Impacts of rationing and missed nursing care : challenges and solutions : RANCARE action

This book reveals how economic restrictions and limited healthcare resources, combined with growing care demands due to advanced technology and more care options, have to a great extent contributed to increased workloads for healthcare professionals and put them under pressure to prioritize their work. This has led to the rationing of care, i.e., to decision-making processes on the allocation of scarce resources, especially human resources, and on which care activities take priority over others; in turn, these processes have led to unfinished or missed care, which has serious implications for quality of care and patient safety. Concerns related to nursing shortages and lean staffing practices have increased the awareness of the problem, as patient outcomes are affected by the quality and quantity of care that they receive and led to intensified scientific inquiry into this phenomenon. This book is written by the members of the Rancare Cost Action group, whose aim is to facilitate discussion about rationing of nursing care based on a cross-national comparative approach with implications for practice and professional development. Four working groups investigated four areas for four years: a) the conceptualization of care rationing and methodological inquiries concerning the investigation of the phenomenon, b) exploration of possible solutions and intervention studies, c) the ethical perspective of care rationing and missed care including patients’ rights and possible discrimination, and d) the educational implications, based on an exploration of the level of patient safety training and care rationing, as well as preparing guidelines for managers. The book will be a valuable resource for nurses, allied healthcare professionals, managers, policymakers, researchers, ethical committees, and educators whose goal is to provide better and safer care. Preface 5 Acknowledgments 7 Contents 9 1: Introduction 11 1.1 Introduction 11 References 18 2: Understanding Missed Care: Definitions, Measures, Conceptualizations, Evidence, Prevalence, and Challenges 19 2.1 Introduction 19 2.2 Methods 20 2.3 Conceptual Development and Intersubjectivity 22 2.3.1 Conceptual Terms for an Emotionally Charged Phenomenon 22 2.3.2 Terminology Trends, Translation, Interpretation, and Preference 24 2.3.3 Drawing a Common Conceptual Picture 27 2.3.4 Looking to Other Disciplines 28 2.3.5 Divergent Perspectives Revealed 30 2.4 Prevalence of Missed Care 30 2.4.1 Prevalence of Missed Care in Acute Care 31 2.4.2 Prevalence of Missed Care Reported in Long Care Facilities for the Aged Population 34 2.4.3 Prevalence of Missed Care in the Community 34 2.4.4 Prevalence of Missed Care Reported by Patients and Non-Focal Nurses 35 2.4.5 Prevalence Complexities 36 2.5 Understanding Missed Care: Useful Theoretical Perspectives 38 2.5.1 Microsystem Perspectives on Missed Care 38 2.5.2 Nurse Characteristics 39 2.5.3 Fundamentals of Care 40 2.5.4 Immediate Nurse Work Environment 40 2.5.5 Macrosystem Perspectives of Missed Care 41 2.5.6 Economics and Time Scarcity 41 2.5.7 Integrated System Perspectives of Missed Care 42 2.6 Outcomes of Missed Care 44 2.6.1 Impact of Missed Care on Patient Outcomes in Hospitals 44 2.6.2 Impact of Missed Care on Resident Outcomes in Nursing Home Settings 45 2.6.3 Impact of Missed Care on Client Outcomes in Primary and Community Care 45 2.6.4 Impact of Missed Care from a Patients’ Perspective 45 2.6.5 Impact of Missed Care on Job Outcomes in Hospitals 45 2.7 Summary and Conclusions 46 Appendix. Translation and Preferences of Missed Care Terms 47 References 51 3: Does Rationing of Nursing Care Presuppose an Acceptance of Missed Care? Philosophical and Legal Aspects 58 3.1 Introduction 58 3.2 The Concept of Omission 59 3.2.1 The Philosophical Distinction 59 3.2.2 The Legal Distinction 60 3.2.3 Omissions by Nurses 62 3.3 Allocation and Rationing of Resources 62 3.3.1 The Concept of Rationing in Medical and Nursing Contexts 63 3.4 Missed Nursing Tasks and Their Consequences 64 3.4.1 Nurses’ Assessment of Their Tasks’ Importance 65 3.4.2 Harm Associated with Missed Nursing Actions 65 3.4.3 Does Missed Care Count as a Nursing Error? 66 3.5 Conclusions 67 References 68 4: Studying Missed Care: Designs, Instruments, and Reporting Guidelines 70 4.1 Introduction 70 4.2 Designs to Study Missed Care 71 4.3 Instruments Measuring Missed Care 73 4.3.1 Validation Studies Available 74 4.3.1.1 MISSCARE Survey 74 4.3.1.2 The Basel Extent of Rationing of Nursing Care 93 4.3.1.3 Task Undone Tool 94 4.3.2 The New Frontiers 94 4.3.2.1 The Unfinished Nursing Care Survey 94 4.3.2.2 The Single Global-Item 95 4.3.3 Issues Regarding Missed Care Tools 95 4.4 The RANCARE Guideline—Strengthening tRansparent Reporting of reseArch on uNfinished Nursing CARE 97 4.4.1 The Development of the RANCARE Guidelines 97 4.4.2 The RANCARE Guideline Implications 98 4.5 Summary 102 References 102 5: An Ethical Perspective of Nursing Care Rationing and Missed Care 106 5.1 Introduction 106 5.2 The Nursing Workforce and Access to the Resource of Nursing Care 107 5.3 Nursing Care Rationing and Missed Care from a Societal and Organisational Perspective 109 5.3.1 Nursing Care as a Reflection of Society’s Values 109 5.3.2 The Organisational Basis for Nursing Care Resource Allocation and Rationing 111 5.4 Empirical Descriptive Ethics Perspective 112 5.4.1 Priorities in Society Meet Nursing 113 5.4.2 Priorities in the Delivery of Nursing Care 114 5.4.3 Professional Ethics—Professional Roles, Responsibilities, and Role Conflicts 115 5.5 Missed Nursing Care from the Patient Perspective 116 5.6 Conclusions 118 References 118 6: Research Ethical Reflections in Researching Missed Nursing Care 123 6.1 Introduction 123 6.2 Research Ethics—Regulations and Principles 125 6.2.1 Research Ethical Principles 125 6.3 Discussion 126 6.3.1 Research Ethical Principles at Risk 127 6.3.2 Research Ethical Responsibilities and Implications 129 6.4 Summary 130 References 131 7: Interventions to Reduce and Limit Rationed and Missed Nursing Care: State of the Art and Future Perspectives 134 7.1 Introduction 134 7.2 Teamwork and Staffing: Two Major Matters in Nursing 136 7.2.1 Teamwork 137 7.2.2 Staffing 140 7.3 Improving the Quality of Nursing Care Processes and Care Reminders 140 7.4 Technological Solutions for a Human Problem 142 7.4.1 Telehealth and Telemonitoring 143 7.4.2 Wearable Devices 143 7.4.3 Unobtrusive Sensing for Patient Monitoring 151 7.4.4 Robots 151 7.5 Tackling Methodological Challenges—Implementation Science 152 7.5.1 Developing Complex Interventions 154 7.5.2 Implementing Interventions 154 7.5.3 Evaluating Interventions 155 7.6 Conclusion 155 References 157 8: Patient Safety in Nurse Education 164 8.1 Introduction 164 8.2 Evolution of Patient Safety as an Important Discipline in Healthcare 165 8.3 Missed Nursing Care as a Patient Safety Issue 166 8.4 Nurses Role in Patient Safety 167 8.5 Recommendations for Patient Safety Content in Nurse Education 168 8.6 Evidence from the Literature Regarding Patient Safety Content in Nurse Curriculum 169 8.7 Patient Safety Skills for Nurses 169 8.8 Voicing Concerns 170 8.9 Clinical Training for Patient Safety 171 8.10 The Role of Nurse Educators 171 8.11 Curriculum Regulation 172 8.12 Recognised Frameworks for Teaching Patient Safety to Nurses 173 8.13 Conclusion 175 References 175 9: Good Management and Clinical Leadership: Supporting Quality Patient Care 179 9.1 Concepts of Leadership and Management 179 9.2 Clinical Governance and its Accountability in Nursing 180 9.3 Leading Through Caring for the Nursing Workforce 181 9.4 Managing the Circumstances Resulting from Rationed Care 182 9.5 Building a Good Practice Guide for Nurse Managers, Regarding the Promotion of Patient Safety Through Minimizing Missed Nursing Care 183 9.5.1 Information Informing the Guide 184 9.5.2 The Guide’s Structure 184 9.5.3 Process of Guide Development 185 9.6 Conclusion 186 References 186 10: Synergies During the RANCARE Project: Opportunities for Networking and Establishment of Collaborations 190 10.1 Introduction 190 10.2 Short-Term Scientific Missions (STSM) 191 10.2.1 Research Methodological Approaches on Understanding the Conceptual Dimensions of Missed Nursing Care 191 10.2.2 Managerial Approaches—Leadership Interventions 194 10.2.3 Education 196 10.2.4 Ethical Aspects of Missed Nursing Care 197 10.3 Research Collaborations/Studies on Missed Nursing Care 198 10.4 Other Projects/Visits 200 10.5 Conclusions 201 References 201 Conclusions and the Way Forward 203 This book reveals how economic restrictions and limited healthcare resources, combined with growing care demands due to advanced technology and more care options, have to a great extent contributed to increased workloads for healthcare professionals and put them under pressure to prioritize their work. This has led to the rationing of care, i.e., to decision-making processes on the allocation of scarce resources, especially human resources, and on which care activities take priority over others; in turn, these processes have led to unfinished or missed care, which has serious implications for quality of care and patient safety. Concerns related to nursing shortages and lean staffing practices have increased the awareness of the problem, as patient outcomes are affected by the quality and quantity of care that they receive and led to intensified scientific inquiry into this phenomenon.This book is written by the members of the Rancare Cost Action group, whose aim is to facilitate discussion about rationing of nursing care based on a cross-national comparative approach with implications for practice and professional development. Four working groups investigated four areas for four years: a) the conceptualization of care rationing and methodological inquiries concerning the investigation of the phenomenon, b) exploration of possible solutions and intervention studies, c) the ethical perspective of care rationing and missed care including patients' rights and possible discrimination, and d) the educational implications, based on an exploration of the level of patient safety training and care rationing, as well as preparing guidelines for managers.The book will be a valuable resource for nurses, allied healthcare professionals, managers, policymakers, researchers, ethical committees, and educators whose goal is to provide better and safer care. [Ed.]