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pdf icon Editorial: Missed – unfinished and rationing nursing care – a key indicator of patient´s safety

Lack of nurses has been a discussed global issue for a long time. Its increase in current period in our conditions is just a consequence of chronic postponing its solution. In 2006 International Council of Nurses presented a proposal of complete measures related to possible solutions of a global lack of nurses. The following areas were defined as a priority – macroeconomics and policy of financing health care sector; policy of employment and its planning including regulation; positive working environment and productivity of the organisation; tension, getting new nurses, migration solving and bad distribution in the country; and last but not least the strategies at the stage of leaders. Only 12 years later, Ministry of health in Slovakia presented more complex proposal of solutions for lack of nurses (increase of interest of students to study in medical-oriented fields, stabilisation of health care professionals in the health care system, increase of salaries for non-medical personnel, law amendment related to practice nurses etc.). Precautions mentioned above are of nature of financial solutions, however, fluctuation and departure of nurses often has “non-financial” reasons – working conditions and interpersonal relationships at working place, overloading. For example, in our research in 2013 (Gurková et al, 2013), we found out that satisfaction of nurses with their duties, competencies as well as working schedule and relationship at working place was a significant predictor of considering to quit a job. Their salary did not confirm to be a significant factor.  

As the issue of the lack of health care professionals intensifies, the issue of its impact on quality of patient´s care and safety becomes more significant. In the research, we can find wide scale of evidence of relationship between a number, composition of health care personnel (so called skill mix) and its impact on the patient. Regarding searching for objective indicators, which would directly reflect this relationship, a new term “unfinished” (or implicitly rationing missed care) is being occurred in research studies in Slovakia.

In terminology related to patient´s safety, this concept is linked to the term such as errors of omission representing one of the forms of underuse of care, which is believed by professionals to be more commonly employed than misuse including, for example, medication errors.

The international study RN4CAST, which initially took place in 12 European countries and consequently, it was replicated in other European countries. It was aimed to observation of the impact of organizational features of hospitals on recruitment, retention of nurses, and patient´s care (Aiken et al., 2014, 2017).

I will mention the most cited and significant findings from the study. Increase of workload of nurses by one patient raised the potential risk of patients´ mortality within 30 days from their admission by 7%. Each increase of 10% of a number of personnel by one nurse with a Bachelor´s degree would decrease the potential of patient mortality by 7%. More qualified personnel (the ratio of nurse versus “practice nurse”, healthcare assistants) is related with lower probability of patients´ mortality as well as worse assessment of a hospital by patients, assessment of safety and other results. Other research studies describe in more details misscare as a key factor of development of adverse events and convincing indicator of quality of hospital care. In my opinion, recently, two significant projects have been done in the European research – MISSCARE STUDY GROUP and RANCARE.

Recent published results of MISSCARE STUDY GROUP in the United Kingdom are the results of RN4CAST completed with other significant findings about a number and structure of staff (Griffiths et al., 2018). Every day when a number of nurses at the ward was below the average, the risk of patient mortality increased by 3%. The results differed widely for healthcare assistants. According to the authors, it confirms that the healthcare assistants and practice nurses cannot manage shortcomings in patient safety resulting from shortage of nurses. They also confirm that incomplete care is bright indicator of quality of care and appropriateness of the staff.

The Slovak republic takes part in RANCARE project as well. By means of international of comparison, it is oriented towards analysis of conceptual, organizational, methodological, and ethical aspects of this phenomenon, defining the interventions of its impact and development of educational programmes in this field. During two years, we have organized interdisciplinary panels and workshops dedicated to consensus in translating and defining of Slovak equivalents for terms missed, implicit rationing, unfinished nursing care as well as making comparisons of conceptual definitions and frameworks. In cooperation with universities abroad, we currently deal with testing the tools and their evaluation. We believe that in the near future we will have the results which could serve as a basis for not only the assessment of status quo in Slovakia, but also for analysis of possibilities how to influence it. Despite the fact that this term may bear negative connotations, for example blaming the nurses from missed care). The research in this field highlights system solutions and emphasizes increasing the capacities for care, for example improving teamwork and management. When there is lack of staff, the nurses have to decide about time management which they have for patients. As the research shows, their decision making on who is the priority and how to care about them is intuitive, without any explicit framework or set of rule on defined priority processes which create the base of decision making. We believe that research in this field will deepen understanding to the causes and consequences of this phenomenon in Slovakia. Moreover, it will raise awareness not only among nurses, but also among the stakeholders who determine health policy. Due to its negative impact both on the patients and nurses, it can finally lead to their leave from work, and profession as such.

assoc. prof. Elena Gurková, MN, PhD.
Palacký University Olomouc, Faculty of Health Sciences, Department of Nursing

Literature

AIKEN, L. H. – SLOANE, D. M. – BRUYNEEL, L. – VAN DEN HEEDE, K. –  GRIFFITHS, P. – BUSSE, R. – DIOMIDOUS, M. – KINNUNEN, J. – KÓZKA, M., LESAFFRE, E. – MCHUGH, M. D. – MORENO-CASBAS, M. T. – RAFFERTY, A. M. –  SCHWENDIMANN, R. – SCOTT, P. A. – TISHELMAN, C. – VAN ACHTERBERG, T. –  SERMEUS, W. –  RN4CAST CONSORTIUM. 2014. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. In The Lancet [online], vol. 383, no. 9931, p. 1824-1830. [cit. 2019-03-21]. Available on: https://linkinghub.elsevier.com/retrieve/pii/S0140673613626318.

AIKEN, L. H. – SLOANE, D. – GRIFFITHS, P. – RAFFERTY, A. M. – BRUYNEEL, L., MCHUGH, M. – … & RN4CAST CONSORTIUM. 2017. Nursing skill mix in european hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. In BMJ Quality & Safety [online]vol. 26, no. 7, p. 559-568. [cit. 2019-03-21]. Available on: http://qualitysafety.bmj.com/lookup/doi/10.1136/bmjqs-2016-005567.

GRIFFITHS, P. – MARUOTTI, A. – RECIO SAUCEDO, A. et al. 2018. Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. In BMJ Quality & Safety [online]. [cit. 2019-03-21]. ISSN 2044-5415. Dostupné na internete: http://qualitysafety.bmj.com/lookup/doi/10.1136/bmjqs-2018-008043.

GURKOVÁ, E. – SOÓSOVÁ, M.S. – HAROKOVÁ, S. – ŽIAKOVÁ K. – ŠERFELOVÁ R. – ZAMBORIOVÁ. M. 2013. Job satisfaction and leaving intentions of Slovak and Czech nurses. In International Nursing Review [online], 2013, vol. 60, no. 1, p. 112-121 [cit. 2019-03-21]. Available on: http://doi.wiley.com/10.1111/j.1466-7657.2012.01030.x.