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

Movement Patterns and Muscular Function Before and After Onset of Sports-Related Groin Pain: A Systematic Review with Meta-analysis

BACKGROUND: Sports-related groin pain (SRGP) is a common entity in rotational sports such as football, rugby and hockey, accounting for 12-18 % of injuries each year, with high recurrence rates and often prolonged time away from sport. OBJECTIVE: This systematic review synthesises movement and muscle function findings to better understand deficits and guide rehabilitation. STUDY SELECTION: Prospective and retrospective cross-sectional studies investigating muscle strength, flexibility, cross-sectional area, electromyographic activation onset and magnitude in patients with SRGP were included. SEARCH METHODS: Four databases (MEDLINE, Web of Knowledge, EBSCOhost and EMBASE) were searched in June 2014. Studies were critiqued using a modified version of the Downs and Black Quality Index, and a meta-analysis was performed. RESULTS: Seventeen studies (14 high quality, 3 low quality; 8 prospective and 9 retrospective) were identified. Prospective findings: moderate evidence indicated decreased hip abduction flexibility as a risk factor for SRGP. Limited or very limited evidence suggested that decreased hip adduction strength during isokinetic testing at ~119°/s was a risk factor for SRGP, but no associations were found at ~30°/s or ~210°/s, or with peak torque angle. Decreased hip abductor strength in angular velocity in ~30°/s but not in ~119°/s and ~210°/s was found as a risk factor for SRGP. No relationships were found with hip internal or external rotation range of movement, nor isokinetic knee extension strength. Decreased isokinetic knee flexion strength also was a potential risk factor for SRGP, at a speed ~60°/s. Retrospective findings: there was strong evidence of decreased hip adductor muscle strength during a squeeze test at 45°, and decreased total hip external rotation range of movement (sum of both legs) being associated with SRGP. There was strong evidence of no relationship to abductor muscle strength nor unilateral hip internal and external rotation range of movement. Moderate evidence suggested that increased abduction flexibility and no change in total hip internal rotation range of movement (sum of both legs) were retrospectively associated with SRGP. Limited or very limited evidence (significant findings only) indicated decreased hip adductor muscle strength during 0° and 30° squeeze tests and during an eccentric hip adduction test, but a decrease in the isometric adductors-to-abductors strength ratio at speed 120°/s; decreased abductors-to-adductors activation ratio in the early phase in the moving leg as well as in all three phases in the weight-bearing leg during standing hip flexion; and increased hip flexors strength during isokinetic and decrease in transversus abdominis muscle resting thickness associated with SRGP. CONCLUSIONS: There were a number of significant movement and muscle function associations observed in athletes both prior to and following the onset of SRGP. The strength of findings was hampered by the lack of consistent terminology and diagnostic criteria, with there being clear guides for future research. Nonetheless, these findings should be considered in rehabilitation and prevention planning

Factors influencing missed nursing care for older people following fragility hip fracture

Willis, EM ORCiD: 0000-0001-7576-971XBackground: Older people suffering fragility hip fractures are among the most fragile and vulnerable hospital patients. They often have complex care needs due to pre-existing and chronic conditions which may exacerbate as a consequence of surgery and hospitalisation. When deviations from best practice occur, care can be missed. Aim: To identify factors that influence missed care for the older person with a hip fracture; inform recommendations for change and highlight the need for further research to achieve best practice nursing care for older people following a fragility hip fracture. Methods: A scoping review was conducted using databases Cumulative Index to Nursing and Allied Health Literature, Medline and Scopus, using a combination of keywords. Findings: Twenty-two relevant papers published between 2010-2018 were identified illustrating areas where nursing care was missed for either patients with hip fractures, older patients or both. Discussion: This paper has reviewed literature related to nursing care for older people following a hip fracture to determine what nursing care may be missed; why it is missed and to identify strategies to improve outcomes through reducing the impact of missed nursing care for this population. Existing missed care literature usually focusses upon structural and organisational issues to the detriment of other factors. Conclusion: Missed nursing care for the hospitalised older person with a hip fracture can be organised under three broad themes: organisational factors, nurse and patient characteristics. © 2019 Australian College of Nursing Lt

Missed infection control care and healthcare associated infections:A qualitative study

Background: Research on missed nursing care reveals individual and systems failure. Research on infection control missed care is minimal. Aims: Investigate nurse perceptions of missed infection control. Design: Qualitative in-depth interviews with 11 Australian infection control nurse experts. Methods: Participants were asked whether nursing and hospital-wide care tasks fundamental to infection control were missed, and what were the underlying causes and contributing factors for these omissions. Qualitative data was mapped against fundamental nursing practice and Australian infection control guidelines. Findings: Omission of infection control care occur at the individual clinician and organisational level. Nurses describe failure to perform standard precautions as well as failure to perform basic care activities. Participants identified a range of institutional and cultural factors which contributed to cascade iatrogenesis resulting in healthcare associated infections for patients. Some factors are outside nurses’ control and include: environmental cleanliness; ward layout; ward culture; resourcing and staffing; integration of infection control into clinical governance; action following audit results; and reviewing evidence base of protocols. Discussion: Care occurs in complex and conflicted settings, with prioritisation essential. Potentially harmful practices are generally done with the intention of care. Nurses are key, but not sole performers in the creation of quality infection control. Conclusion: Mapping missed care related to infection control against standard frameworks of nursing practice revealed “gaps in the chain of infection” that contribute to “cascade iatrogenesis” with negative outcomes for patients

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

Comparing infection control and ward nurses' views of the omission of infection control activities using the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey

Aim: To compare the perceptions of nurses with infection control expertise and ward nurses as to what infection control activities are missed and the reasons why these activities are omitted. Background: Infection prevention activities are viewed as important for reducing health care-acquired infections (HAIs) but are often poorly performed. Methods: Data were collected through the Missed Nursing Care Infection Prevention and Control (MNCIPC) Survey delivered to 500 Australian nurses prior to COVID-19. Results: Significant differences were found on the mean scores between infection control and other nurses on ten items. In eight cases, five relating to hand hygiene, infection control specialists viewed the activity as more likely to be missed. Factors viewed as having greater contribution to omission of infection control prevention were as follows: 'Patients have to share bathrooms', 'Urgent patient situation' and 'Unexpected rise in patient volume and/or acuity on the ward/unit'. Infection control nurses were more likely to highlight the role of organisational and management factors in preventing effective infection control. Conclusions: Differences in response between nurses suggest that the extent of omission of infection control precautions may be under-estimated by ward nurses. Implications for Nursing Management: Infection control specialists are more likely to identify organisational barriers to effective infection control than other nurses. Work demands arising from pandemic management may contribute to infection control precautions being missed

Causes of missed nursing care: Qualitative responses to a survey of Australian nurses

There is a growing nursing literature that views missed nursing care as an inevitable consequence of work intensification associated with the rationing of the human and material resources required to deliver care. A modified MISSCARE survey was administered to 4431 nurses and midwives in New South Wales in November 2014. This paper reports on 947 responses to an open question contained in the survey which asked respondents ‘Is there anything else you would like to tell us about missed care?’ Responses were analysed using qualitative content analysis and focused upon both the causes and impact of missed care. Analysis identified two major causes of missed care: the impact of work intensification and staffing issues. Participants associated work intensification with patient acuity and cost containment, while the staffing issues identified included: undermining prescribed staffing ratios; skill mix; changing workloads across shifts; and poor support from other staff. Respondents identified insufficient resources, albeit staffing or other resources, to meet patient care needs reflecting findings in similar studies. Missed or delayed nursing care in this context is associated with resource issues leading nurses to ration the care they can provide. While work intensification is not a new phenomenon, its increasing use in the public hospital sector across a number of OECD countries has become a major consequence of new public management (NPM) strategies aimed at cost containment

Mapping social processes at work in nursing knowledge development

Harvey, CL ORCiD: 0000-0001-9016-8840In 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. © 2014 Wiley Publishing Asia Pty Ltd