We have no clear way to “ increase the nursing dose .” We rely on clever and articular shift managers , on ward managers communicating their needs to hospital administrators , or reviews of workload models , sometimes in conjunction with nursing unions . So , I would reiterate – we need to promote that higher risk of complications means the need for higher prophylaxis , and nursing care needs to be recognized and recommended as prophylaxis .”
HHM Is the current focus on healthcare professional burnout and nurse exodus from the field peri- and post-pandemic perhaps shedding more light on the issue of missed nursing care ?
KB : The professional burnout has been an ongoing issue , but not really addressed , hence the ongoing issues . The pandemic brought the underlying issues to the fore at a time when even the best health systems in the world are stretched . The National Health Service ( NHS ) reaching its 75th birthday has been highlighted about the conflation of expectations and health management strategies ( See : https :// www . theguardian . com / books / 2023 / jun / 17 / fighting-for-life-by-isabel-hardman-our-nhs-byandrew-seaton-review-the-nhs-at-75 ). The intersection between burnout and missed nursing care , and the factors that can ameliorate them , is a key area for research and intervention . The new attempt at Magnet rollout in Europe attests to this . ( See : https :// www . magnet4europe . eu / and https :// www . magnet4europe . eu / blog-page / four-questions-to-walter-sermeus )
HHM Is the average nurse even aware of the concept of Cascade iatrogenesis ? Is it a concept that should be included in nursing education ?
KB : That ’ s a good question . Certainly , all the undergraduates in my university course would be exposed to this concept ; however , university degrees are often contested with so many specialty areas vying for space . I suspect that as a complex issue it is perhaps not well covered ( it would be a great research project for an honors or PhD student ). Many health organizations don ’ t understand it well ; all over the world we are trying to get the right balance of risk assessment ( sometimes called comprehensive assessment ), and then providing ameliorating or risk-modifying interventions . However , these are in addition to whatever the admitting diagnosis is ( for hospitals , or other health services similarly ). I would argue that cascade iatrogenesis is less the issue , than the ability of the staff to provide comprehensive care . In other research I ’ ve done it ’ s shown that nurses are under such pressure to complete the assessments – that is what is audited – but what care they provide to respond to that assessment is harder to audit . And so , there ’ s a perverse incentive , based on how clinical governance ends up working , that emphasizes the assessment and its documentation rather than the delivery of care . The reason this is an issue in relation to cascade iatrogenesis is that health services struggle to get the right balance to support staff to make decisions about patients that may be deteriorating . Missing someone ’ s cup of tea is a justifiable decision when it means making sure someone else ’ s antibiotic is administered on time . But when multiple cups of tea get missed , and then dehydration occurs , and then that isn ’ t assessed or identified and responded to , then the risk profile for that patient goes up . But arguably a large issue as to why cascade iatrogenesis may be occurring is less about what is taught , as what is translated into practice , and what is sustained based on the work environments . We also need to promote that the higher risk of complications means the need for higher prophylaxis . That sounds logical – when the risk for deep vein thrombosis is higher , there are protocols for clexane or heparin ; when the risk for infection is higher , then there are protocols for antibiotic cover . However , with many of the competing nursing issues – confused patients , long wound dressings , complex medication regimes – there aren ’ t protocols to increase the prophylaxis , because the increased prophylaxis is increased nursing care . We have no clear way to “ increase the nursing dose .” We rely on clever and articular shift managers , on ward managers communicating their needs to hospital administrators , or reviews of workload models , sometimes in conjunction with nursing unions . So , I would reiterate – we need to promote that higher risk of complications means the need for higher prophylaxis , and nursing care needs to be recognized and recommended as prophylaxis .
HHM Do most nurses struggle with their decision to omit care , or is it more of an unconscious occurrence ?
KB : This is a difficult question to answer . The old adage about “ applying the oxygen mask to yourself before helping others ” must be considered . Self-preservation is a natural response under threat – the increased pressure during covid that has intensified the front-line responses as well as public awareness of these tensions . Yes , nurses struggle with any decisions to omit care , but significantly , I would argue for the language of “ rationing ” rather than “ omitting care .” All healthcare gets rationed , all health services make decisions about what they can and can ’ t provide , who ’ s within and who ’ s outside the boundaries of care , which medications make it to the subsidized list , which services are provided to which areas , which rural area gets the next diagnostic scanning machine ( X-ray , MRI , CT , PET ). But the difference with nurses is that it ’ s very direct , it is within the four walls of the ward that the decisions are made , which is all the more reason that the emotional labor of those nurses making the decisions must be considered . Research shows that many nurses leave roles when they are dissatisfied with the quality of care they are able to provide . But equally , yes , nurses will unconsciously omit care . There is research that highlights that some rationing of care can become habitual – that nurses may be used to being busy and get used to using the most streamlined approach they have developed to save them in times of duress . I believe patient teeth-brushing has been habitually sacrificed , and the evidence seems to back this , as one of the most
12 august 2023 • www . healthcarehygienemagazine . com