What's care rationing and what are its effects? Nurses need to understand care rationing, its impact on patients and on themselves, and take action to make it visible.
Subject: Nurses (Practice)
Health care rationing (Management)
Author: Lawless, Jane
Pub Date: 08/01/2009
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2009 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: August, 2009 Source Volume: 15 Source Issue: 7
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 206850919
Full Text: We live in a society where health care is rationed because there is a limit to how much we are able (or willing?) to invest in publicly funded health care. Therefore choices must be made around who will have access to health care and--by default--who will not. How many people will get hip replacements? How many grommets will be funded? If we offer Herceptin to one group, what pharmaceuticals will we not be able to fund for others?

As a nation, we have become used to these difficult debates but struggle to resolve them. As nurses (and members of society) we have an interest in high-level rationing decisions. But unless those decisions affect us personally, we are somewhat buffered from the human cost of rationed health services. We are (rightly) most concerned with this patient, in this moment, with these needs. However, increasingly nurses are confronted with the responsibility and decision making around rationing care to patients.

Withholding necessary nursing measures

Rationing of nursing care has been defined as "the withholding of or failure to carry out necessary nursing measures for patients due to a lack of nursing resources (staffing, skill mix, time)". (1) Rationing is different to the many decisions we make each day, as we juggle patients' needs. Negotiating, re-allocating, delegating and sometimes deferring care does not necessarily imply rationing--this is normal workload management.

Rationing is when any nursing activity that has been identified by clinical consensus as "important]or the patient to achieve the desired outcomes" is omitted. (2) Examples include surveillance, prevention or prophylaxis, rehabilitation, education or documentation. (2) For nurses, rationing begins as a process of compromise but may progress to nurses feeling compromised in the care they deliver.

Rationing occurs when the care available does not meet the patient's requirement for care. This can be expressed as a deficit in care capacity. This is different to bed capacity. Bed capacity is measured by the number of physical spaces available into which patients can be admitted and averaged acuity.

In New Zealand, we have developed terms to cover situations where care is rationed, eg "essential cares" or "prioritising care". These terms are misnomers because they imply nursing can be broken down into a hierarchy of tasks--must have and nice to have. This way of looking at nursing care is not compatible with how nursing practice and the purpose of nursing is understood. Consider the following scenario:

You are an expert surgical nurse caring for Anna, 43, who had a radical mastectomy two days ago. Today, the surgeon told her she has five positive lymph nodes. Her pain has required ongoing management and she needs assistance with dressing and showering. She has been tearful this morning, had a restless night and is sweaty and uncomfortable. Anna's discharge has been tentatively planned for tomorrow. Anna has not yet received self care education about wound care, pain management, or lymphoedema prevention. She has not yet been able to discuss her diagnosis or prognosis with a health professional since she was given the news.

You have four other patients requiring your attention. Delegation is not an option. You will not be able to meet all Anna's needs. What care activities wilt you ration? Do you prioritise her physical comfort today over her emotional and psychological recovery over the next few weeks? What are the risks associated with any of these options? What wilt you document? Would you report this as unsafe staffing? How do you feet about withholding care?

This is a common scenario. Despite this, not much is known about how a nurse makes such decisions or, indeed, the effect of these decisions on both patient and nurse. Studies have shown even low levels of rationing are strongly associated with deteriorating patient outcomes. (3) But because rationing of nursing care rarely overtly results in measurably adverse outcomes, the subtle harm and distress associated with care rationing for both nurse and patient generally "flies under the organisational radar".

The invisibility of care rationing within our organisations means tolerance for situations where rationing occurs may gradually rise--rationing can become the "new normal". Some district health boards have developed processes that allow nurses to document tasks not completed. However, these cannot measure less obvious harm and, if reporting care deficits does not result in sustainable systems and process changes, nurses will be less inclined to report them, thus making rationing even less visible.

Patients who have nursing care rationed will probably have some aspect of their recovery compromised. Consequently, nurses who work in environments where care is regularly rationed may experience a range of negative emotions ranging from disquiet, dissatisfaction, distress to, ultimately, disengagement.

Regular care rationing is a sign the system is under significant stress and change is required. Effective change requires a whole-of-organisation approach which, in turn, is part of a wider societal conversation around health care resourcing. However, nursing's lack of voice around rationing is something nursing can change.

Make rationing visible

Every nurse can help make care rationing visible. We need to call it what it is--to ourselves, our organisations and our patients. We need to work with our organisations to describe it and to assess its impact. Nursing plays a key rote in determining the standards for safe, quality patient care. Having an active and constructive voice in ensuring rationing of care to patients is the exception and not the rule, is part of our professional commitment to society.

Jane Lawless, RN, PGDip (Nsng), is the director of the Safe Staffing Healthy Workplaces Unit. This article is the first of three on the concept of care rationing.

References

(1) Schubert, M., Schaffert-Witvliet, B., De Geest, S., Glass, T., Aiken, L., Sloane, D.S. et al. (2005) RICH-Nursing Study: Rationing of Nursing Care in Switzerland. Effects of Rationing of Nursing Care in Switzerland on Patient' and Nurses" Outcomes. (Final report, Grant, Swiss Federal Office of Public Health, Bern, Switzerland). Basel, Switzerland: Institute of Nursing Science, University of Basel

(2) Schubert, M., Glass,T.R., Clarke, S., Schaffert-Witvliet, B., & De Geest, S. (2007) Validation of the Basel Extent of Rationing of Nursing Care Instrument. Nursing Research; 56: 6, pp 416-424.

(3) Schubert, M. (2008) Rationing of Nursing Care: Associations with Patient Safety and Quality of Hospital Care. http://edoc.unibas.ch/849/1/DissB_8447.pdf. Retrieved 09/07/09.
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