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Rationed care a reality in New Zealand hospitals.

Early research into care rationing in some district health boards (DHBs) has revealed it is happening in every unit, and to an alarming degree in some, a symposium on care rationing in Wellington last month was told.

Safe Staffing Healthy Workplaces (SSHW) Unit director Jane Lawless told the symposium that good quality data was vital to force recognition of the problem. She said data had been collected from more than 20 units in six DHBs, providing evidence that care rationing was a reality in New Zealand hospitals.

Nurses were asked to write down what they were doing every 15 minutes, and also to note what they were not doing--if care was missed, unduly delayed, done to a substandard level or inappropriately delegated.

Lawless said collection of the data was "totally reliant on staff willingness and honesty and we have put strong boundaries around this process to ensure their safety."

The unit defines rationed care as: Any occasion when an aspect of a patient's required care is either missed altogether, unduly delayed, performed to a sub-optimal standard or inappropriately delegated to someone not qualified to perform the activity.

The research showed the most commonly rationed care elements were: maintaining a clean and tidy environment, updating care plans, monitoring vital signs, discussing goals and care plans with patients, patient requests for assistance and hygiene.

Lawless said the SSHW Unit wants care rationing data collected as part of the care capacity demand management programme.

She told the symposium that rationed care was a new field of study in New Zealand and the symposium was an important step in starting a "national conversation" about it.

The unit was working with NZNO, DHBs and the Public Service Association (PSA) on safe staffing levels in terms of numbers and hours. But ensuring high quality nursing care was about more than just numbers--it involved leadership, teamwork and resources.

"We are learning about the role of context--when a practitioner walks in to work, the scene is already set for their day. If we deliver them a deficient environment, they are limited in what they can do," Lawless said.

Nursing Council chair Margaret Southwick told the symposium that the council could not, by law, take into account any adverse context a nurse was working in, when investigating her practice.


Lawless said system changes required good quality data which was lacking, so it was hard for the funders and planners to get it right. "Nurses just say: "I'm busy', which is not enough for funders and planners to work with."

Any missed care was undesirable she said, and it was vital that rationed levels of care did not become the new norm, but were regarded as extreme scenarios which needed correction.

The keynote speaker at the symposium, US nurse researcher and academic Dr Beatrice Kalisch, said missed care was the "hidden secret" of hospital care and it made nurses unhappy with their jobs.

Where levels of missed care were higher, nurses were more dissatisfied, leading to higher turnover and nursing shortages, she said.

Kalisch said missed care was now an everyday occurrence in US hospitals. It involved errors of omission, rather than errors of commission, where the focus usually was. "Standard required care is not being done--it is a hidden secret. Nurses know about it and feel miserable about it."

According to her research in US hospitals, missed care was caused by three things--lack of staff, lack of resources, and lack of team work, she said. "It's not that nurses don't want to do a good job--but what system issues get in the way of doing a good job."

Where there was higher staffing, there was less missed care. Lack of resources came from bad organisation where drugs or equipment, in working order, were not available when nurses needed them.

Good teamwork and communication were also a vital part of ensuring proper care. Nurses needed to communicate well with doctors, other nurses, nurse aides and other departments.

Kalisch said she was very interested in teamwork and the difference it could make. "Most nurses don't know how to work well as a team, because no-one has taught them. We assume if you are a good clinician, you can work well as a team--it is not true."

She said she did not blame nurses for not knowing how to work as a team--it was a management issue and nurses should be taught how to do it.

She said basic care was being missed, which did make a difference. For example, if a patient was not ambulated when they should be, they were more likely to get depressed, their wounds healed more slowly and their muscles atrophied. "They walk in but they can't walk out," she said.

According to her US research, the top five missed cares were: ambulation, attending interdisciplinary care conferences, mouth care, timely medication and turning.

And her research said the reasons were: too few staff; the time required for the task; poor use of existing staff; a "not my job" attitude; ineffective delegation; habit; and denial.

Culture and attitude--the intangibles--made a difference, Kalisch said. Her research showed Magnet and non-Magnet hospitals had the same staffing levels, but Magnet hospitals, which had better communication, had less missed care.

The first step in addressing the issue was to admit there was a problem. "We need open dialogue in a non-punitive environment." Then the amount of missed care, and its impact, needed to be measured. And nursing needed to develop a culture of mindfulness, which meant nurses keeping their focus when doing the same things over and over again.

Lawless said the US and New Zealand research had thrown up differing kinds of care being missed or rationed, but that was likely due to differing research methodology, and New Zealand methods needed to shift into line with those used internationally.


Nurses around the country celebrated International Nurses Day (IND) last month in a variety of ways--from offering health checks and information to the public, attending award ceremonies honouring professional practice, listening to speakers address the theme Closing the gap--from evidence to action, to a health-related quiz night.

In Auckland's Aotea Square, around 30 nurses, including "Florence Nightingale", turned out on the day, (Saturday, May 12) promoting the diversity of nursing as a career, offering information on asthma, smoking cessation, breast screening, healthy eating and exercise, and offering blood pressure and blood sugar checks.

Greater Auckland Regional Council chair Sue Sharpe said the celebration had been a real success. "We met retired nurses, members of the public who were very proud of having a nurse in their family, and a retired delegate in her late 70s. Lots of people with a huge amount of nursing history, as well as student nurses, came to see us in our marquees," she said.

Sharpe said it would not be the last time nurses would be out interacting with the public and she thanked all those who had taken part.

Twelve teams of nurses took part in the quiz night held annually to mark IND in Dunedin, with the Waverley Wanderers from Dunedin Hospital emerging victorious. The Southern Regional Council holds a nursing study day each January to raise funds for two $500 scholarships for professional and clinical excellence in nursing and midwifery. This year's winners were surgical nurse Fern Washington and emergency department nurse Carly Hawkins, both of whom will use the money towards postgraduate study.

In Wellington, nursing leaders from academia, the Ministry of Health, district health boards (DHBs) and the private sector joined NZNO delegates and staff at the first IND celebrations organised by the Greater Wellington Regional Council. NZNO policy analyst Marilyn Head and Pharmac's general manager Maori Health, Marama Parore, spoke to the gathering of around 30. "They challenged us to critically examine evidence and to apply it to close gaps in health status--especially between Maori and non-Maori," council chair Grant Brookes said.

NZNO president Nano Tunnicliff, speaking at the Top of the South's celebration, emphasised the importance of the nursing voice at the national policy table and of the importance of evidence to change practice. Be Well nurse Penny Molnar spoke of her two decades of community work, during which she learned a great deal that had stood her in very good stead in her current role at Victory Community Health Centre in one of Nelson's most disadvantaged communities. "My most important work is building relationships with families who have been alienated or who have alienated themselves," she said.

In Christchurch, NZNO delegates organised celebrations in their individual workplaces, Canterbury Regional Council chair Janine Randle said. Executive director of nursing for Canterbury and West Coast DHBs Mary Gordon said, internationally, nurses were fast becoming the first and primary point of contact for health services..

West Coast DHB nurses celebrated with a series of presentations by nurses based on the IND theme, with nurses from other parts of the Coast able to videoconference into Grey Base Hospital for the presentations.

'Invaluable' work

Whanganui Hospital's senior nurses visited every ward in the hospital to acknowledge the invaluable, 24/7 work of nurses. Whanganui District Health Board director of nursing Sandy Blake said the fact 56 per cent of board staff were nurses put their contribution into perspective.

A number of DHBs marked IND with award ceremonies, including Nelson Marlborough DHB. Award winners at the DHB were Nelson Hospital senior surgical nurse Carolyn Anderson, Wairau Hospital high dependency unit and emergency department nurse Sharon North and specialty clinical nurse wound care Suzie Wendlebourn. NZNO nursing policy adviser/researcher Jill Clendon gave a presentation at the DHB's celebrations in Nelson and Blenheim, Social networking for nurses--peril or promise?, which explored both the pitfalls of social media for nurses and its potential to improve practice. Kai Tiaki Nursing New Zealand co-editor Teresa O'Connor also spoke at Nelson and Blenheim on the limitations of the current primary health care (PHC) system to meet the needs of those who need it most.

Waikato DHB held a peer nomination ceremony. Particularly poignant was the nomination of neonatal intensive care (NICU) nurse, Elaine Peters, who was unable to attend as she was terminally ill. Her colleagues arranged for her to see the certificate before she died later that day.

The New Zealand College of PHC Nurses NZNO used the day to publicise the multifarious roles of PHC nurses in communities.

Nurses' 'critical role' in closing income gap

Politicians weighed in, with Labour health spokesperson Maryan Street saying the IND theme was very appropriate, given the increasing gap in health outcomes between the rich and the poor in New Zealand. "Nurses will play a critical and expanding role in closing that gap. Nurses are at the sharp end of health care delivery and they know what it is like for families out there in the community. On this particular day, we thank them for everything they do," she said.

Health Minister Tony Ryall thanked nurses, saying they were "hugely valuable and part of the backbone of our health service". There were many great examples of nurses identifying areas in health that needed improvement, researching a solution and then changing practice to improve services for patients. He cited Wellington Hospital NICU nurse Sandy Bryant, whose research into central-line insertion had changed practice in the unit, leading to a reduction in the unit's bloodstream infection rates, and annual savings of around $500,000.
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Title Annotation:NEWS AND EVENTS
Author:Stodart, Kathy
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jun 1, 2012
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