Beatrice J. Kalisch

Missed nursing care: a qualitative study.

The purpose of this study was to determine nursing care regularly missed on medical-surgical units and reasons for missed care. Nine elements of regularly missed nursing care (ambulation, turning, delayed or missed feedings, patient teaching, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance) and 7 themes relative to the reasons for missing this care were reported by nursing staff.

Missed nursing care: Errors of omission

This study examines what and why nursing care is missed. A sample of 459 nurses in 3 hospitals completed the Missed Nursing Care (MISSCARE) Survey. Assessment was reported to be missed by 44% of respondents while interventions, basic care, and planning were reported to be missed by > 70% of the survey respondents. Reasons for missed care were labor resources (85%), material resources (56%), and communication (38%). A comparison of the hospitals showed consistency across all 3 hospitals. Associate degree nurses reported more missed care than baccalaureate-prepared and diploma-educated nurses. The results of this study lead to the conclusion that a large proportion of all hospitalized patients are being placed in jeopardy because of missed nursing care or errors of omission. Furthermore, changes in Center for Medicare and Medicaid Services (CMS) regulations which will eliminate payment for acute care services when any one of a common set of complications occurs, such as pressure ulcers and patient falls, point to serious cost implications for hospitals.

Missed nursing care: a concept analysis

AIM This paper is a report of the analysis of the concept of missed nursing care. BACKGROUND According to patient safety literature, missed nursing care is an error of omission. This concept has been conspicuously absent in quality and patient safety literature, with individual aspects of nursing care left undone given only occasional mention. METHOD An 8-step method of concept analysis - select concept, determine purpose, identify uses, define attributes, identify model case, describe related and contrary cases, identify antecedents and consequences and define empirical referents - was used to examine the concept of missed nursing care. The sources for the analysis were identified by systematic searches of the World Wide Web, MEDLINE, CINAHL and reference lists of related journal articles with a timeline of 1970 to April 2008. FINDINGS Missed nursing care, conceptualized within the Missed Nursing Care Model, is defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed. Various attribute categories reported by nurses in acute care settings contribute to missed nursing care: (1) antecedents that catalyse the need for a decision about priorities; (2) elements of the nursing process and (3) internal perceptions and values of the nurse. Multiple elements in the nursing environment and internal to nurses influence whether needed nursing care is provided. CONCLUSION Missed care as conceptualized within the Missed Care Model is a universal phenomenon. The concept is expected to occur across all cultures and countries, thus being international in scope.

Development and Psychometric Testing of a Tool to Measure Missed Nursing Care

Background: In a qualitative study, medical-surgical and intensive care staff nurses reported that they did not complete a significant amount of nursing care on regular basis. Thus, it was determined that a quantitative tool was needed to measure the amount and type of missed nursing care and the reasons for missing care. Objective: The authors report the results of a psychometric evaluation of this tool (The Missed Nursing Care Survey [MISSCARE Survey]) to measure missed nursing care (part A) and the reasons for missed nursing care (part B). Study Methods: Two studies were conducted-study 1 (n = 459) and study 2 (n = 639). A sample of staff nurses was drawn from 35 medical-surgical, rehabilitation, and intensive care patient units in 4 acute care hospitals. Results: Acceptability was high, with 85% of the respondents answering all items on the survey. Factor analysis with Varimax rotation resulted in a 3-factor solution for part 2 (communication, labor resources, and material resources). Cronbach &agr; values ranged from 0.64 to 0.86. Confirmatory factor analysis demonstrated a good fit of the data. Using a contrasting group approach, a comparison of nurses perceptions of missed care on intensive care units versus rehabilitation units resulted, as hypothesized, in a significantly lower amount of missed care on intensive care units. Pearson correlation coefficient on a test-retest of the same subjects yielded a value of 0.87 on part A and 0.86 on part B. Conclusion: Although further validation of the MISSCARE Survey is needed, current evidence demonstrates that the tool meets stringent psychometric standards.

An Intervention to Enhance Nursing Staff Teamwork and Engagement

Numerous studies have concluded that work group teamwork leads to higher staff job satisfaction, increased patient safety, improved quality of care, and greater patient satisfaction. Although there have been studies on the impact of multidisciplinary teamwork in healthcare, the teamwork among nursing staff on a patient care unit has received very little attention from researchers. In this study, an intervention to enhance teamwork and staff engagement was tested on a medical unit in an acute care hospital. The results showed that the intervention resulted in a significantly lower patient fall rate, staff ratings of improved teamwork on the unit, and lower staff turnover and vacancy rates. Patient satisfaction ratings approached, but did not reach, statistical significance.

HOSPITAL VARIATION IN MISSED NURSING CARE

Quality of nursing care across hospitals is variable, and this variation can result in poor patient outcomes. One aspect of quality nursing care is the amount of necessary care that is omitted. This article reports on the extent and type of nursing care missed and the reasons for missed care. The MISSCARE Survey was administered to nursing staff (n = 4086) who provide direct patient care in 10 acute care hospitals. Missed nursing care patterns as well as reasons for missing care (labor resources, material resources, and communication) were common across all hospitals. Job title (ie, registered nurse vs nursing assistant), shift worked, absenteeism, perceived staffing adequacy, and patient work loads were significantly associated with missed care. The data from this study can inform quality improvement efforts to reduce missed nursing care and promote favorable patient outcomes.

The impact of teamwork on missed nursing care

Previous studies have shown that missed nursing care is a significant problem in acute care hospitals. Other studies have demonstrated that teamwork is a critical element in assuring patient safety and quality of care. The purpose of this study was to determine if the level of nursing teamwork impacts the extent and nature of missed nursing care. A sample of 2 216 nursing staff members on 50 acute care patient care units in 4 hospitals completed the Nursing Teamwork Survey and the MISSCARE Survey. The response rate was 59.7%. Controlling for occupation of staff members (eg, RN/LPN, NA) and staff characteristics (eg, education, shift worked, experience, etc), teamwork alone accounted for about 11% of missed nursing care. The results of this study show that the level of nursing teamwork impacts the nature and extent of missed nursing care. The study results point to a need to invest in methods of enhancing teamwork in these settings.

Missed nursing care, staffing, and patient falls

Patient falls in hospitals continue to be a major and costly problem. This study tested the mediating effect of missed nursing care on the relationship of staffing levels (hours per patient day [HPPD]) and patient falls. The sample was 124 patient units in 11 hospitals. The HPPD was negatively associated with patient falls (r = −0.36, P < .01), and missed nursing care was found to mediate the relationship between HPPD and patient falls.

What does nursing teamwork look like? A qualitative study.

A qualitative study was conducted applying a theoretically based model of teamwork to determine relevant team processes among nurses. Nurses from 5 patient care units participated in focus groups, describing team processes in their daily work. Responses were analyzed in the Salas framework to develop a concrete conceptualization of teamwork within nursing teams. Results support the framework as a means for describing teamwork among nurses.

Improving nursing unit teamwork.

A lack of teamwork among nursing staff affects care delivery and unit operations. Barriers present in the structure of a typical patient care unit that make it extremely difficult to achieve a high level of teamwork include large team size, lack of familiarity, instability of the work force and assignments, the absence of a common purpose and destiny, and an inhibiting physical environment. The authors discuss strategies to overcome these obstacles to teamwork.