In Part One, I told about traveling by plane to another U.S. city and, while there, being hospitalized for seven days with acute pancreatitis. During that time, I was not ambulated at all and wound up needing physical therapy for six weeks post-hospitalization. I also developed hospital-acquired pneumonia and, although I was NPO, the only mouth care I received was a two-swab packet—and that, only after I asked for it. During the entire hospitalization, I received two baths (showers), the last of which was just before discharge. That, too, would not have happened had I not insisted on it. During my stay, I observed no members of the nursing staff washing their hands.
Many more instances of missed nursing care could have been included in this true story about this one hospitalization. Unfortunately, my experience is not atypical. Missed nursing care, defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed (Kalisch, Landstrom, & Hinshaw, 2009), appears to be occurring on a regular basis in hospitals everywhere.
Patient safety errors are divided into errors of commission (e.g., giving the wrong medication, hanging the incorrect blood) and errors of omission (e.g., not giving a medication, failing to feed a patient). Missed nursing care involves errors of omission. The Agency for Healthcare Research and Quality (AHRQ, n.d.) has pointed out that there are, undoubtedly, many more errors of omission than commission. To date, the patient safety movement has dealt primarily with errors of commission. However, AHRQ has stated that there are many more errors of omission than commission and, thus, the impact of errors of omission is vastly greater.
We have conducted a series of studies that show that missed nursing care is a significant problem. The first study was qualitative (Kalisch, 2006). A total of 173 nursing staff members in two acute-care hospitals were interviewed in 25 focus groups. Findings from this study uncovered nine areas of missed care that involved omissions of the following: ambulation, turning, delayed or missed feedings, patient teaching, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance. Seven reasons were cited for the missing care: too few staff members, poor use of existing staff resources, time required for the nursing intervention, lack of teamwork, ineffective delegation, habit and denial.
To study missed care widely, a survey instrument known as The MISSCARE Survey was developed and tested for its psychometric properties (Kalisch & Williams, 2009). This survey, which identifies elements of missed care and reasons for missed care, has been administered in more than15 hospitals and involved an estimated 5,000 nursing staff members. Across all of these hospitals, selected items of care are consistently on the most missed list. Ambulation is almost always the number one missed element of care, and mouth care and administering medications on time are in the top five (Kalisch, Landstrom, & Williams, 2009; Kalisch, Tschannen, & Lee). Consistently, the least missed care tasks are patient assessment on each shift, vital signs and bedside glucose monitoring.
Reasons for missed care have also been investigated and the results, again, are consistent across hospitals of varying sizes and types. The reason cited most is inadequate labor or staff resources, followed by lack of material resources (pharmaceuticals, equipment and supplies) and, finally, communication problems (Kalisch, Landstrom, & Williams, 2009; Kalisch, Tschannen, & Lee). Other more elusive and difficult-to-measure reasons for missed care also emerged from the study (Kalisch, 2006), such as failing to do certain types of care out of habit. In other words, if ambulation is missed one day, it is easier not to do it the next and, eventually, it becomes a habit.
Other reasons for missed care are peer pressure and team norms. Nurses in focus groups repeatedly said that, when they consulted with team members about not completing aspects of care, it was not uncommon for their peers to say: “Oh, we don’t do that. Don’t worry about it” (Kalisch, 2006). It appears that, over time, a “culture of missing care” has somehow evolved. Nurses who have practiced more than 20 years point to a major decline in completeness of nursing care over the last several decades.
Missed nursing care potentially leads to negative outcomes, as in my experience, and even life-threatening results. The impact of not ambulating is one example. Mobility standards for hospitalized patients indicate that patients should be progressively mobilized three times per day (Schubert et al., 2008). However, Callen, Mahoney, Grieves, Wells, and Enloe (2004) studied the frequency of hallway walking by adults hospitalized on a medical unit and found that 73 percent did not walk at all, 19 percent walked only once, 5 percent walked twice and 3 percent more than twice. Patients, especially those over age 65, often leave the hospital less able to function or move than before they were admitted. Lack of ambulation has been reported to result in 5 percent loss of muscle strength per day (Harper & Lyles, 1988). One study showed that 17 percent of older patients who, two weeks before hospitalization, were able to walk on their own needed help to walk post-hospitalization (Harper & Lyles).
Deconditioning, caused by bed rest without proper ambulation, can be debilitating to patients who later attempt to reambulate to normal, active life. Failure to ambulate patients has been linked to new-onset delirium, pneumonia, delayed wound healing, decubitus ulcers, increased length of stay and delayed discharge, increased pain and discomfort, muscle wasting and fatigue, and physical disability. Frequent, aggressive and effective ambulation has been shown to increase local perfusion, tissue oxygen levels and bowel movements, thus preventing venous thromboembolism and ileus, both of which are significant causes of morbidity and mortality. The results of one study showed that exercise resulted in reduced lengths of stay and patients returning home instead of to nursing homes or other care facilities.
In addition to the negative impact missed nursing care has on the quality and cost of health care, we have found that missed care leads to job dissatisfaction, which probably results in greater turnover and nursing shortages (Kalisch, Tschanen, & Lee). The vast majority of nurses want to do a “good” job. Nurses report that they feel distressed when they don’t complete all of the care they feel a patient needs, and this lowers their self-image and causes them to regard themselves as less competent.
Another study we completed compared missed care identified by nurses versus missed care identified by assistive personnel. Elements of nursing care were categorized as 1) those completed mostly by nurses, 2) those shared between nurses and assistive staff and 3) those carried out primarily by assistive personnel. Nurses identified more missed care than nursing assistants and, of even more interest, the nurses felt that elements of care completed by assistants were missed more than other aspects of care. This suggests a lack of trust between nurses and assistants, which contributes to a lack of teamwork (Kalisch, 2009).
So what should be done to deal with this problem? The first step is to recognize it and bring it out into the open. This is the only way it can be addressed. Nurses report that missed care is a “hidden secret” that they would like to bring out in the open and address. This is similar to the patient safety movement. Until 11 years ago, when the IOM report To Err is Human was published, little attention was given to the issue (Kohn, Corrigan, & Donaldson, 2000). Today, safety is a major focal point in health provider organizations and funding agencies. Now, we even have patient safety officers in some hospitals.
Like the patient safety movement, a punitive culture must be avoided. If nursing staff members are “punished” because they acknowledge missing care, they will not be open about it, nothing will be done and it will remain “hidden.” Encouraging reporting of missed nursing care requires creative approaches, such as doing a round robin at change-of-shift about what care was missed on the previous shift.
Once there is open sharing about what care is missed, the extent and type of missed nursing care on any given patient care unit can be compiled. Using the MISSCARE Survey on a regular basis and tracking the results help staff members become and remain informed about missed nursing care on their patient care unit. A root-cause analysis of the reasons for missed nursing care also needs to be conducted. Why, for example, are patients not receiving mouth care on this unit? This information will provide insight into the problem at the local level and, typically, will lead to solutions. Outcome targets, such as 90 percent of our patients will be ambulated three times a day, need to be established by the nursing staff.
In summary, nurses are responsible for the quality of nursing care they provide and are the only ones who can address the problem of incomplete care. We need to support and facilitate each nursing team to address this issue forthrightly and provide the team with the means to solve the problem. RNL
Missed nursing care: View from the hospital bed (Part One)
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Beatrice Kalisch |
Beatrice J. Kalisch, PhD, RN, FAAN, is Titus Distinguished Professor, Chair of Division III, at the University of Michigan School of Nursing in Ann Arbor, Michigan, USA.
References:
Agency for Healthcare Research and Quality (AHRQ). (n.d.). AHRQ PSNet Patient Safety Network: Glossary. Retrieved 17 January 2008 from http://psnet.ahrq.gov/glossary.aspx
Callen, B.L., Mahoney, J.E., Grieves, C.B., Wells, T.J., & Enloe, M. (2004). Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatric Nursing, 25(4), 212-217.
Harper, C.M., & Lyles, Y.M. (1988). Physiology and complications of bed rest .Journal of the American Geriatrics Society, 36(11), 1047-1054.
Kalisch, B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.
Kalisch, B. (2009). Nurse and nurse assistant perceptions of missed nursing care: What does it tell us about teamwork? Journal of Nursing Administration, 39(11), 485-493.
Kalisch, B., Landstrom G, & Williams, R. (2009). Missed nursing care: Errors of omission. Nursing Outlook, 57(1), 3-9.
Kalisch, B., Tschannen, D., & Lee, H. Missed nursing care: A comparison of 10 hospitals. Manuscript submitted for publication.
Kalisch B., & Williams W. (2009). The development and testing of a tool to measure missed nursing care. Journal of Nursing Administration, Research issue, 39(5), 211-219.
Kalisch, B.J., Landstrom, G., & Hinshaw, A.S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517.
Kalisch, B.J., Tschanen, D., & Lee, H. Does missed nursing care impact staff satisfaction? Unpublished manuscript under consideration for publication.
Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
