Tea, Ellison & Feghali, 2008). • Tasmania is a small state with low population and a resource base limited by low revenue. • Tasmanian health care like the rest of Australia it is a mixed system. There are 27 public and 14 private hospitals in the State. Four of the public hospitals are major providers, the other 23 are rural or community based. These smaller hospitals offer varying services from residential aged care, emergency, primary care and sub-acute and same day surgery. • Health outcomes for Tasmanians are below Australian national averages. This is reflected in lower life expectancy rates for both males and females, and the percentages of the population who smoke, are obese or overweight, as well as prevalence of chronic conditions - all of which are higher than national average. • Health system performance in Tasmania is also below peer hospitals in other states, with outcomes for patients influenced by where they live. • The major reform direction for 2015 and beyond is to organise the sector into one system, rather than three health organisations with specific hospitals operating as centres of excellence. • The concept of universal health care equity and access, the corner stone of the 1983 Medicare agreements has given way to quality and risk reduction, and a stronger focus on medical expertise. • Similar to mainland Australia, people living in Tasmania have access to private health care services. There are 14 private hospitals in Tasmania. However, the number of people with private health insurance in below the national average. • According to the Australian Health Practitioner Regulation Authority Nursing and Midwifery (AHPRA) statistics (March 2015) there are 7989 registered [6429 - 792 male] and enrolled nurses [1426- 127 male] plus 47 with dual qualifications in Tasmania with around 87 of these not practicing. There are 647 nurse/midwives with 7 not practicing and 17 midwives with a single qualification. • One of the confounding issues for Tasmania is remoteness. New South Wales has the highest average available beds per 1,000 population in Remote areas (5.0 beds per 1,000 population) and Tasmania had the lowest (1.5 beds per 1,000 population). • The NEAT target for Tasmania for 2015 is 90 per cent of patients to be attended to in Accident & Emergency (A&E) within the four hour time allocation. Current performance is between 65 and 70 per cent (AIHW 2015; DHHS 2015b). Meeting this target will impact on missed care. Tasmania also has long waits for elective surgery. • Participants reported a broad range of beliefs about the frequency of missed care with the bulk of staff indicating that missed care is occasionally to frequently missed. Staff did not indicate whether that care is always missed or never missed at all. • Missed nursing care can be categorised into treatment related, lower priority (emotional support, patient education and discharge planning) and high priority care (handwashing, IV/CV lines, call bells, BSL, vital signs). Treatment (intermediate) related care is the most likely form of care to be missed. These are nursing specific tasks such as feeding, turning, wound care, medications given on time, ambulation, mouth hygiene, and toileting. This finding is consistent with survey results from NSW and Victoria. • The frequency of missed care across the three shifts does not deviate significantly from each other, in terms of not only missed care frequency but also the different aspects of missed care. • Focused reassessment according to patient condition is missed the most frequently across all shifts, whereas staff hand-washing is missed the least frequently for the same corresponding time periods. • Staffs’ perception of how effective they are in managing their daily work tasks are strong predictors underlying the frequency of and types of missed care • Hospital or unit characteristics including the location of the health care service (regional or city based) and whether the health unit is publicly or privately owned has no effect on missed care during any shift. • Increased day shift missed care is associated with two factors: staff effectiveness in self-managing their work, and the staffs’ level of (dis)satisfaction with being a member of a team in their own workplace. • Nurses/Midwives who experience difficulty managing their daily work, who are not satisfied with their current job, nor their current work rosters, or who are working less than thirty hours per week and believe their clinical areas are not adequately staffed for long periods of time, indicate greater incidences of day treatment-related missed care. • Current job (dis)satisfaction remains a significant influence on missed care during the afternoon shift, particularly with staff employed on a part-time basis. • Staff age, particularly younger staff, are more likely to miss lower priority tasks during afternoon shifts than older staff. • Afternoon and night shift staff link missed treatment-related care to consequence of work rosters and would prefer to change these. • Staff holding a Bachelor’s degree (or above) indicate a greater likelihood for missing higher-priority care tasks during the night shift than staff with hospital qualifications or at diploma level. Length of clinical experience is a factor in missed care; staff with less experience are more likely to miss higher-priority care at night. • Reasons for missed care identified by nurses in order of magnitude are; the provision of resources for care (+0.51), communication tensions between the care providers (+ 0.34), workload predictability (+0.19), issues related to workload intensity (+0.14), and finally satisfaction levels of staff in their role as a team member (-0.15). • Hospital location is a significant factor behind why care is missed. Tasmanian regional sector venues are more likely to be identified as contributing to missed care compared to city based health care venues. • The average frequency of missed care is approximately the same for both morning and afternoon shifts, and is significantly less overall in all shifts compared to NSW and Victorian. • Employer type (private of public agency) was not a factor associated with missed care in Tasmania. • The use of rounding practices in the clinical arenas has produced (a small) negative result in both the frequencies and types of missed care

After hours nurse staffing, work intensity and quality of care - Missed Care Study: South Australia

During November, 2012, the Flinders University After Hours Nurse Staffing, Work Intensity and Quality of Care project team, in collaboration with the Australian Nursing and Midwifery Federation, SA Branch (ANMFSA), administered the MISSCARE survey to a sample of 354 nurse/midwife members of ANMFSA. The survey contained 13 demographic questions, 28 questions that explored working conditions, 96 questions concerning missed nursing care (defined as care that is omitted, postponed, or incomplete) and 17 questions concerning perceived reasons care is omitted in the settings in which the nurse/midwives practice. In addition, respondents were asked to add comments of their own concerning nursing care that is missed and why

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

Author version made available in accordance with the publisher's policy for non-mandated open access submission. Under Elsevier's copyright, non-mandated authors are permitted to make work available in an institutional repository. NOTICE: this is the author’s version of a work that was accepted for publication in Collegian. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in COLLEGIAN, [2014] DOI:10.1016/ j.colegn.2014.09.001Background 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. Recurring issues were identified from qualitative data within the survey and three main reasons for missed care emerged. 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 respondents’ 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

Progress in nursing: multidisciplinary and shared care

Sydney, NS

From de-institutionalisation to neo-Taylorism

Hawthorn Vic