Promoting patient-centred fundamental care in acute healthcare systems

International Journal of Nursing Studies 57 (2016) 1–11

Contents lists available at ScienceDirect

International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Promoting patient-centred fundamental care in acute healthcare systems Rebecca Feo, Alison Kitson * School of Nursing, The University of Adelaide, Eleanor Harrald Building, Frome Rd, Adelaide, South Australia 5000, Australia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 30 September 2015 Received in revised form 7 December 2015 Accepted 22 January 2016

Meeting patients’ fundamental care needs is essential for optimal safety and recovery and positive experiences within any healthcare setting. There is growing international evidence, however, that these fundamentals are often poorly executed in acute care settings, resulting in patient safety threats, poorer and costly care outcomes, and dehumanising experiences for patients and families. Whilst care standards and policy initiatives are attempting to address these issues, their impact has been limited. This discussion paper explores, through a series of propositions, why fundamental care can be overlooked in sophisticated, high technology acute care settings. We argue that the central problem lies in the invisibility and subsequent devaluing of fundamental care. Such care is perceived to involve simple tasks that require little skill to execute and have minimal impact on patient outcomes. The propositions explore the potential origins of this prevailing perception, focusing upon the impact of the biomedical model, the consequences of managerial approaches that drive healthcare cultures, and the devaluing of fundamental care by nurses themselves. These multiple sources of invisibility and devaluing surrounding fundamental care have rendered the concept underdeveloped and misunderstood both conceptually and theoretically. Likewise, there remains minimal role clarification around who should be responsible for and deliver such care, and a dearth of empirical evidence and evidence-based metrics. In explicating these propositions, we argue that key to transforming the delivery of acute healthcare is a substantial shift in the conceptualisation of fundamental care. The propositions present a cogent argument that counters the prevailing perception that fundamental care is basic and does not require systematic investigation. We conclude by calling for the explicit valuing and embedding of fundamental care in healthcare education, research, practice and policy. Without this re-conceptualisation and subsequent action, poor quality, depersonalised fundamental care will prevail. ß 2016 Elsevier Ltd. All rights reserved.

Keywords: Caring Fundamentals of care Patient-centred care Patient safety

What is already known about the topic?  International evidence shows that the delivery of fundamental care is variable across acute healthcare systems with such failures resulting in adverse patient outcomes and poor care experiences.

 Scholars are attempting to understand why fundamental care is being poorly delivered and many healthcare organisations have begun implementing strategies to address the problem.

What this paper adds * Corresponding author. Tel.: +61 8313 0511. E-mail address: [email protected] (A. Kitson). http://dx.doi.org/10.1016/j.ijnurstu.2016.01.006 0020-7489/ß 2016 Elsevier Ltd. All rights reserved.

 The paper argues that fundamental care is poorly delivered in acute care due to the invisibility and

2

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

subsequent devaluing of such care across entire acute healthcare systems.  Fundamental care is rendered invisible and devalued by: (1) the dominance of the biomedical model, (2) managerial approaches to care, and (3) the devaluing of fundamental care by nurses.  For a substantial shift in the delivery of fundamental care to occur, these widely-held beliefs must be challenged. This can be achieved through: (1) re-conceptualising the value of fundamental care, (2) developing the evidence base behind the fundamentals, (3) creating metrics for the fundamentals of care, (4) greater role clarification, (5) systematically embedding the fundamentals of care into nursing and other healthcare curricula; and (6) increased community involvement. 1. Introduction People engage in a range of self-care activities, such as eating and personal hygiene, on a daily basis to ensure their survival, health and wellbeing. In the context of acute or chronic illness, injury or disability, an individual’s capacity to perform these vital and intimate care activities can be compromised, necessitating support from nurses and other health professionals. ‘Fundamentals of care’ (or fundamental care) is one of the many terms – and the one used in this paper – given to these care activities that are required for every person, regardless of their clinical condition or healthcare setting (Kitson et al., 2010). The term fundamental reflects the centrality of these activities to reducing harm, optimising recovery (Kitson et al., 2013a; Rantz and Zwygart-Stauffacher, 2004; Vollman, 2013), and ensuring positive patient experiences (Garling, 2008; Kitson and Muntlin Athlin, 2013; Kitson et al., 2013b). Traditionally in acute settings, discrete fundamental care activities, such as helping people with eating, drinking and elimination, have been carried out by nurses on behalf of the wider healthcare team (Kitson et al., 2013a). Whilst fundamental care is not a new concept, in recent years increasing attention has been placed on the ways in which such care is delivered in practice, particularly by nurses (Vollman, 2009). One reason for this renewed focus is the increased emphasis on patient-centred care,1 which has become the cornerstone of quality healthcare in many developed countries and is explicitly referenced in healthcare policies (Department of Health, 2012; MacKinnon, 2011; NSW Department of Health, 2009; SA Health, 2015). Patient-centred care focuses on healthcare that involves patients via greater decision-making and choice, and which is sensitive to patients’ unique physical, psychosocial, cultural and emotional needs (Kitson and Muntlin Athlin, 2013; Kitson et al., 2013c). Attention is now turning to the ways in which people can be better

1 Whilst the term patient-centred is often used interchangeably with person-centred, the latter represents a holistic approach to care, predicated on viewing the person as a whole rather than as a patient with a condition. We therefore use the term patient-centred to represent current biomedical and managerial approaches to care, which we explore in this paper.

supported to participate in the delivery and management of their fundamental care needs as a means of providing respectful, dignified patient-centred care (Kitson et al., 2013b). In addition to the patient-centred care movement, the higher burden of disease brought about by an ageing population; global migration; complex health conditions characterised by multi-morbidities; and increases in chronic, incurable illnesses, is creating higher demand for high-quality fundamental care and placing increased scrutiny on the way in which such care is delivered in acute care settings. However, the renewed focus on fundamental care is underpinned mostly by growing evidence of recurrent failures to attend to people’s fundamental care needs, resulting in poor patient safety and quality of care. Studies of acute healthcare settings in Australia, the US, UK and Canada have reported deficits in numerous fundamentals of care, including nutrition and hydration, with people unable to reach water and not receiving adequate assistance to eat (Bureau of Health Information, 2014; Francis, 2013; Garling, 2008; Kalisch, 2006). Problems have been noted around elimination, with an enquiry into acute hospital care in the UK hearing that patients were routinely left in soiled bed clothes for lengthy periods and did not receive help in their toileting, despite persistent requests (Francis, 2013). Nurses also report regularly missing ambulation and pressure area care, with patients turned every 4, 6, or 8 h rather than the recommended two (Kalisch, 2006; Kalisch et al., 2009, 2011). Personal hygiene, including oral care, is also routinely missed, with nurses in one US study reporting that patients were often not bathed for two or three days (Kalisch, 2006; Kalisch et al., 2009, 2011). Patients’ psychosocial and cultural needs are also routinely overlooked (Kalisch, 2006; SA Health, 2012). Basic communication, such as introducing oneself to patients and families, often does not occur, whilst patients who require an interpreter do not always have access to one (Bureau of Health Information, 2014; SA Health, 2012). Many patients and families report a lack of adequate information from health professionals, who often do not explain aspects of care in ways that patients can understand (Bureau of Health Information, 2014; Garling, 2008; Gill et al., 2014; SA Health, 2012). Dignity, respect and privacy are also compromised, with patients reporting being spoken to in a condescending or dismissive manner (Care Quality Commission, 2011; Francis, 2013). Emotional support, in particular, is an area where irregularities and inconsistencies are common. Patients in hospital report being unable to find a staff member to talk to about their worries (SA Health, 2012), whilst nurses report that they do not attend to patients’ emotional or psychosocial needs consistently (Kalisch, 2006). The breadth of evidence concerning poor quality fundamental care in acute care settings across a number of countries indicates the significance of the problem. These are not rare or isolated incidents of poor care but systematic failures across and within acute healthcare systems. Given this evidence, two central questions arise: (1) why is this happening? And (2) what can be done about it? In attempting to uncover the reasons behind the

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

documented failures in patient care, some scholars, clinicians and policy-makers are looking to the environments in which healthcare takes place, blaming staff shortages, poor skill mix and funding cuts for nurses’ inability to attend to fundamental care (Aiken et al., 2014). Whilst time and economic pressures undoubtedly play their part, we argue that the root cause of the problem lies in the way in which fundamental care is perceived. Fundamentals of care are rendered ‘invisible’ and subsequently devalued, seen only as marginal contributors to patient outcomes that are delivered by lower level staff. Hence, broader systems issues, such as nursing numbers, constitute only part of the problem – and only part of the solution. Following enquiries into acute care in countries such as Australia and the UK, work is being done to address poor quality fundamental care. Healthcare organisations have created fundamental care standards, some of which in the UK are sanctioned by law (Care Quality Commission, 2010; NSW Department of Health, 2009). A group of nursing experts have developed a framework that conceptualises the underlying dimensions of fundamental care (Kitson et al., 2013a). Some researchers have designed and implemented interventions around different fundamentals, such as hygiene and oral care (Carr and Benoit, 2009; McGuckin et al., 2008; Vollman, 2009, 2013). Despite these initiatives, we are yet to see a significant change in how fundamental care is delivered. We argue that fundamentals of care standards, conceptual frameworks and other similar work will continue to have minimal impact until there is a substantial shift in the way in which fundamental care is conceptualised and valued across healthcare systems. To get to the heart of the problem we need to challenge underlying assumptions and values that are deeply embedded in our healthcare systems and, if left unchallenged, will prolong the suboptimal fundamental care experiences of patients. In this paper we develop a series of propositions that outline the multiple ways in which fundamental care is rendered invisible in acute care systems (see Table 1). We do not argue that this list of propositions is exhaustive. However, we believe the propositions represent some of the most pressing concerns for modern healthcare systems and will generate much-needed discussion about the delivery of fundamental care. In explicating these propositions we illuminate and challenge widely-held assumptions around fundamental care that have contributed to its poor delivery globally. We argue that, to successfully transform fundamental care and see improvements in patient safety, cost effectiveness, and patients’ care

Table 1 Why fundamental care is rendered invisible and devalued: the propositions. Proposition 1:

Proposition 2: Proposition 3:

The biomedical model continues to dominate over more patient-centred biopsychosocial models Healthcare systems do not value the delivery of fundamental care Nurses themselves do not (or cannot) value fundamental care

3

experiences in acute care, we must reconceptualise the way in which the fundamentals of care are valued, and systematically embed them into health research, education, policy and practice.

2. The invisibility of caring activities In putting forth our argument we are cautious not to conflate the broader concept of caring with fundamental care. However, the two are inextricably linked. Definitions of caring typically involve references to attending to a person’s physical and emotional needs, in addition to feelings of concern or empathy for the other (Cancian and Oliker, 2000). As such, the fundamentals of care – assisting people in a dignified and respectful manner with intimate care activities – can be seen as the basis of caring. The way in which caring is valued therefore inevitably impacts how fundamental care is perceived and delivered by health professionals. In the propositions that follow, then, we focus, where necessary, on both caring and fundamental care to understand the multitude of ways in which fundamentals of care are rendered invisible. We also conceptualise fundamentals of care as comprising physical, psychosocial and relational aspects of care, such as hygiene, nutrition, dignity, respect, and empathy (Kitson et al., 2013a). Table 2 provides working definitions of fundamental care and the activities that comprise it. Proposition 1. The biomedical model continues to dominate over more patient-centred biopsychosocial models The biomedical model has been a dominating influence in Western, allopathic medicine. The model, as characterised from its genesis in the 19th century, assumes that all disease results from a single physical cause, such as cellular abnormalities or imbalances in homeostasis (Wade and Halligan, 2004). The model prioritises activities that lead to the diagnosis and cure of physical anomalies, and places primary value on a rational and analytic approach to healthcare that is underpinned by objective knowledge (such as physical examination and observation) and physician expertise (Russell, 2014). To achieve its aim of diagnosis and cure, the model adheres to elements of Cartesian philosophy, emphasising mind-body dualism and likening the body to a machine that can be reduced to its component parts (Russell, 2014; Treiber and Jones, 2015). The model’s focus on underlying pathophysiology was pivotal in addressing the pressing medical problems of the 19th and early 20th centuries, namely infectious diseases; traumatic illness; and childhood disease, including polio (Weiner, 2007). Through the identification of physical causes, the model successfully contributed to the development of such modern healthcare staples as antibiotics and vaccinations and to substantial increases in life expectancy across the developed world. Taken to an extreme, however, and with increasing reliance on this worldview without the countervailing force of care, many core tenets of the model have resulted in the devaluing of fundamental care as pivotal to patient illness and recovery. The model’s singular focus on physical aspects of disease typically leads to the exclusion

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

4

Table 2 Working definitions of the Fundamentals of Care. Working definition of the Fundamentals of Care: Essential elements of care, encompassing physical, psychosocial and relational aspects, that are required by every patient regardless of their clinical condition or the setting in which they are receiving care. Psychosocial

Physical

Relational

Fundamental of care

Description

Fundamental of care

Description

Fundamental of care

Description

Safety

Patients are safe from physical, psychosocial and environmental harm

Calm

Patients’ concerns and frustrations are addressed. Noise and distractions are minimised.

Being empathic

Professionals seek to understand patients’ perspectives, are sincere, and genuinely care about what happens to patients

Comfort (including warmth and rest)

Patients are comfortable, receive adequate relief from nausea and/or pain and receive adequate rest and sleep

Able to cope

Patients are encouraged to talk about their needs, and these are genuinely listened to. Patients’ emotional reactions are validated. Professionals use plain language.

Being respectful

The health professionalpatient relationship is positive and does no harm. Professionals are courteous and considerate when interacting with patients.

Nutrition and hydration

Patients have adequate food and drink. Patients are assisted to eat/drink when mobility or cognitive impairment is an issue. Patients’ dietary requirements are respected.

Hopeful

Goals for care are set to help patients feel hopeful about their situation and their care regardless of their clinical condition or chance of recovery

Being compassionate

Professionals are conscious of others’ distress, suffering, and misfortune, and demonstrate sensitivity, kindness and warmth

Mobility

Patients’ mobility is assessed and they are assisted in activities that require them to be mobile

Respected

Patients’ choices relating to their care, including religious or cultural practices that might be affected by (or affect) care, are respected

Being consistent

Professionals ensure coordinated and uninterrupted healthcare

Hygiene and personal dressing

Patients’ preferences with regard to hygiene and physical appearance are respected. Patients’ right to privacy when cleaning and dressing is respected.

Involved and Informed

Patients are consulted and given opportunities to contribute to decisions about their care. Patients are kept up-to-date about their proposed and ongoing care.

Ensuring goals are set

Mutually agreed, realistic targets for care are set. Patients are free to renegotiate these goals at any point during their care.

Elimination and continence

Patients’ toileting needs are met (e.g., assisting them to the toilet, helping them to toilet and providing alternative means for toileting)

Dignified

Patients are treated with dignity regardless of age, gender, sexual orientation, religion, linguistic or cultural background or the presence of a mental health issue, disability, illness or injury

Ensuring continuity

There is continuity across the delivery, facilitation and coordination of care

Adapted from Conroy et al. (2016).

of those aspects of illness and treatment that are not easily explained by cellular and molecular processes occurring within the body. Within the strict adherence to this model, social, psychological, relational, cultural and spiritual determinants of health and illness are routinely overlooked in diagnosis and treatment. Likewise, non-physical aspects of healthcare delivery, such as the relational elements of compassion and empathy, are thought to contribute little to the core activity of cure (Borell-Carrio´ et al., 2004; Russell, 2014). The model therefore neglects to consider how the meanings patients ascribe to symptoms and treatment impact their recovery, and how the professional-patient relationship influences patient outcomes and care experiences (Borell-Carrio´ et al., 2004). Physical fundamentals of care, such as nutrition, hygiene and mobility, arguably have a more readily visible impact on the biology of disease and cure than psychosocial and relational fundamentals. However, an inevitable

and predictable consequence of the biomedical model’s reductionist approach is that these activities are becoming increasingly disaggregated and specialised; divided into a series of discrete tasks that are focused on a particular area of the body and carried out in isolation from other aspects of care. These tasks are then often delivered to patients by different healthcare professionals. For example, certain aspects of mobility and nutrition are delivered by allied health professionals, such as physiotherapists and dieticians, with or without collaboration with nursing staff who still have overall responsibility for patients’ nutrition and mobilisation in the acute care setting. There is also a tendency in some healthcare systems, notably in the US and Canada, for doctors to create medical orders around mobilising, turning, and feeding to be executed by nurses. The delivery of many (if not most) physical fundamentals is therefore becoming increasingly fragmented. There is minimal attempt to deliver the fundamentals based on a

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

patient’s holistic care experience and to incorporate psychosocial and relational elements of fundamental care as part of this experience. Likewise, there is little consideration given to how different health professionals – nurses, allied health professionals, doctors – can work together to provide integrated and consistent physical fundamental care. The biomedical model continues to play a significant role in the delivery of healthcare in the Western world (Weiner, 2007) despite the introduction of alternate models that provide a broader lens through which to understand and operationalise care delivery. One such approach is integrative medicine, which blends traditional biomedical practice with a focus on the whole person to better understand how the mind, body, and spirit contribute to illness and recovery (Geist-Martin et al., 2015). The biopsychosocial model similarly argues that the causes and consequences of illness exist at multiple levels of organisation – biological, psychological and social (Borell-Carrio´ et al., 2004; Engel, 1978; Weiner, 2007). The model provides more integrated, holistic explanations for the development, progression and treatment of disease than afforded by the biomedical model. It is therefore better equipped to explain and deal with current health challenges, such as the increasing complexity of disease; the acquisition and experience of illnesses related to lifestyle factors; and the higher incidence of chronic conditions, often with co-morbid situational depression. The increased burden that such diseases place on patients, families and healthcare systems means that, in addition to diagnosis and cure, these systems must focus on long-term care and management, including end-of-life care, within the acute care setting. A key challenge for modern acute healthcare systems is therefore helping people who have complex and chronic conditions with fundamental care needs, including helping them to move from dependence to independence (where possible) with respect to the completion of such needs. Integrative, biopsychosocial models provide useful explanatory frameworks for – and help to make more readily visible – the complexity associated with addressing fundamentals of care in order to promote quality of life. Meeting another person’s fundamental care needs involves more than simply attending to a biological need (i.e., providing food to stop hunger); it requires that a number of psychosocial needs (i.e., being treated with dignity and respect) and relational needs (i.e., receiving compassion) are also met. Such models help to make evident this complexity that might otherwise be obscured under a biomedical approach. The biopsychosocial model further argues that subjective experiences – the ways in which people conceive of and are affected by their illness – are essential to accurate diagnosis and positive outcomes (Borell-Carrio´ et al., 2004). The model therefore advocates that people receiving care are not seen merely as patients with a disease but as persons with unique circumstances that impact their illness and recovery. This emphasis on holistic care and subjective experiences aligns with the contemporary patient-centred care paradigm (Kitson and Muntlin Athlin, 2013; Kitson et al., 2013c).

5

Despite the emergence of holistic, biopsychosocial models and their ties with patient-centred care, the biomedical model continues to be the dominate influence in modern healthcare. Whilst we are not the first to note this dominance (Matthews, 2015) and its impact on healthcare delivery (De Arau´jo Ferreira et al., 2015; Millar et al., 2013; Rubio-Valera et al., 2014), few have explicitly linked this dominance to the invisibility and devaluing of fundamental care. We further argue that the continued dominance of the biomedical model, and the inability for the biopsychosocial and more integrated, patient-centred models to flourish, is a result of how modern acute healthcare systems are designed. For these more holistic models to be successful they need to be implemented within a system that is focused on a broad range of patient outcomes – not just cure – and which values the ways in which psychosocial and relational elements of care contribute to these outcomes. However, most healthcare systems in the developed world continue to be predicated on the goal of cure (the hallmark of the biomedical model) with increasing emphasis placed on patient throughput and output (Dewar and Nolan, 2013). Fundamentals of care have no currency in such systems and are therefore rendered invisible and devalued. Proposition 2. Healthcare systems do not value the delivery of fundamental care Increasingly, healthcare systems are operating within a managerial framework where the focus is on task completion, outcome evaluation, and benchmarking as a means to deliver evidence-based care at reduced cost and increased productivity and efficiency (Griffiths et al., 2012; Maben, 2008). The performance of health professionals and healthcare organisations is measured by objective, codifiable activities (Bridges et al., 2013; Maben, 2008; Maben et al., 2010). The inevitable consequence is that nursing work is conceptualised solely as technical and physical work (Bridges et al., 2013), resulting in a model of care that is depersonalised, mechanistic, and transactional, where the focus is on patient throughput and output, at the expense of a relational model focused on engaging meaningfully with people to deliver personalised care (Kitson et al., 2014; Maben et al., 2010). The emphasis is therefore on ‘caring for’ a patient rather than ‘caring about’ a person (Maben et al., 2010). Bathing a patient, for instance, is seen simply as an act to attain cleanliness rather than an opportunity to connect with the patient as a means to provide patient-centred care. This focus on the patient as a body to do things to, rather than a person to engage with, is reinforced by some electronic nursing records that are built on body systems and which identify discrete diagnostic and nursing interventions without demonstrating how these interventions come together to create an integrated care plan and positive experience for the patient (Ha¨yrinen et al., 2008; Kitson et al., 2014). The relationship between patient and nurse, however, is crucial to the delivery of fundamental care (Kitson et al., 2013a; Wiechula et al., 2016). For each person, fundamentals of care carry a unique cultural, social and personal history that becomes exposed and challenged when

6

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

receiving care (Kitson et al., 2013a). As such, the execution of fundamental care activities can become a source of embarrassment, frustration and distress for people who are unable to provide such care for themselves. Meeting another person’s intimate care needs is therefore not a simple transactional process; it requires focusing on and connecting meaningfully with the person, understanding their unique care needs, and interacting with them in such a way that feelings of embarrassment, frustration and distress are minimised or avoided (Kitson et al., 2013a, 2014). Yet a managerial approach does not seem to value the development of a nurse-patient relationship that would allow this to happen. The emphasis on patient throughput under a managerial approach also means that metrics of patient outcomes relate primarily to risk, such as around infection, and not to positive patient experiences (Kitson et al., 2014). For instance, recent years have seen a shift in the conceptualisation of oral care as a practice for ensuring patient comfort to an infection control practice, specifically for the prevention of ventilator-associated pneumonia (VAP) (Dale et al., 2013), leading to increased reliance on metrics around VAP for care improvement. Whilst patient safety risks are undoubtedly important, patients’ psychosocial outcomes, and the ways in which fundamental care contributes to these outcomes, are overlooked. In most modern acute care systems, there is a dearth of reliable indicators for psychosocial and relational aspects of care, such as those in Table 2. Most patient-reported outcome measures (PROMs) reflect patients’ clinical outcomes rather than their personal care experiences. One reason for the lack of relational metrics is the common perception that caring activities, such as empathy and compassion, are abstract, subjective, and intangible, and therefore difficult to define, operationalise, and measure (Chiovitti, 2008; Maben, 2008; McCance et al., 1997; Treiber and Jones, 2015). As such, there is little concerted research effort to identify suitable metrics. This is further compounded by the continued dominance of the biomedical model and its focus on that which is physical, visible and objectively measurable. Fundamentals of care – whether physical, psychosocial or relational – are also perceived by health professionals, including nurses, as simple, common sense tasks that require little skill to execute (Heaven et al., 2013). Such perceptions further reduce the need for formal measurement and evaluation of fundamental care, and the investment of time and energy into the development of metrics. It is perhaps unsurprising, then, that even the completion of physical fundamentals of care is overlooked in acute care systems, with activities such as ambulation not readily recorded in nursing documentation (Kalisch et al., 2011). There is also minimal understanding of how and at what point nurses’ fundamental care work intersects with that of other health professionals, such as those in allied health. For instance, how does a nurse’s daily engagement with an immobile patient link to the recovery goal for mobilisation set by the physical therapist and rehabilitation physician, and how should this be negotiated, understood and measured? The only time the fundamentals of care appear to be measured is after the fact; when they are incomplete

and/or an adverse event occurs. Recent years have seen the proliferation of instruments designed to identify and measure missed fundamental care (e.g., HCAHPS, MISSCARE and BERNCA) (Giordano et al., 2010; Kalisch and Williams, 2009; Schubert et al., 2007) but not to proactively measure the successful delivery of such care or to integrate such metrics into patient and nursing records. Such recording practices reinforce the minimal value placed on caring activities and render invisible to healthcare policy-makers and managers the role of fundamental care in patient recovery (Dubois et al., 2013; Kucera et al., 2010). The focus on increased efficiency under a managerial approach also places pressure on nurses to exercise a choice around what tasks they prioritise in order to allocate the scarce resource of their time to the care of their patients (Kitson et al., 2013a). When this prioritisation occurs, it is often fundamental care that is left undone. Nurses report that, due to time constraints, they often do not complete fundamentals, such as oral hygiene and comforting and educating patients and their families/carers (Aiken et al., 2014; Bjerrum et al., 2012; Costello and Coyne, 2008; Landstro¨m et al., 2009; Lucero et al., 2010; Pettit et al., 2012). Some nurses also report that time-consuming fundamental care activities and those that require assistance from others, such as mobility, turning, talking to patients, psychological support, and hygiene, are less likely to be attempted or completed (Ausserhofer et al., 2014; Kalisch, 2006; Kalisch et al., 2011). Activities around pain management and treatment, however, are less often missed (Aiken et al., 2014). Observational studies provide further evidence that nurses spend more time undertaking tasks such as medication rounds and charting than addressing patients’ psychosocial needs (Williams et al., 2009). Whilst the legacy of the biomedical model and the recording practices emphasised under a managerial approach play a crucial role in influencing nurses’ prioritisation of care tasks, they alone do not account for the prioritisation that sees fundamental care left undone. Even if care was predicated on a holistic, relational model, with nurses afforded sufficient time to deliver care, it is not inevitable that high-quality fundamental care would be provided. Nurses need to value such care for it to be delivered. However, there is growing evidence to suggest that nurses do not perceive fundamental care to be as important as other clinical aspects of care. We therefore argue that one reason nurses’ prioritisation of care tasks sees fundamental care relegated to the bottom and rendered invisible is because nurses themselves do not value such care. Proposition 3. Nurses themselves do not (or cannot) value fundamental care Nurses appear to afford fundamental care relatively little priority and value in comparison to other care tasks (Adamsen and Tewes, 2000; Flatley and Bridges, 2008; Juve´-Udina et al., 2014; Vollman, 2009). Highly specialised and technical forms of nursing are often seen by nurses as more prestigious than basic nursing care, with nurses who practice in highly specialised fields afforded higher level status (Adamsen and Tewes, 2000; Flatley and Bridges, 2008). Nutrition, for instance, is conceptualised as one of

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

the most elementary tasks in hospitals, despite the recognition that mealtimes and the act of eating are moments where dignity can be threatened, particularly if patients are unable to feed themselves (Heaven et al., 2013). The only time nutrition might receive elevated status is when patients have difficulties swallowing and/or are at high risk of choking. The act of assisting with food intake then becomes seen as highly technical and therefore valued (Heaven et al., 2013). This devaluing of fundamental care has created a division in care delivery, with more educated and experienced nurses carrying out technical, cure-directed acts such as administering complex medications and surgical wound care, whilst less skilled nurses are focusing on fundamental care (Wolf, 2014). In many organisations, fundamental care is now delivered by healthcare assistants, nursing assistants, vocational nurses, and nursing auxiliaries rather than registered nurses (Allan, 2007; Darbyshire and McKenna, 2013; De Bellis, 2010; Hasson et al., 2013; Maben, 2008; Willis, 2012; Wolf, 2014). This re-organisation of care delivery not only reflects a costsaving strategy (fewer registered nurses means less money spent on salaries) but is also precipitated by many registered nurses’ belief that delivering fundamental care is no longer part of their job. In a US study of registered nurses, licensed practical nurses and nursing assistants in surgical–medical units, one of the main reasons fundamental care was missed was because registered nurses did not believe it was their role to deliver such care (Kalisch, 2006). Nursing assistants reported that registered nurses gave greater priority to administering medication as opposed to fundamental care, and would often delegate tasks such as getting a cup of water to nursing assistants. The relegation of fundamental care to healthcare assistants has also been identified as contributing to the devaluing of such care by nursing students. Evidence suggests that student nurses perceive care tasks as existing in a hierarchy, with basic nursing care positioned at the bottom relative to more complex technical skills (Thomas et al., 2012). The relegation of fundamental care to healthcare assistants means that, on clinical placements, students regularly observe qualified, registered nurses undertaking technical work only, and might be paired with a care assistant to learn fundamental care (Allan and Smith, 2009). As such, students begin to equate nursing with technical rather than caring work, leading them to reject fundamental care as central to the role of the registered nurse (Allan, 2007; Allan and Smith, 2009). Some students have even lamented that undertaking fundamental care tasks on clinical placements limits their opportunities for learning (Allan and Smith, 2009). Nurses’ devaluing of fundamental care is evidenced also by the minimal research activity surrounding such care. This minimal activity has meant the underlying evidence base for fundamentals of care remains sparse, with poor consistency and clarity around the concept itself and (as discussed above) a dearth of reliable metrics. There currently exist a multitude of terms to describe fundamental care, including self-care, activities of daily living, functional ability, essentials of care and basic nursing care, and these terms are not always interpreted consistently

7

(Kitson et al., 2010). In the US and Canada the term ‘fundamentals of care’ is synonymous with rudimentary skills encapsulated in introductory textbooks aimed at beginner nursing students (Kagan, 2013), which reinforces the idea that fundamental care requires little technical skill. Given the challenges nurses face when working and learning in an environment that does not reward or recognise caring, it is perhaps understandable that some nurses no longer see the value in it. Routinely engaging in work that is not valued or being unable to provide quality fundamental care under the constraints of a managerial framework can be morally distressing (Bridges et al., 2013). As such, whilst many nurses might initially value caring and enter the profession with the desire to provide high-quality fundamental care, working in a task-based environment can lead to disengagement from patients and the devaluing of fundamental care as a means of coping and self-preservation (Bridges et al., 2013). Of course some scholars argue that poor quality care results not from nurses’ poor attitude towards caring but from broader systems issues, such as staff shortages, which inhibit nurses from having sufficient time to provide fundamental care (Aiken et al., 2014; Ma et al., 2015). Research has shown some support for this idea, with reduced workloads and improved staff–patient ratios and skills mix resulting in lower mortality and morbidity and fewer complications and complaints (Aiken et al., 2002; Kane et al., 2007; Needleman et al., 2002; Rogers et al., 2004). Given the evidence linking poor quality care to staffing issues, we must ask ourselves whether we are concentrating our efforts in the wrong area by focusing on the invisibility of fundamental care. However, we challenge nursing scholars, practitioners, healthcare managers and policy-makers to conceive of how having more nurses on a shift will result automatically and inevitably in highquality fundamental care when such care is devalued both by nurses and the environment in which they work. Even if nurse staffing numbers improved, an unlikely prospect given the current economic climate and forecasts of future nurse shortages (Health Workforce Australia, 2012; Institute of Medicine, 2011; National Expert Commission, 2012), nurses will inevitably experience times of increased workload and patient demands. In these instances, it is fundamental care that will continue to be ignored unless it is valued and prioritised. There is also evidence to suggest that increasing staff numbers and having more time in which to complete work does not necessarily result in nurses spending more time with patients (Henderson et al., 2007; Sandford et al., 1990). This is perhaps unsurprising given the types of activities that are privileged under a managerial framework. As such, whilst time constraints are undoubtedly a pressing issue for many nurses, they alone do not account for poor quality fundamental care. The propositions explicate deep-seated beliefs about the fundamentals of care and their value, which have contributed to their poor and inconsistent delivery. The task, now, is to challenge these beliefs and substantially re-think the way in which fundamental care is conceptualised. We argue that this shift in thinking requires: (1) re-conceptualising the value of fundamental care, (2) conceptual clarity, (3) greater role clarification, (4)

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

8

Table 3 Strategies for transforming the delivery of fundamental care in acute care settings. Strategy 1: Strategy 2:

Strategy 3:

Strategy 4:

Strategy 5:

Strategy 6:

Re-conceptualisation of the value of fundamental care across the acute healthcare system Development of a consistent conceptual understanding around the fundamentals of care that is underpinned by empirical evidence Greater role clarification to determine who is primarily responsible for overseeing and carrying out the delivery of fundamental care Improved metrics around the fundamentals of care that move the acute health system from reporting deficits to reporting the positive contributions of fundamentals of care to patient outcomes Novel nursing curriculum design and co-design, including systematically embedding the fundamentals of care into the nursing and other healthcare curricula across all year levels Active engagement with policy makers and the community to better understand what kind of care they want and are willing to pay for

improved metrics, (5) the embedding of fundamental care into nursing and other healthcare curricula, and (6) greater involvement with the community (see Table 3). 3. Discussion Our first task is to change the way we think such that fundamental care is no longer seen as conveying little value or requiring little skill but is recognised as a complex activity crucial to patient safety, recovery and wellbeing. For this to occur, the entire system – research, education, policy and practice – must play its part. These elements do not occur in isolation but have a profound effect on each other. Each element must instil a commitment to fundamental care and require that this commitment is a core competence of all nurses. To avoid further disaggregation of fundamental care, part of this re-conceptualisation must involve determining how fundamental care fits with other healthcare policy agendas, such as patient or person-centred care (e.g., World Health Organisation, 2007) and compassionate care (e.g., Cummings and Bennett, 2012). We do not want to run the risk of fundamental care being seen as distinct from, or a competitor to, these other policy agendas, leading to fundamental care, patient/person-centred care and compassionate care becoming siloed areas of nursing work, running parallel to one another rather than in synchrony. Avoiding this disaggregation will require deep and disciplined analysis and reflection, with nursing leaders working together to find integrated solutions. This work also requires consistency and clarity around the concept of fundamental care. Without a clear taxonomy and conceptual clarity there is little hope that a systematic approach to the delivery, research and education of fundamental care can be developed. Our task, then, is to develop a consistent, evidence-based understanding of fundamental care to enable the effective operationalisation and consistent implementation of the fundamentals in practice and education. This requires

nursing scholars and others to engage in empirical research around fundamental care in order to develop its underlying evidence base and understand how best to translate evidence to practice. Whilst the development of conceptual clarity and evidence underpinning the fundamentals should take a multi-disciplinary approach, involving input from all health professionals who provide direct care to patients, nursing must take the lead in determining what type of evidence to develop and how best to develop it. We also need to establish who is primarily responsible for overseeing and delivering fundamental care: registered nurses, enrolled nurses, licensed practical nurses, associate nurses, nursing aides, unpaid carers, relatives or a mixture? We must engage with allied health professional colleagues to understand how fundamental care links with specialised interventions. Role clarification is also crucial for the success of policy initiatives and healthcare reforms – there is little advantage in creating fundamental care standards for nurses if they do not think it is their job to carry out such care with patients. Linked to the policy debate around nursing roles and responsibilities is the need to clarify the nurse’s role in educating patients and their families around fundamental self-care. Consider the significant impact if registered nurses were to act as promoters of expert fundamental care and work with patients and families to help them care for themselves more healthily. Given the projections around chronic illness, multi- and co-morbidities, and illnesses related to ageing, it would be wise to ensure that fundamental selfcare behaviours were clearly embedded in relationships, families and communities. A key element of an empirically-based understanding of the fundamentals of care is the development of metrics for such care. These metrics will render visible to nurses, other health professionals, healthcare managers and policymakers the ways in which the fundamentals of care contribute positively to patient outcomes and care experiences. We must therefore concentrate research efforts on identifying and operationalising reliable indicators of physical, psychosocial and relational aspects of fundamental care, and determine how the supposedly vague and subjective aspects of such care can be translated into readily identifiable and measureable activities. As part of this work, there is an urgent need to explicate the observable behaviours required by nurses to develop and sustain trusting, positive relationships with their patients (Wiechula et al., 2016). Measures need to be developed around these nursing behaviours to create suitable metrics for the relational aspects of fundamental care. As an important policy agenda, fundamental care metrics must be made visible in nursing documentation and electronic patient records to move nurses, managers and policy-makers away from a system focused on reporting deficits to a system focused on reporting the positive contributions of fundamental care to patient outcomes. Changing our current recording practices will also allow for data around the fundamentals to be readily retrieved for the purposes of evaluation and research. Without creating metrics and embedding them into nursing and patient documentation, policy initiatives

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

and healthcare reforms on fundamental care will continue to have minimal impact. If healthcare organisations cannot see value (both monetary and in terms of patient outcomes) from delivering high-quality fundamental care they will not invest time and energy in supporting nurses to deliver such care nor embedding metrics around fundamental care into electronic systems. Likewise, if the fundamentals are not readily recorded then there is little onus on (or reward for) nurses to complete them to a consistently high standard. As argued above, there is evidence to suggest that nursing education, particularly in the context of clinical placement, is contributing to the devaluing of fundamental care by nursing students. It is therefore imperative that the fundamentals of care are systematically embedded into nursing curricula across all year levels. Research is also required to identify the hidden curriculum around fundamental care – the values and practices that are not explicitly taught but which students nonetheless learn – and how current nursing education is contributing to this implicit knowledge transfer (e.g., by pairing students with nursing assistants to learn fundamental care). Research on fundamental care is also required to ensure students are provided the best available evidence on how such care impacts patient outcomes and how it should be delivered in practice. The increased role of allied and other health professionals in the delivery of fundamental care also calls for the systematic integration of evidence-based fundamental care into all healthcare curricula; not just nursing. Curriculum co-design amongst the health professions and multi-disciplinary learning and teaching will equip students with the necessary skills to deliver fundamental care as part of a team-based approach, ensuring the delivery of care that is co-ordinated and consistent rather than fragmented and contradictory. Our final, and arguably most important, task is to engage the wider community in conversations about the sort of healthcare experiences they want and are prepared to pay for in acute settings. There is growing disconnect between the rhetoric of patient-centred, fundamental care and people’s lived experiences of hospitalisation (Bureau of Health Information, 2014; Francis, 2013; SA Health, 2012). Patients are not being provided the type of care in acute settings that policy initiatives would have them expect. Perhaps, if it is too late to think about humanising the health system, then the appropriate thing to do is to be transparent that patients can expect care driven by tasks, interventions and cost effectiveness rather than care constructed to provide a personalised experience. In this way, patients’ expectations around care will better match reality. Written in this way we realise the challenges confronting nursing and the community. It requires a concerted and continuous effort to create the sorts of acute health systems in which we would wish to be cared for and this should be what drives us to achieve it. 4. Conclusions The challenges and at times failure in the delivery of fundamental care across acute health systems is an international phenomenon. We argue that it is an

9

inevitable consequence of the invisibility of such care, brought about by the continued dominance of the biomedical model, managerial approaches adhered to by most healthcare systems, and the devaluing of fundamental care by nurses themselves. This devaluing of fundamental care has become a destructive cycle and selffulfilling prophecy: fundamental care is seen to hold less value than other aspects of clinical care, and so is not researched or taught systematically and is not implemented to a consistently high standard. The lack of educative and research attention paid to fundamental care, and its conspicuous absence in practice, only works to reinforce (and justify) the idea that such care is unimportant, allowing us to continue ignoring it. Thus the devaluing of fundamental care leaves us with a poorly conceptualised and operationalised concept that is becoming increasingly difficult to integrate into evidence-based practice, healthcare systems and nursing curricula. The end result is that patients’ safety and welfare are compromised. It would seem timely to respond to these challenges by changing the way we think about – and take action towards – the fundamentals of care. Conflict of interest There are no conflicts of interest. Acknowledgements We would like to thank Kathleen MacMillan and Tiffany Conroy for their comments on an earlier version of this paper. References Adamsen, L., Tewes, M., 2000. Discrepancy between patients perspectives, staff’s documentation and reflections on basic nursing care. Scand. J. Caring Sci. 14 (2), 120–129. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H., 2002. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. J. Am. Med. Assoc. 288 (16), 1987–1993. Aiken, L.H., Rafferty, A.M., Sermeus, W., 2014. Caring nurses hit by a quality storm. Nurs. Stand. 28, 22–25. Allan, H., 2007. The rhetoric of caring and the recruitment of overseas nurses: the social production of a care gap. J. Clin. Nurs. 16 (12), 2204– 2212, http://dx.doi.org/10.1111/j.1365-2702.2007.02095.x. Allan, H., Smith, P., 2009. How student nurses’ supernumerary status affects the way they think about nursing. Nurs. Times 105 (43), 10–13. Ausserhofer, D., Zander, B., Busse, R., Schubert, M., Geest, S.D., Rafferty, A.M., Ball, J., Scott, A., Kinnunen, J., Heinen, M., Sjetne, I.S., Moreno-Casbas, T., Ko´zka, M., Lindqvist, R., Diomidous, M., Bruyneel, L., Sermeus, W., Aiken, L.H., Schwendimann, R., 2014. Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual. Saf. 23 (2), 126–135, http://dx.doi.org/10.1136/bmjqs-2013-002318. Bjerrum, M., Tewes, M., Pedersen, P., 2012. Nurses’ self-reported knowledge about and attitude to nutrition – before and after a training programme. Scand. J. Caring Sci. 26 (1), 81–89, http://dx.doi.org/ 10.1111/j.1471-6712.2011.00906.x. Borell-Carrio´, F., Suchman, A.L., Epstein, R.M., 2004. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann. Fam. Med. 2 (6), 576–582, http://dx.doi.org/10.1370/afm.245. Bridges, J., Nicholson, C., Maben, J., Pope, C., Flatley, M., Wilkinson, C., Meyer, J., Tziggili, M., 2013. Capacity for care: meta-ethnography of acute care nurses’ experiences of the nurse–patient relationship. J. Adv. Nurs. 69 (4), 760–772, http://dx.doi.org/10.1111/jan.12050. Bureau of Health Information, 2014. Adult Admitted Patient Survey 2013 Results. Snapshot Report NSW Patient Survey Program. BHI, NSW.

10

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11

Cancian, F.M., Oliker, S.J., 2000. Caring and Gender. Pine Forge Press, Thousand Oaks, CA. Care Quality Commission, 2010. Essential Standards of Quality and Safety. CQC, London. Care Quality Commission, 2011. The state of health care and adult social care in England. An overview of key themes 2010/11. The Stationery Office Limited on behalf of the Controller of Her Majesty’s Stationery Office, UK. Carr, D., Benoit, R., 2009. The role of interventional patient hygiene in improving clinical and economic outcomes. Adv. Skin Wound Care 22 (2), 74–78. Chiovitti, R.F., 2008. Nurses’ meaning of caring with patients in acute psychiatric hospital settings: a grounded theory study. Int. J. Nurs. Stud. 45 (2), 203–223, http://dx.doi.org/10.1016/j.ijnurstu.2006.08.018. Conroy, T., Feo, R., Alderman, J., Kitson, A., 2016. Building nursing practice: the fundamentals of care framework. In: Crisp, J., Douglas, C., Rebeiro, G., Waters, D. (Eds.), Potter & Perry’s Fundamentals of Nursing. 5th ed. Elsevier. Costello, T., Coyne, I., 2008. Nurses’ knowledge of mouth care practices. Br. J. Nurs. 17 (4), 264–268. Cummings, J., Bennett, V., 2012. Compassion in Practice. Nursing, Midwifer and Care Staff. Our Vision and Strategy. Department of Health and NHS Commissioning Board, UK. Dale, C., Angus, J.E., Sinuff, T., Mykhalovskiy, E., 2013. Mouth care for orally intubated patients: a critical ethnographic review of the nursing literature. Intensive Crit. Care Nurs. 29 (5), 266–274, http:// dx.doi.org/10.1016/j.iccn.2012.09.003. Darbyshire, P., McKenna, L., 2013. Nursing’s crisis of care: what part does nursing education own? Nurse Educ. Today 33 (4), 305–307, http:// dx.doi.org/10.1016/j.nedt.2013.03.002. De Arau´jo Ferreira, S.M., De Oliveira Gozzo, T., Panobianco, M.S., Dos Santos, M., De Almeida, A.M., 2015. Barriers for the inclusion of sexuality in nursing care for women with gynecological and breast cancer: perspective of professionals. Rev. Lat. Am. Enferm. 23 (1), 82–89. De Bellis, A., 2010. Australian residential aged care and the quality of nursing care provision. Contemp. Nurse 35 (1), 100–113, http:// dx.doi.org/10.5172/conu.2010.35.1.100. Department of Health, 2012. Best care for older people everywhere. The toolkit. Government of Victoria, Victoria. Dewar, B., Nolan, M., 2013. Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting. Int. J. Nurs. Stud. 50 (9), 1247–1258, http:// dx.doi.org/10.1016/j.ijnurstu.2013.01.008. Dubois, C.A., D’Amour, D., Pomey, M.P., Girard, F., Brault, I., 2013. Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review. BMC Nursing 12 (1), 1–20, http://dx.doi.org/10.1186/1472-6955-12-7. Engel, G.L., 1978. The biopsychosocial model and the education of health professionals. Ann. N.Y. Acad. Sci. 310, 169–181. Flatley, M., Bridges, J., 2008. Promoting the art of caring for older people. Int. J. Nurs. Stud. 45 (3), 333–334, http://dx.doi.org/10.1016/j.ijnurstu.2007.09.007. Francis, R., 2013. Report of the Mid Staffordshire NHS Foundation Trust public inquiry. Controller of Her Majesty’s Stationery Office. Contains public sector information licensed under the Open Government Licence v2.0, London. Garling, P., 2008. Final report of the Special Commission of Inquiry Acute Care Services in NSW Public Hospitals. Special Commission of Inquiry: Acute Care Services in New South Wales Public Hospitals, Sydney, Australia. Geist-Martin, P., Bollinger, B.J., Wiechert, K.N., Plump, B., Sharf, B.F., 2015. Challenging integration: clinicians’ perspectives of communicating collaboration in a center for integrative medicine. Health Commun., http://dx.doi.org/10.1080/10410236.2014.976605. Gill, A., Kuluski, K., Jaakkimainen, L., Naganathan, G., Upshur, R., Wodchis, W.P., 2014. Where do we go from here? Health system frustrations expressed by patients with multimorbidity, their caregivers and family physicians. Healthc. Policy 9 (4), 73–89, http://dx.doi.org/ 10.1111/hex.12085. Giordano, L.A., Elliott, M.N., Goldstein, E., Lehrman, W.G., Spencer, P.A., 2010. Development, implementation, and public reporting of the HCAHPS survey. Med. Care Res. Rev. 67 (1), 27–37, http:// dx.doi.org/10.1177/1077558709341065. Griffiths, J., Speed, S., Horne, M., Keeley, P., 2012. A caring professional attitude’: what service users and carers seek in graduate nurses and the challenge for educators. Nurse Educ. Today 32 (2), 121–127, http://dx.doi.org/10.1016/j.nedt.2011.06.005. Hasson, F., McKenna, H.P., Keeney, S., 2013. Perceptions of the unregistered healthcare worker’s role in pre-registration student nurses’

clinical training. J. Adv. Nurs. 69 (7), 1618–1629, http://dx.doi.org/ 10.1111/jan.12023. Ha¨yrinen, K., Saranto, K., Nyka¨nen, P., 2008. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int. J. Med. Inf. 77 (5), 291–304, http://dx.doi.org/10.1016/ j.ijmedinf.2007.09.001. Health Workforce Australia, 2012. Health Workforce 2025 – Doctors, Nurses and Midwives, vol. 1. Australian Government, Canberra, Australia. Heaven, B., Bamford, C., May, C., Moynihan, P., 2013. Food work and feeding assistance on hospital wards. Sociol. Health Illn. 35 (4), 628– 642, http://dx.doi.org/10.1111/j. 1467-9566.2012.01515.x. Henderson, A., Van Eps, M.A., Pearson, K., James, C., Henderson, P., Osborne, Y., 2007. ‘Caring for’ behaviours that indicate to patients that nurses ‘care about’ them. J. Adv. Nurs. 60 (2), 146–153, http:// dx.doi.org/10.1111/j.1365-2648.2007.04382.x. Institute of Medicine, 2011. The Future of Nursing. Leading Change, Advancing Health. National Academic Press, Washington, DC. Juve´-Udina, M.E., Pe´rez, E.Z., Padre´s, N.F., Samartino, M.G., Garcı´a, M.R., Creus, M.C., Batllori, N.V., Calvo, C.M., 2014. Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting. J. Nurs. Scholarsh. 46 (1), 65–72, http://dx.doi.org/10.1111/jnu.12062. Kagan, S., 2013. Implications of the fundamentals of care for nursing education. In: MacMillan, K. (Ed.), Proceedings of a Think Tank on the Future of Undergraduate Nursing Education in Canada. Dalhousie University School of Nursing, Halifax, pp. 47–54. Kalisch, B.J., 2006. Missed nursing care: a qualitative study. J. Nurs. Care Qual. 21 (4), 306–313. Kalisch, B.J., Landstrom, G., Williams, R.A., 2009. Missed nursing care: errors of omission. Nurs. Outlook 57 (1), 3–9, http://dx.doi.org/ 10.1016/j.outlook.2008.05.007. Kalisch, B.J., Tschannen, D., Lee, H., Friese, C.R., 2011. Hospital variation in missed nursing care. Am. J. Med. Qual. 26 (4), 291–299, http:// dx.doi.org/10.1177/1062860610395929. Kalisch, B.J., Williams, R.A., 2009. Development and psychometric testing of a tool to measure missed nursing care. J. Nurs. Adm. 39 (5), 211– 219, http://dx.doi.org/10.1097/NNA.0b013e3181a23cf5. Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med. Care 45 (12), 1195–1204, http://dx.doi.org/10.1097/MLR.0b013e3181468ca3. Kitson, A., Conroy, T., Kuluski, K., Locock, L., Lyons, R., 2013a. Reclaiming and Redefining the Fundamentals of Care: Nursing’s Response to Meeting Patients’ Basic Human Needs. School of Nursing, The University of Adelaide, Adelaide, South Australia. Kitson, A., Conroy, T., Wengstrom, Y., Profetto-McGrath, J., RobertsonMalt, S., 2010. Defining the fundamentals of care. Int. J. Nurs. Pract. 16, 423–434, http://dx.doi.org/10.1111/j.1440-172X.2010.01861.x. Kitson, A., Dow, C., Calabrese, J.D., Locock, L., Muntlin Athlin, A., 2013b. Stroke survivors’ experiences of the fundamentals of care: a qualitative analysis. Int. J. Nurs. Stud. 50, 392–403, http://dx.doi.org/ 10.1016/j.ijnurstu.2012.09.017. Kitson, A., Marshall, A., Bassett, K., Zeitz, K., 2013c. What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. J. Adv. Nurs. 69 (1), 4–15, http://dx.doi.org/10.1111/j.1365-2648.2012.06064.x. Kitson, A., Muntlin Athlin, A., 2013. Development and preliminary testing of a framework to evaluate patients’ experiences of the fundamentals of care: a secondary analysis of three stroke survivor narratives. Nurs. Res. Pract. 572437. Kitson, A., Muntlin Athlin, A., Conroy, T., 2014. Anything but basic: nursing’s challenge in meeting patients’ fundamental care needs. J. Nurs. Scholarsh. 46 (5), 331–339, http://dx.doi.org/10.1111/jnu. 12081. Kucera, K., Higgins, I., McMillan, M., 2010. Advanced nursing practice: a futures model derived from narrative analysis of nurses’ stories. Aust. J. Adv. Nurs. 27 (4), 43–53. Landstro¨m, M., Rehn, I.M., Frisman, G.H., 2009. Perceptions of registered and enrolled nurses on thirst in mechanically ventilated adult patients in intensive care units. A phenomenographic study. Intensive Crit. Care Nurs. 25 (3), 133–139, http://dx.doi.org/10.1016/j.iccn. 2009.03.001. Lucero, R.J., Lake, E.T., Aiken, L.H., 2010. Nursing care quality and adverse events in US hospitals. J. Clin. Nurs. 19 (15–16), 2185–2195, http:// dx.doi.org/10.1111/j.1365-2702.2010.03250.x. Ma, C., McHugh, M.D., Aiken, L.H., 2015. Organization of hospital nursing and 30-Day readmissions in Medicare patients undergoing surgery. Med. Care 53 (1), 65–70.

R. Feo, A. Kitson / International Journal of Nursing Studies 57 (2016) 1–11 Maben, J., 2008. The art of caring: invisible and subordinated? A response to Juliet Corbin: ‘Is caring a lost art in nursing?’. Int. J. Nurs. Stud. 45 (3), 335–338, http://dx.doi.org/10.1016/j.ijnurstu.2007.09.002. Maben, J., Cornwell, J., Sweeney, K., 2010. In praise of compassion. J. Res. Nurs. 15 (1), 9–13, http://dx.doi.org/10.1177/1744987109353689. MacKinnon, H.A., 2011. Quality Education for a Healthier Scotland – NES Nursing and Midwifery Strategy: 2011–2014. NHS, Edinburgh. Matthews, D., 2015. Can sociology help to improve nursing practice? Nurs. Times 111 (41), 18–20. McCance, T.V., McKenna, H.P., Boore, J.R.P., 1997. Caring: dealing with a difficult concept. Int. J. Nurs. Stud. 34 (4), 241–248. McGuckin, M., Shubin, A., Hujcs, M., 2008. Interventional patient hygiene model: infection control and nursing share responsibility for patient safety. Am. J. Infect. Control 36 (1), 59–62, http://dx.doi.org/10.1016/ j.ajic.2007.01.010. Millar, C., Reid, J., Porter, S., 2013. Healthcare professionals’ response to cachexia in advanced cancer: a qualitative study. Oncol. Nurs. Forum 40 (6), E393–E402. National Expert Commission, 2012. The Health of Our Nation, the Future of Our Health System: A Nursing Call to Action. Canadian Nurses Association, Ottawa, Ontario, Canada. Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., Zelevinsky, K., 2002. Nurse-staffing levels and the quality of care in hospitals. N. Engl. J. Med. 346 (22), 1715–1722, http://dx.doi.org/10.1056/NEJMsa012247. NSW Department of Health, 2009. Working with Essentials of Care: A resource Guide for Facilitators. NSW Department of Health, Sydney, NSW. Pettit, S.L., McCann, A.L., Schneiderman, E.D., Farren, E.A., Campbell, P.R., 2012. Dimensions of oral care management in Texas hospitals. J. Dent. Hyg. 86 (2), 91–103. Rantz, M.J., Zwygart-Stauffacher, M., 2004. Back to the fundamentals of care: a roadmap to improve nursing home care quality. J. Nurs. Care Qual. 19 (2), 92–94. Rogers, A.E., Hwang, W.T., Scott, L.D., Aiken, L.H., Dinges, D.F., 2004. The working hours of hospital staff nurses and patient safety. Health Aff. (Millwood) 23 (4), 202–212, http://dx.doi.org/10.1377/hlthaff.23.4.202. Rubio-Valera, M., Pons-Vigue´s, M., Martı´nez-Andre´s, M., Moreno-Peral, P., Berenguera, A., Ferna´ndez, A., 2014. Barriers and facilitators for the implementation of primary prevention and health promotion activities in primary care: a synthesis through meta-ethnography. PLoS One 9 (2), e89554. Russell, L., 2014. Sociology for Health Professionals. Sage Publications. SA Health, 2015. Delivering Transforming Health. Department for Health and Ageing, Government of South Australia, Adelaide, South Australia. SA Health, 2012. Measuring Consumer Experience. SA Public Hospital Inpatient Annual Report, March 2012. Safety and Quality Unit, Public Health & Clinical Systems, SA, Health, Adelaide, South Australia.

11

Sandford, D.A., Elzinga, R.H., Iversen, R., 1990. A quantitative study of nursing staff interactions in psychiatric wards. Acta Psychiatr. Scand. 81 (1), 46–51. Schubert, M., Glass, T.R., Clarke, S.P., Schaffert-Witvliet, B., De Geest, S., 2007. Validation of the basel extent of rationing of nursing care instrument. Nurs. Res. 56 (6), 416–424, http://dx.doi.org/10.1097/ 01.NNR.0000299853.52429.62. Thomas, J., Jack, B.A., Jinks, A.M., 2012. Resilience to care: a systematic review and meta-synthesis of the qualitative literature concerning the experiences of student nurses in adult hospital settings in the UK. Nurse Educ. Today 32 (6), 657–664, http://dx.doi.org/10.1016/ j.nedt.2011.09.005. Treiber, L.A., Jones, J., 2015. The care/cure dichotomy: nursing’s struggle with dualism. Health Sociol. Rev., http://dx.doi.org/10.1080/14461242. 2014.999404. Vollman, K., 2009. Back to the fundamentals of care: why now, why us! Aust. Crit. Care 22 (4), 152–154, http://dx.doi.org/10.1016/ j.aucc.2009.09.001. Vollman, K., 2013. Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics. Intensive Crit. Care Nurs. 29 (5), 250–255, http://dx.doi.org/10.1016/ j.iccn.2013.04.004. Wade, D.T., Halligan, P.W., 2004. Do biomedical models of illness make for good healthcare systems? Br. Med. J. 329 (7479), 1398–1401. Weiner, B.K., 2007. Difficult medical problems: on explanatory models and a pragmatic alternative. Med. Hypotheses 68 (3), 474–479, http:// dx.doi.org/10.1016/j.mehy.2006.09.015. Wiechula, R., Conroy, T., Kitson, A., Marshall, R.J., Whitaker, N., Rasmussen, P., 2016. Umbrella review of the evidence: what factors influence the caring relationship between a nurse and patient? J. Adv. Nurs., http://dx.doi.org/10.1111/jan.12862. Williams, H., Harris, R., Turner-Stokes, L., 2009. Work sampling: a quantitative analysis of nursing activity in a neuro-rehabilitation setting. J. Adv. Nurs. 65 (10), 2097–2107, http://dx.doi.org/10.1111/j.13652648.2009.05073.x. Willis, G., 2012. Quality with compassion: The future of nursing education. Report of the Willis Commission on Nursing Education. The Royal College of Nursing on behalf of the independent Willis Commission on Nursing Education. . Wolf, K.A., 2014. Critical perspectives on nursing as bodywork. Adv. Nurs. Sci. 37 (2), 147–160, http://dx.doi.org/10.1111/jan.1286210.1097/ ANS.0000000000000028. World Health Organisation, 2007. People-Centred Health Care: A Policy Framework. WHO.