Priced to care: Factors underpinning missed care

Abstract

This article examines missed care through dialogues examining the perceptions of nurses in regard to missed care occasions. Using a critical discourse analysis (CDA), the study explores the truth claims of participants who describe the challenges they encounter in daily attempts to deliver what they consider effective patient care. These are compared to the mandates of state and organisational policy prescribing clinical practice. The boundaries of tension that are expressed by nurses within the milieu of missed care are explored through in-depth interviews. CDA is interested in social organisation and the interplay of people's activities within it, the focus being on how they construe and internalise such activity. Nurses' perceptions and realities become central to any investigation because they are often organised by more than their own intentions or motivations, with influences such as professional standards or organisational rules subconsciously locating their reality. Instead of identifying occasions of omitted care, nurses spoke of constraints related to budget, staffing, skill mix and mandated policy as constraining their ability to complete care activities. Factors emerged that suggest that missed care is the consequence of routinised and standardised practice, cited as cost effective care, at the expense of professional autonomy.

Keywords

Economic change employee health employee voice organisational culture quality of work life

Introduction

Workforce shortage, stress and working conditions have been topics of interest in nursing for decades (Hayes et al., 2012). For nurses, working conditions directly impact on their ability to provide safe and effective care (Ausserhofer et al., 2013). When those conditions impinge on nurses' ability to carry out their work, then care is missed, rationed or left undone (Jones et al., 2015). It is also known that when making mistakes in care delivery, the resultant emotions of the nurse transcends both personal and professional boundaries that are ethically and morally charged (Oh and Gastmans, 2015). Whilst the emotional connections of nursing work have been explored (Bartram et al., 2012; Biron and Van Veldhoven, 2012; Bolton, 2000), it has not necessarily been examined from the viewpoint of why nurses leave work undone (Kalisch et al., 2009). Moreover, recent literature contends that the emotional labour construct is no longer relevant in today's rapidly changing, technologically driven, health care environment (Johnstone and Hutchinson, 2015). Despite these standpoints on nursing work, it does not detract from the fact that care is routinely missed in today's budget driven health care milieu, and it has a roll on effect on nurses, organisations and above all, patients (Jones et al., 2015; Kalisch and Williams, 2009).

Kalisch and Williams (2009: 211) define missed care as ‘any aspect of required care that is omitted either in part or in whole or delayed’. Jones et al. (2015) identify missed care as a quality issue in the health care industry because it signifies services that have not been provided. If the factors that are associated with the provision of care are limited, absent or obstructed, then the quality of that care affects patient outcomes (Jones et al., 2015).

This article links nurses' commentaries on missed nursing care to the wider implications of patient outcomes and staff satisfaction. The study, based in South Australia (SA), draws on work by Kalisch (2006) who identified key areas of regularly missed nursing care, such as patient mobilisation, pressure area care, feeding of patients, hygiene, patient documentation and education – the reasons for which are influenced by external factors associated with staffing, human and material resources.

Background

Missed nursing care is not a new concept, but with increasing limitations to care budgets the challenge of maintaining the quality of that care is topical (Kalisch and Xie, 2014). Escalating health care costs require governments to develop strategies to reduce the burden of these costs. One strategy has been the introduction of new public management techniques (NPM). NPM has been associated with a range of strategies, including flatter management structures and the creation of administrative units which control the budget for that unit, outsourcing of service delivery, the introduction of performance incentives and the tying of financial bonuses to meeting performance indicators (Willis et al., 2015). Wages as a major component of the health care budget have been managed through enterprise bargaining in which salary increases are tied to improvements in productivity and efficiency, leading to tensions arising from delivering services with reduced staff (Willis et al., 2015). The establishment of performance indicators increases indirect control of nursing work through policies established external to the institution. Studies have shown that human resources in care work is an essential factor, the quality (level of skill) and quantity (ratio of nurse to patient) of which directly impact on patient outcomes (Kalisch et al., 2013). In contemporary health budgets, costing of care resources has followed the NPM system (O'Donnell et al., 2011). Within this setting the recognition of the actual care entailed in keeping the patient safe has not always been realised, because quantity, related to how much care costs, has become more important than the quality of care delivered (Bosa, 2010).

One of the problems with managing care in a cost constrained environment is the fact that care has not been adequately defined and therefore it cannot be measured, because it is ‘demonstrated through [her] emotional attunement and [her] suspicion of the objective/rationale domain’ (Nelson, 2004: 19). Care is thus synonymous with women's work, self-sacrifice and duty – all remnants of the founding years of formal nursing development by such orders and individuals as the Kaiserswerth Deaconesses and Florence Nightingale of the 19th century (Dolan et al., 1983; Nelson and Gordon, 2004). According to Benner (2001), caring is intuitive, something that is experientially developed and, as Nelson (2004: 19) noted, ‘the nurse develops a repertoire of skills to engage in practice that privileges faith over reason, and follows her well-calibrated moral compass through her finely tuned emotional responses’. Thus, measuring care is problematic, because it is emotional and is intuitively managed in which ‘working with patients is reward enough’ (Buresh and Gordon, 2000: 33).

Nursing has attempted to streamline care to meet predicted targets, through the use of technology and systematic care orders to predict care against the human resources required to deliver care, within specific time and activity parameters (Bergh et al., 2014). Examples of this are the development of clinical pathways and protocols which, although they provide opportunity for a financial audit trail to care delivery, have the tendency to become prescriptive (Bail et al., 2009).

These strategies to manage how care is delivered remove the ability of the nurse to provide individualised care, a matter that supports cost containment over the recognition that illness does not follow a predictable path (Safeek and Safeek, 2009). Often this situation is unquestioned, with nurses getting on with business-as-usual so that using a pathway creates unconscious constraints on nurses' professional practice (Harvey, 2010; DeVault, 2013). The juxtaposition thus created becomes evident when nurses' perceptions of care requirements are at odds with the performance targets set out for care delivery (Schubert, 2014). Not only does this create anxiety for the nurses, but it has been shown to influence the quality of care, relational to care left undone or missed (Kalisch et al., 2011).

Method

The SA study used the MISSCARE survey (Kalisch and Williams, 2009), with the addition of participant interviews. This article interrogates one of the key antecedents of missed care – cost containment – by illustrating the way nurses are positioned to operate within the confines of scarce human and material resources, as well as conflicting policy agendas. Texts from two major tertiary hospitals and state government sources were used to analyse findings in order to examine the wider institutional paradigm within which nurses are positioned. Interviews and survey commentaries were analysed using a critical discourse analysis (CDA), allowing analyses of nurses' experiences in managing the care they give to their patients, through a discursive lens that ‘makes documents or texts visible as constituents of social relations’ (Smith, 1984: 59). What we wanted to examine was how nurses described their situation in caring for their patients, vis-a-vis missing care, against the backdrop of targets that are defining the way care is operationalised.

Although Hardy and Thomas (2015: 692) suggest that exploring discourse needs to take into account ‘how discourse is materialized in the production and distribution and consumption of texts’, Smith (1984) and Fairclough (2001) argue that power relations are embedded in everything that occurs in an institution so that texts are used by players to describe their experience, and reflect the policy and philosophy of the organisation. Fairclough (2001: 87) suggests that ‘naturalisation of the meaning of words is an effective way of constraining the contents of discourse and, in the long term, knowledge and beliefs’. Thus, Fairclough (2012: 2) argues that it is not the power in an institution that we need to be examining, but the power ‘behind the discourse’, because it is how ‘people with power shape orders of discourse as well as the social order in general’, and how this is portrayed in general discourse. The focus of attention here is care that is missed (visible) and what drives the reasons for missing care (hidden), made visible in the way it is described by the nurses.

Our analysis explored aspects of practice that have been the subject of recent external policy changes. In this setting, official documents can be examined for what is identified as a problem, for how the problem was defined, and for the language used to construct practice (Bacchi, 2009). The interview and survey data were analysed for nurses' experience of change and the extent to which they internalised and reproduced the dominant discourse. By asking nurses to describe their work in relation to what is missed in the care they provide, a picture is formed of the factors that drive care and how it affects their ability to provide that care.

The MISSCARE questionnaire was delivered to 354 nurses and midwives through Survey Monkey™, sponsored by the Australian Nursing and Midwifery Federation SA Branch. A second data source was official documents, including policy documents, reports and hospital statistics published on the Internet, as well as enterprise bargaining agreements (EBAs).

Recruitment for interviews occurred through information sessions at two large public tertiary hospitals. Twenty-one registered nurses were interviewed. The nurses held a range of roles from senior management to first year registered nurses. All were working in the acute hospital setting, with a range of clinical areas represented, from general medical and surgical wards to specialised units. Nurses were asked to describe their experiences relating to the quality of nursing care offered on after-hours and weekend shifts when ancillary services are scaled back and there are fewer staff on duty. In addition, 843 qualitative comments were reviewed from the MISSCARE survey from the 354 nurses who completed it. Ethics approval was gained from both the Flinders University Social and Behavioural Research Ethics Committee and the South Australian Health Ethics Committee.

Information was analysed against policy directives and literature that allowed for the broader analysis of the themes (Fairclough, 2012; Smith, 1984). Thus, as Smith (1984: 62) notes, texts can be used to ‘objectify knowledge, organization, and decision-processes, distinguishing what individuals do organizationally and discursively, thereby constituting properties of formal organization or of discourse that cannot be attributed to individuals’.

Analysis and discussion

Critical social research allows the use of literature to support analysis of findings (Babbie, 1992; Robson, 1998). This section therefore combined both the analysis of the nurses' commentaries against policy documents relevant to the discussion, and supporting literature around the subject for discussion.

Commentaries by the participants were commonly directed at financially driven directives constraining practice and reducing nurses' ability to effectively do their job, rather than identifying spaces that endorsed opportunity for rationed or missed care. Such financial proclamations intrinsically link nursing knowledge and judgement to the ‘corporate bottom line’ (Campbell, 2001: 233). From the commentaries and interviews, policy directed discourses emerged, of which three are now described.

The paradox of care: Nurse to patient ratios

Balancing the ‘bottom line’ was a predominant feature in many of the comments where participants told of the pressures placed upon them at work:

We don't get paid overtime but have it as time off in lieu.

No fixed hours therefore no overtime entitlement.

[Hospital] is not allowing overtime at all costs therefore we are made to work with what we are given and struggle to achieve workloads often not to our satisfaction (Survey commentary)

Identifying the notion that nurses tend to conform to the requirements at work, one nurse said:

The thing is, instead of accepting that pressure I used to fight back and that's even more wearing, sometimes it's a lot easier just to accept it. (Interview #1)

The increased stress placed upon nurses is evident in the following comment:

Fatigue is common especially when areas are heavy. Sick leave increases as people need time away from the area just to recharge. Perhaps the high sick leave could be eased if management only took the time to look after their staff but rarely is that the case. (Survey commentary)

Staffing is managed using Excelcare™,¹ an internationally recognised computer software program allowing organisations to plan staffing requirements based on patient numbers and their care needs, formulated from predetermined, generic diagnostic-related factors. Nurses on every shift input data on their patient requirements based on these computerised clinical parameters, and then allocations of staff are computed for the next shift. The co-ordination of this is undertaken by specific nurse managers (e.g. Bed Flow Manager). In a recent evaluation on poor productivity in public hospitals in SA, Deloitte Touche Tohmatsu (2012) found that Excelcare provided more nurses per patient than any other state in Australia. Despite this finding, participants indicated that the information collected was not always reflective of patient need or staff requirement, as this participant noted:

The Excelcare hours don't seem to cover the actual care that the patients really need, these are people that we deal with and their care can't be put down on paper as evaluating to the minute. Every person is different but they get their care categorised just the same as every other patient on the ward. (Interview #4)

Although Excelcare has been in place since 1992, care costs have remained an acknowledged impediment in budget overspends. In the 2012–2013 SA State Budget review, conducted by Deloitte Touche Tohmatsu (2012), they identified the need to ‘improve the appropriate controls to reduce nursing labour costs’ through the optimisation of nurse resourcing and rostering, identifying the ‘optimal number of nurses required for the level of activity’ (p. 12). The report advised the need to ‘educate staff on revenue procedures’ (p. 19) and to improve the ‘quantification of the workforce strategy’ (p. 22). The patient features as ‘length of stay’ (LOS) in which services are required to ‘optimise financial performance related to LOS by improving patient flow and service efficiency, thereby capturing or releasing bed capacity to reduce staffing requirements’ (p. 10). Such government strategies reinforce the need to use computerised staffing allocation programs to predict the unpredictable, as described in these responses:

… we're staffing to nursing hours or patient care hours using our Excelcare, so it's quite difficult because unless you actually put a physical patient in that bed, and an Excelcare care plan is actually done, these guys are not going to get the staff they need to actually deliver the nursing care. (Interview #7)

We can do a prediction with Excelcare earlier on [in a shift] but that is reliant on the fact that there is not much change … it's one of those interesting – stuck between a rock and a hard place sometimes, because if ED [Emergency Department] is really busy, your focus is to try and get those patients out of ED, but then you're impacting on the staff on night duty, by getting admissions in, so it's trying to work out where there is the least harm I guess. (Interview #3)

Being ‘stuck between a rock and a hard place’ supports Campbell's (2001) notion that staff decision making is directed by policy rulings rather than the front-line decisions based on clinical judgement. As Knauf et al. (2006: 287) identified however, the cost of inpatient nursing care accounts for the ‘single largest share of a hospital’s budget', and because of the lack of care definition it is best to quantify it in other ways. This does not allow for the recognition that patients tend not to follow specific pathways according to a diagnostic pathology. This was highlighted by a participant:

There has always been a lack of quantity of nursing staff based on the unit of care needed on Excelcare. We may receive a patient on my [xxx] ward that may not be so ill at time of admission, but then their health can decline and you need to spend more time with that patient and your other three patients' care suffers. (Interview #7)

Participants also expressed concern with staff to patient ratios due to ‘unfair allocation of patients’ arising from patient acuity, supporting the idea that patients and care cannot be quantified into a ratio or monetary value:

A large cause of missed care in our ward stems from inadequate staffing. Often we are staffed at less than Excelcare requirements however, even when we are, we are not necessarily adequately staffed. Excelcare allows minimal time for admissions that are not already on the ward so multiple expected surgical patients (who may need full admission, ECG, blood work, etc.) do not change our Excelcare requirements enough to allow for adequate staff. (Survey commentary)

In considering nurses' concerns, Cooke (2006) identified a conflict between the technical control of work and delivery of required care by suggesting that because of the cost constraints in health services, there was a focus on processes that get more for less from the nursing workforce. This was identified by one respondent:

One of my biggest frustrations is my feeling of not getting very much support from senior management. Particularly now we're having so many financial difficulties, the dollar is absolutely the first thing they think of, and so the resources are less and less available. I am at my 70/30 mix with RN's/ENs but, we're not very kind to our staff, we don't look after them, and if we don't care for them, they aren't going to care for their patients, and I'm feeling that more and more. (Interview #11)

In a study by Howard et al. (2013) nurses reported experiencing high workloads with parallel pressures to meet patient needs. Thus, a relationship between inadequate care, burnout of staff and cost-responsive (but staff unfriendly) staffing predictions began to emerge. This was echoed in our survey:

I am on contract and worried if I take any more sick leave my contract will not be extended. I have had 5 sick days in 5 months.

Every time I called in sick past 5 times I was really sick, coordinator asked WHY I was taking sick leaves. The experience traumatised me so even though I'm extremely tired and mentally exhausted, I still come in to work because it's better than being questioned and intimidated.

Maben et al. (2007) also found that skill mix and reduced numbers of nurses was related to patient care being undermined, thus placing unrealistic demands on nurses. This is supported by the following response:

Changes in skill mix has significantly impacted on this. Junior staff are no longer given the time to learn the specialty area before being thrust into senior roles, giving dangerous cytotoxic drugs etc. it seems it is only getting worse unfortunately. The senior staff are leaving and the juniors are feeling very pressured and anxious about their roles. (Survey commentary)

As far back as 1960, hospital reforms were reducing costs and reforming care, with cuts in the workforce being as high as 24% (Sengin and Dreisbach, 1995). Deloitte Touche Tohmatsu have continued that streamlining trend in the advent of NPM in the 1980s. Whilst Alonso et al. (2015) found that there was no improvement in the way care was managed when working to a management model, the Mid Staffordshire Inquiry (Francis, 2013; Newdick, 2014) outlined systems failures in managing care because of its focus on finance that led to the poor maintenance of clinical and professional standards. It sends an alert to activities that increase the mismatch between patient need and financial balancing, a situation that nurses have become entangled with in their efforts to maintain their focus on patient care.

Optimising care: Service performance indicators

Deloitte Touche Tohmatsu (2012) identified that LOS is an important factor in streamlining health care costs. As part of this initiative the SA Government implemented a web based ‘Dashboard’ for the Emergency Department (ED) and the inpatient section (IP), providing updates on patient numbers. The aim of these dashboards is to assist staff to monitor and manage patient flow. Being a public document freely available on the Internet, it delivers information on such activities as the mandated four-hour waiting time in ED as well as a real-time look at all the waiting times in the surrounding hospitals. The IP dashboard provides information of all hospitals in the region related to occupancy, LOS and current inpatient numbers with figures updated every 30 minutes. Whilst this real-time approach to hospital information affords a transparent hospital information system, it has increased public expectations of health service performance, something that Deloitte Touche Tohmatsu (2012) encourages. It also places further stress on the workforce to perform to this response, a factor identified through the state government's incentivised medical officers' ED flow targets, linked to the EBA for Salaried Medical Officers (Government of South Australia, 2013). Further impacting on this are the allocations of time to service linked to predetermined financial incentives based on the states' ability to meet National Access Targets set by the Federal Government (Commonwealth of Australia, 2010), for example the four-hour waiting time for patients in EDs. Nurses have no control over these targets, whether imposed by the medical officers, state or national policy, or incentives. The essence of this is captured in the following comment:

So observations get done, but your fluid balance charts get missed, because people [are] just running, rushing, you rush in and rushing out, just doing the basics that you can. The busier it gets, the more that gets missed, medications don't necessarily get given on time, because you're – you might be doing but something serious where you've got a patient who's been admitted to the hospital sitting there waiting to go up on the ward, and so they'll get less care. (Interview #14)

Even although Excelcare was claimed to be responsive to patient to nursing ratios, it appears to not adequately align with patient flow incentives or waiting time targets so that the push–pull dynamic of transferring and discharging patients is not factored into any care workload, demonstrated in this declaration:

I am authorised to flex up beds which has a direct impact on your staffing. (Interview # 7)

These added pressures on nursing time contribute to what has been described as ‘failure to rescue’, where care that is missed manifests in clinically deteriorating patients (Patterson, 2011), a fact identified in the interviews:

Great pressure, to get patients out of emergency, within 4 hours, but then the inability to discharge patients, from the hospital, often causes bed blocks … And presumably that person from ED is more unwell than anyone else we have on the ward, and they don't get the care that they require because they're the extra, and a bit of a nuisance. Who wants to take them, well nobody wants an extra patient! (Interview #18)

Rounding the care

Patient rounding is another mandated control over nursing work. The aim of the policy is to reduce patient risk such as falls and pressure ulcers as well as any missed care. Rounding as a practice necessitates the nurse using a mandatory checklist to monitor patients every hour, and sign to verify that they have offered the patient toilet privileges, changed their position in bed and assessed their pain levels. The patient information sheet provided by one hospital further acknowledges that ‘a nurse will come into the room each hour and check position, comfort, bells, and requirements for toileting, access to TV, rubbish bags, phone and bell’ ([Hospital²], 2010). These care elements are an integral part of nursing work, yet have now been mandated as a hospital requirement for completion. This has not only added pressure to staff who struggle to achieve all the essential clinical tasks in a day, brought about by reduced staff to patient ratios (based on Excelcare predictions), but has undermined the very essence of nursing. As one nurse said,

Rounding is talked about, endlessly. I would suggest that we do a fair amount of rounding, anyway, and it's become a bit of a, one of those things that everyone's talking about, but we're doing it anyway, that it's not really necessary to have another piece of paper to say that we've done it. Because part of the problem is we have too many pieces of paper, and you just don't have time to fill in 25 bits of paper for 1 patient, when you've got 9 of them. It becomes, a nonsense. (Interview #11)

In a post-implementation patient satisfaction survey from one hospital, a bulletin was circulated to staff in which it stated that ‘proactive patient care rounding has been proven to reduce patient falls, hospital acquired pressure ulcers, and call light usage as well as improve patient and staff satisfaction by addressing specific needs of patients and focusing on best nursing practice’ ([Hospital], 2012). Comments and statistics made no mention of any actual analysis related to patient falls or bed ulcers, rather they focused on the attitude of staff and their responsiveness to needs, communication and nursing care. Responses by patients to questions were good, with the comments relating to caring staff within a busy environment being common. For example, ‘I rate the staff of this hospital 100%. The caring they give has to be seen to be believed’ and ‘All nurses are very responsive, they do more than their call of duty. If it wasn’t for the caring I would not come back to the [hospital]'. Despite these positive comments, the fact that the nurse sees the patient every hour is not necessarily going to identify whether care has been given, missed or delivered responsively. As one nurse said,

I think that most nurses that were very good nurses anyway did it without thinking, and that element is in their nursing care anyway … but toileting, I have a problem with it, toileting hourly, I personally think that – especially our elderly patients, don't take them to the toilet every hour, it's actually not good for their bladders and bowels and they don't need to sit on the toilet every hour, they actually should be doing it every couple of hours, or when they need to go otherwise, I don't know, I personally have issues there within the continence. (Interview #10)

Patient rounding was presented to staff using a patient care standpoint, Instead of encouraging staff to comply with the policy, comments suggest increased stress and anxiety in nurses. Campbell (2001: 233) identified this as ‘exploiting staff for the purposes of effective management’, supporting Smith's (1984) theory that authority is given in accordance with management policy rather than nursing authority. One participant captured this view by saying:

A lot of the senior staff that are around the place are actually insulted by it, clearly 'cause they feel that they do it anyway … I mean it takes out that whole thought process, it makes us little robots, we do this now and we do this now and we do this now and we do this now. It’s very task orientated, it's very policy driven, I don't think we as nurses want to go back to that, I think that detracts from what we are actually trained to do. As I said, I see some merit in it, but at the end of the day I think it really does downgrade what we do, what we've been trained to do. (Interview #7)

Despite the fact that nurses acknowledged the lack of congruity between managerial assessment of care and the allocation of resources to actual patient needs, they also showed the unconscious adoption of the organisational language, for example this nurse co-ordinator described what is done in this way:

… so we always try and decant [patients] to there, and we've got a lot of systems in place to be able to determine, and predict really what sort of beds we're going to require, so, we've got a [hospital admission] system, which I'm sure they use elsewhere, I can look at that [hospital admission] system, and I can determine how many surgical meds, and how many medical beds I'm going to need roughly, by looking at what's actually coming in the door and so then I'll go right I need to get some surgical beds upstairs, I'm going to decant into the hot floor [ward with available beds and designated as taking admission for the day] and I'll move from the hot floor up and I'll flex up these beds and at which point I'd say, right what's the staffing, and I'd ring the manager what are the Excelcare hours, can they cope with another. (Interview #7)

‘Decanting’ patients removes the personal, emotional and care factor, allowing nurses to adopt the language required by organisations to define and contain care. This positioning has been described in other studies, identified as ‘avoidance’ in order to manage the moral distress when contending with conflicting care and organisational demand (Wilson et al., 2013). Wilson et al. (2013: 1455) contends that to not do so would ‘result in a painful, psychological disequilibrium’. As Buunk et al. (2007) suggest, this emotive toll creates demonstrative exhaustion resulting from interpersonal demands that cannot be fully reconciled. This results in burnout which is identified as work-related stress occurring in ‘normal individuals who do not suffer from psychopathology’ (Buunk et al., 2007: 472), a matter that creates an environment ripe for missing care. This was also identified by Dyrbye and Shanafelt (2011), who described a direct relationship between burnout and reported medical errors, empathy levels and poor patient satisfaction in physicians working within health care reform measures. Survey commentaries supported these views:

Nursing staff are frustrated by their inability to be everywhere and do everything. Most go home worrying that they haven't done everything they were meant to, even though they have checked their charts several times. The nurses who care the most are stressed out by their inability to be the nurses they want to be due to lack of time. We are all just doing the best we can with what we've got.

Management always says that we have poor time management skills when unable to complete all tasks expected with resident care. Will only pay for half hour over time at most, even though we often do more hours. We are expected to pass onto next shift what we don't finish but this then of course results in that following shift being overburdened!

Discussion: Caring for costs

This article has reported nursing care delivery that is influenced by organisational factors in how nurses carry out their work. We argue that financial constraints have contributed to the establishment of policies and performance incentives which direct nursing practice from a distance through monitoring service outcomes. This has effectively eliminated individualised patient care, based on the skilled assessment of nurses – a factor that has failed to recognise the art and science of nursing, and care as core nursing work. Campbell (2001) suggests that nurses are adaptable and readily comply with company policy taking on new practices required by the organisation, often justifying it as essential for those they care for. In this way nurses have unconsciously justified slippage in care – care handed over or left undone.

From Fairclough's (2001) perspective, the internalisation of missed care represents the symptom of a more hidden directive associated with a situation that nurses have no control over. In internalising their stress and their struggle to effectively do their job, nurses have taken on the terminology of the governing dialogue by describing their work in financial terms. Orrock and Lawler (2008: 25) contend that this behaviour is a result of tension that is created between organisational expectations and the concept of caring. This identifies nurses with the ‘fractured self’ because of

first the historical and continuing ethos of nursing as humanitarian, caring work; second, the increasingly technocratic expectations of health care systems and the people who control them; and thirdly, the consequent clash of values structures and ideologies that are at play in current western health care systems.

This mix of imposed institutional compliance, coupled with nurses' inward focus on stress related to their work situation, is indicative of two things: first that nurses want to care in the traditional manner, and second that organisations want them to comply with policy that constrains this practice. Nurses are thus faced with divergent perceptions of identity: nurses as a commodity, and nurses as professionals.

The use of care predictor tools to forecast patient to nurse ratios are professed as supporting nurses' ability to manage care, but in fact create care restraint rather than empowerment, the success of which manifests in financial outcomes rather than effective care outcomes (Purcell et al., 2011). In this situation nurses are subjects within the discourses of health care and work under what is accepted as ‘normal processes’ as employees working within defined rules and conditions (Smith, 1984). In this space both the autonomy and value of the nurses, and more importantly, the needs of patients, are lost. The tensions between nurses' values and organisational indicators manifest in ‘compassion fatigue’ and ‘moral distress’, largely influenced by the mismatch between nurses' lesser status in the organisation, intra-professional conflict, and cost reduction in the clinical setting (McGibbon et al., 2010: 1353, 1355).

Conclusion

What started out as exploring what nurses viewed as missed care, emerged as tensions in practice between professional identity and organisational commodity. Missed care became a symptom of tension, implied through nurses' inability to manage the daily expectations imposed upon them by their own need to provide care, in the face of organisational directives that controlled what and how to care based on a financial value rather than a care value. This tension has spilt over into an endlessly revolving, emotionally charged, unconscious attempt to do the right thing by their employers and their patients, the practices for which are oxymoronic.

Although the overt challenges of cost containment providing effective health care have been identified, there is little that drills down to the discourses behind those symptoms and their effects on real clinically focused outcomes. Researchers such as Nelson and Gordon (2004) and Fairman (2008) have identified historical issues surrounding the influence of the tradition of nursing within contemporary health care delivery, but they have not identified those factors hidden from view that command nursing work. More recent literature has explored the impact of NPM on nursing work (Willis et al., 2015), from which further study on how nurses make decisions about what care to leave undone needs to be explored. Research needs to examine the value of caring, and how this can be quantified to ensure that patents do receive responsive care delivered by educationally prepared professionals, rather than care that is driven by policy directives.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Flinders University of South Australia Seeding Research Grant and a Robert Wood Johnson Foundation grant.

Notes

Biographical notes

Clare Harvey is an Associate Professor at the Eastern Institute of Technology in New Zealand, with academic status at Flinders University of South Australia. Her interests are in advancing nursing practice, professional practice issues and primary health care. Clare is interested in addressing inequality both in clinical practice, particularly in access to care and equity in care, and in professional practice settings related to workforce issues, specifically managing care provision and the utilization of professional roles in practice.

Eileen Willis is Deputy Executive Dean, Faculty of Medicine, Nursing and Health Sciences. Her research interests are in working time in health care with a specific focus on nurses. She has published in the areas of missed care and work intensification and explored the impact of new public management of the work of nurses in acute and community settings.

Julie Henderson is a Senior Research Fellow at Flinders University of South Australia currently working on a project to identify staffing needs and skill mix for aged care.

Patti Hamilton is Professor Emeritus, Texas Woman's University, College of Nursing. She also holds the post of visiting academic at Flinders University in Adelaide, South Australia. Her grant-sponsored research projects have focused on missed nursing care, off-peak work environments for nurses, and excess mortality risks among births on weekends.

Luisa Toffoli is a Lecturer and Program Coordinator Bachelor of Nursing (Theory) in the School of Nursing and Midwifery, UniSA. Her research interest is in the use of theoretical approaches to explore the nature and work of nursing. She has a strong interest in the use of qualitative methodologies and critical approaches to the issues of the health care workforce in general and nursing in particular. Dr Toffoli continues to research in the area of missed nursing care as part of an international collaboration that comprises researchers from the United States of America and New Zealand.

Claire Verrall is a Lecturer in the School of Nursing and Midwifery at Flinders University of South Australia.

Ian Blackman is a Lecturer in the School of Nursing and Midwifery at Flinders University. He has written on the psychometric properties of Kalisch's missed care tool as well as the frequencies and reasons behind missed care in an Australian context.

Elizabeth Abery is a Lecturer in the Social Health Sciences unit at Flinders University teaching and topic co-ordinating into the Bachelor of Health Sciences degree. Her research areas of interest are varied, ranging from ‘Healthy Eating’ policies in school canteens, first year of university transition and pedagogy, work-integrated learning and the influences on missed care in nursing and midwifery practice.

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