Challenges in care co-ordination: missed care in community nursing

Abstract

Primary healthcare is a major focus of health policy in Ireland and elsewhere. Many disciplines work with communities to potentialise health and well being. Community nurses are one of these health professionals whose philosophy is based on health promotion, early detection of health issues, rehabilitation and addressing inequality and inequity through a lens of the social determinants of health. In Ireland, within the Community Healthcare Organsiations, there are public health nurses and community registered general nurses who manage 'cradle to the grave' geographical caseloads. However, despite structural, population changes and increased complexity of healthcare, reform in community nursing has been absent. This paper describes a study which used the concept of missed care to examine the work of community nurses in Ireland. Missed care may be defined ‘any aspect of required client care that is omitted either in part or in whole or delayed’ Kalisch et al. 2009a: 1510 and has been linked to due to challenges in client safety, client health outcomes, staffing and the underuse of health services. Following full ethical approval from UNiversity College Dublin, community nurses were recruited through the Irish Nurses and Midwives Organsiation. Three methods of data collection are used: a community based missed care survey developed for this study to look at community nurses experience of missed care within a week timeframe; four semi-structured interviews to explore the concept of contemporary missed care in Ireland; and a focus group to develop the impact of missed care through a health economy lens. Within the community based survey all 64 domain questions demonstrated some level of missed care. The data from the interviews and the focus groups supported the findings within the survey. Reasons for missed care were similar to Kalisch et al’s 2009a,b findings for acute care settings: inadequate staffing levels, unanticipated rise in client volume and/acuity/complexity and a lack of administrative support. In particular, missed care was associated with having to provide long term cover when colleagues were sick, on leave or had retired. Role boundaries were seen as fluid and community staff did not appear to have control over what consituted legitimate caseloads under their generalist role. The lack of comprehensive leadership in community nurisng and career clinical development for communty nurses was also identified. The findings are significant in the context of both the job desciptions and health policies in Ireland which emphasise a health promotion and vertical equity approach to care. The experiences of the community nurses demonstrate that they are prioritising clincal work and legislation obligations and although missed care was identified at lower rates in these domains, this was at the expense of health promotion and disease prevention. However, in applying case scenarios based on cost benefit analysis of addressing health promotion areas in a comprehensive way, clear potential economic saving can be made. Consequentally, urgent reform is required to facilitate the community nursing healthforce to adequately contribute to contemporary health demands at primary, secondary and tertiary care levels for individuals, families and communities.