Understanding how nurses ration care

Abstract

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.

Nurses’ views on workload, care rationing and work environments

“…Nurses for these interviews were drawn from the 400 responses to a nation‐wide survey on MNC (Harvey et al., 2018), in which 54 nurses indicated an interest in participating in follow‐up interviews. Ten of these 54 participants were interviewed in an initial first round of interviews.…”

“…The results reported here are drawn from in‐depth interviews with four experienced registered nurses from a range of practice roles. The interviews were undertaken following a wider survey conducted in New Zealand to understand what decisions nurses made when facing care rationing situations (Harvey, Thompson, Willis, Meyer, & Pearson, 2018). In the survey, nurses reported a lack of control over their work, with significant pressure to perform within increasing time constraints.…”

Perceptions of nursing workloads and contributing factors, and their impact on implicit care rationing: A Queensland, Australia study

“…Additionally, nurse managers have not been able adequately to address this issue because of their financial accountability (Newman & Lawler, ). This has resulted in emotional conflict where nurses address patient needs in unpaid time after the completion of their shift (Harvey, Thompson, Willis, Meyer, & Pearson, ). This has been shown to increase the stress and burnout in nurses, a factor confounding missed care (Boos et al, ).…”

A qualitative descriptive inquiry of the influences on nurses’ missed care decision‐making processes in acute hospital paediatric care

“…Our focus on identifying and strengthening nurses’ decision‐making is important, because more information is needed to more fully understand the close working mechanisms locally that influence missed care. Missed care decisions are not taken lightly, and therefore, more in‐depth investigations of missed care decision‐making by nurses, and potential influencing factors, are needed to inform practice developments (Harvey, Thompson, Willis, Meyer, & Pearson, 2018). Understanding the important dimension of decision‐making regarding missed care could help the health care leader to obtain information needed to an early warning system that could identify problems to prevent missed care (Ball et al, 2018).…”