Make time for quality

Studies show the benefits to patients of time spent under a nurse’s care after surgery. 

Increased pressure on administrative systems to cut costs and improve business efficiency has hospitals whipping out patients hours after surgery – which isn’t necessarily in their best interest.

In Australia, more than 50 per cent of patients admitted to hospital for surgery in 2010–11 were discharged the same day, the Australian Institute of Health and Welfare states.

“Day admissions are the biggest con job that I have seen for many years,” says Linda Shields, professor of nursing, tropical health, James Cook University and Townsville Health Service District.

Indeed, research shows having qualified medical staff around you for at least a day after surgery can do wonders to put a patient’s mind at rest and speed up recovery. That’s one reason many nurses say budget administrators have seriously underplayed their role.

A study published in The Lancet titled, “Nurse staffing and education and hospital mortality in nine European countries” found that an increase in nurses’ workloads by one patient increased the likelihood of an in-patient dying within 30 days of admission. It also found that every 10 per cent increase in the proportion of nurses with bachelor’s degrees was associated with a decrease in the likelihood of such patient deaths.

Increasing the knowledge of the nursing staff and providing them with adequate resources and a manageable patient load will ultimately result in better healthcare, with patients making a speedier and healthier recovery.

Meanwhile, there is little evidence that sending patients home early benefits them.

“There is much evidence that shows how it saves money for the health service in a big way,” Shields says. “And this might be argued is a good thing as it makes funds available to be used for other things, such as more patients.

“I am sure day admission is good for some people and families, but we have very little rigorous evidence about patient outcomes. In fact, we don’t even know what infection rates are anymore because if a patient goes home after four hours and the infection shows up after that, then the patient is much more likely to go to their GP for treatment and busy GPs might or might not report the infection back to the hospital.”

The statistics from the European study show that staff reductions at facilities similar to Sir Charles Gardiner Hospital in Perth – where more than 200 jobs will be cut, including doctors and nurses – can put patient care and recovery at risk. Charles Gardiner has more than 600 beds and is one of Australia’s leading teaching tertiary hospitals, treating more than 400,000 patients each year.

At least 70 per cent of hospital funding comes from the federal and state governments, which are under increasing pressure to increase revenue and cut costs. Australian households too are constantly spending regular and increasing amounts of money looking after their health. And that doesn’t take into account the emotional cost and time and care dedicated by family members and relatives of patients.

“We don’t ask what the emotional cost is to the family and the carers and the patient,” Shields says. “Are they happy to take the person home? Are they scared about caring for someone who has just had surgery or a procedure of some kind? Are they fully prepared to care for the person? Do they really know what to do if something goes wrong – apart from the instructions given pre-discharge and on a leaflet given to them?

“Are they warned of the dangers and risks? What about financial costs? Do parents have to take days off work to look after a child post-surgery, or any patient for that matter? Do they have to use their holidays, or their own sick leave? We don’t ask any of these things and so we have no idea what day stay creates in the way of burdens for families and patients. This is something that we need desperately to do some research about.”

In February 2013, Shields published a paper titled, “The Core Business of Caring: A nursing oxymoron?” in SciVerse ScienceDirect. In it, she states that one of the primary reasons for discharging patients from day surgery is that it reduces the risk of hospital infections. It also allows the patient to be cared for by a family member. However, she also points to many downsides, going on to say nurses, who are trained to detect early warning signs in deteriorating patients, can’t do so if the patient has been discharged.

“[Day surgery] needs a critical examination of what it is doing to nurses’ clinical decision-making.”

As previously noted, the European study concluded that having a greater proportion of nurses with bachelor degrees, and fewer patients per nurse, reduces mortality rates.

Specifically, hospitals where 60 per cent of nurses had bachelor’s degrees and the average nurse cared for six patients had a mortality rate 30 per cent lower than institutions with only 30 per cent bachelor-degreed nurses and an average of eight patients per nurse.

Which is why Shields says it’s surprising that hospital administrations around Australia are constantly seeking staffing help from Europe, especially the UK, to fill roles in Australia.

In her paper, Shields points out that 90 per cent of nurses from England are educated only to diploma level and even though the UK’s Nursing and Midwifery Council declared in 2013 that all nurses in England will require a degree for registration, the British prime minister and his cabinet do not support this move.

The nursing standards in England simply do no match those in Australia.

Shields states in her article that the UK practice of employing unregulated healthcare assistants in  Australia has serious ramifications for the local industry. Australia began employing these workers a few years because of the growing inability of our services to recruit and employ registered or enrolled nurses, and also because they are cheaper.

Registered nurses in Australia should know that these healthcare assistants are uneducated in healthcare and are not regulated by any codes or government policy; therefore, registered nurses retain all legal responsibility for their work.

“The role of the nurse is changing to one of interdependence and collaboration with other health professionals, where nurses are responsible and accountable for their own practice and patient outcomes,” says professor Elizabeth Patterson, head of the department of nursing at the University of Melbourne.

Patterson continues: “Tertiary education for nurses has resulted in nursing practice that is evidence-based and nurses who are critical thinkers, able to make a significant and valuable contribution to positive patient outcomes, particularly in recognising and responding to deterioration in a patient’s condition. Nurses are now actively engaged in researching their practice to make both efficient and effective changes to their care.”

Patterson sees that the economic difficulties of running a health service make it a juggling act to provide the perfect outcome for all parties involved, but still says money should not be the reason patients are discharged quickly.

“Hospitals have to undertake cost-benefit analyses of staffing levels and skill mix within their budgets, as well as meeting targets set by government health departments,” she says. “I believe that patients are being discharged soon after surgery for a variety of reasons – similar to the overseas experience – rising healthcare costs have led to hospital bed closures and staff cuts in an attempt to curtail expenditure. [However,] lower-SES patients are more likely to be adversely impacted if these supports are not accessible and affordable and/or the patient is economically driven to return to work or other home duties before fully recovered.”

David Thompson, professor of nursing at the Cardiovascular Research Centre at the Australian Catholic University believes discharging patients quicker can cause “undue worry and stress for patients and their families but also concerns for clinical staff”.

Thompson believes further research needs to be conducted on patient demand, as throughput and turnover have increased significantly, but he also says Australian nursing, whilst strong, is undervalued.

“I would argue nursing is generally changing for the better but that it is still undervalued and under-resourced, and that there is a shortage of nurses in terms of staffing numbers and with a university nursing education,” he says. “[The European study] makes a convincing case that nursing should be an all-graduate profession. The ‘hard’ mortality benefits of a nursing degree found in the study will be key to its influence, but the benefits of degree-level preparation for nurses are already well known.

“Nursing degrees should be better marketed to attract more high-calibre applicants. Too much variation remains in the quality of nursing degree programs and thus more quality assurance and regulation is needed.”

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