Research published in a recent report by the BMJ Quality and Safety Journal suggests that initiatives such as the logging of missed care tasks can provide an early warning for healthcare managers, alerting them to the fact that systems may be failing.
The research, carried out with just under 3,000 registered nurses working in general medical or surgical wards in NHS hospitals across the country, required respondents to flag up aspects of routine daily care that were being regularly sacrificed due to pressure of work.
Nurses were asked to monitor thirteen tasks linked to different aspects of nursing care, including patient monitoring, documentation and pain management. They were also asked to rate the quality of care on their wards and assess the quality of the working environment, using the Practice Environment Scale (PES), as well as indicating the complexity of their patients' needs.
Researchers wanted to see whether staffing levels had a significant bearing on episodes of missed care and whether such omissions had an effect on overall perceptions of care quality and patient safety on a ward.
They discovered that on average nurses were unable to complete four out of the 13 tasks listed because of time pressure. 86% of the 2917 nurses questioned said that at least one job on their last shift had not been tackled due to lack of time. The most common tasks left undone were 'talking to and comforting patients' (66%); 'educating patients' (52%) and 'developing or updating care plans' (47%).
Some core nursing duties were also left out, with 7% reporting they had not addressed pain management while 11% had failed to offer treatment or undertake a medical procedure.
On wards nurses rated as 'failing on patient safety', around eight tasks were left undone, compared with around 2.5 tasks on wards rated as 'excellent'. The quality of the working environment was also found to be inferior on wards where more care activities were left undone.
The nurses who participated in the survey were in no doubt that low staffing levels were primarily responsible for episodes of missed care, and - worryingly for managers - nearly half admitted that completing documentation was one of the activities that suffered the most when they were pushed for time.
Although the BMJ report was focused on hospital care, it's easy to see how nurses in other healthcare settings, such as care homes, may be tempted to cut corners on completing record sheets and care plans if they are short of time.
A 2014 report by the Joseph Rowntree Foundation on the role of paperwork in care homes quotes a frontline care worker as saying: "Sometimes in handover we don't see each other, if someone's late or already busy doing something. Without something like this [ie patient documentation] we'd struggle to get up to speed; I know I would – there simply aren't enough hours in the day." Another admitted: "People are taking people to court more often these days. It's about having the information there, so you can say what you're doing. We're doing it in case we get sued."
Damilola Segun, Resident Engagement Officer for C&C Care Homes across London agrees that it is vital to monitor staff performance to ensure patient safety and satisfy the CQC: "With the introduction of the Care Act, the CQC is scrutinizing Care Homes more than ever. Beyond that we owe it to our residents and their relatives to be able to prove we are doing what we can to provide the best care possible. Having all the information recorded can only help.
The authors of the BMJ report have proposed that "hospitals could use a nurse-rated assessment of 'missed care' as an early warning measure to identify wards with inadequate nurse staffing."
In a climate where many healthcare providers are looking to reduce, rather than increase, staffing levels, the authors recognise that their proposal could raise some "difficult questions": but at a time when hospitals and care home managers are already under so much pressure, any initiatives that increase efficiency – or tackle problematical areas of healthcare delivery – must surely be welcomed with open arms.
By: Robert Anderson
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