infection prevention
infection prevention
By Kelly M . Pyrek
Rationing Rather Than Omitting Care : A Nursing Expert Addresses an Alarming Trend
Kasia Bail , PhD
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In the February 2023 and April 2023 issues of Healthcare Hygiene magazine , we examined the impact of missed nursing care on patient safety as well as infection prevention and control . In this column , we feature a conversation with nursing expert Kasia Bail , PhD , a professor of gerontological nursing at the University of Canberra in Australia , about the tough choices nurses make during every shift .
HHM What do you believe has been the impetus for the recent number of papers on missing care ?
Kasia Bail : Given the time that it takes to establish the research and publish it , I suspect that the surge in numbers has more to do with the prevalence of the issue and the momentum that science gains when there ’ s a phenomenon that justifies examination . Developing and examining evidence is slow and happens incrementally and has been building for the last 20 years .
HHM Did COVID perhaps bring this issue to the forefront ? And how might COVID have exacerbated an already problematic trend of missed nursing care ?
KB : This has certainly been the case and there are publications to support it ( See : https :// qualitysafety . bmj . com / content / 30 / 8 / 639 . abstract ). I would argue that “ missed nursing care ” isn ’ t a new problem so much as it is a labeling of an ongoing issue . Nursing will always , and has always , rationed care in different ways . I think we need to involve the public in choosing what it wants nursing to ration . For example , my older nursing peers will often make jokes about how they used their time during shifts to make sure none of the pillowcase openings were facing the door , and to line up the wheels on the bed . Anecdotally , this was clinically and theoretically practical , to make sure the sand didn ’ t get into the pillowcases and the beds could be wheeled into the operating theatre promptly – various hang-ups from the Crimean War , perhaps . There is no evidence that I ’ m aware of , but one can assume nurses were choosing to use their time on these activities , rather than perhaps talking with patients or supporting family relationships or performing hygiene practices , which might have a stronger evidence base and cultural support now . Pillowcases and trolley wheels might sound like facetious examples , but the point being that the activities that nurses spend time on have always required prioritization ; care has always been rationed . These days , if a nurse must choose between brushing someone ’ s teeth , administering a life-saving antibiotic on time , and admitting a new patient onto the ward so that a new bed can be created in the emergency department , it is logical that the teeth brushing will be the lowest priority . That doesn ’ t mean a nurse chooses not to do it but chooses not to do it right now and may choose to delay it within her shift or to hand it over to the next nurse . In the “ Failure to Maintain ” article I referred to , this kind of nurse decision making as “ in-hospital triage .” I am a strong advocate for a “ nurse interrupted ” button in new digital information systems . Nurses work in multi-tasking , interrupted manners , yet many of the workflows being developed don ’ t recognize this and try to tie the nurse to the computer to complete her documentation . Nurses need to be able to make these decisions about immediate prioritization and be supported in delaying or postponing care but still communicating their need , to create a functional work environment that recognizes the reality of care rationing . Similarly , we need better data to help us make these decisions , and to support resourcing . For example , we often don ’ t have any clear measurable and comparable indicators about patient load – whether patients are self-caring and independent with showers or need bed sponges and two-hour wound dressings . Nurses are the flex of any hospital system , and we rely on their decision making within patient allocations and ward allocations to ensure care continues to be delivered . But that is rarely acknowledged in hospital governance systems , and minimal research . I recommend a key measure is the introduction of International Functional Standard – currently in use in rehabilitation hospitals only – to be included in acute-care hospitals for ICF ( International Classification of Functioning , Disability and Health ). This would still be a crude measure , but it would provide some indication of workload . There are many in use across the world , but many are resource intensive and require nurses to do more work to identify how much work they must do , which is ironic .
Nurses are the flex of any hospital system , and we rely on their decision making within patient allocations and ward allocations to ensure care continues to be delivered . But that is rarely acknowledged in hospital governance systems , and minimal research .”
10 august 2023 • www . healthcarehygienemagazine . com