Missed Nursing Care Reported by Medical-Surgical RNs in a Community Hospital

Background: Missed nursing care is defined as any lapse in essential patient care. It is a previously studied, persistent phenomenon. If unrecognized, it can compromise patients’ recoveries, trigger adverse events, and increase healthcare costs. Objectives: To examine the prevalence of missed nursing care reported by medical-surgical registered nurses (RNs) and contributing factors for its occurrence. Methods: The project used a cross-sectional, correlational design. A convenience sample of 96 RNs, recruited from three medical-surgical units, completed the MISSCARE Survey between September and October 2017. An analysis of survey responses quantified the frequency, nature, and common contributing factors for care omissions. The project was set in a small, Northeast, Pathway to Excellence® designated hospital. Results: Fifty-two RNs completed surveys, most who were female (94.2%), held a Bachelor’s in Nursing degree (53.8%), and had 10+ years of work experience (34.6%). Over 1 in 5 respondents reported five nursing tasks were “frequently” or “always” missed: care conferences (46.1%), scheduled ambulation (36.5%), turning (34.6%), monitoring intake and output (23.1%), and timely medications administration (23.1%). Significant contributors to care omissions were: heavy admission/discharge activity (57.7%), fewer assistive personnel (55.8%), staff shortages (50.0%), and unbalanced patient assignments (40.4%). Conclusions: RNs identified the top five missed nursing care items in a small, community hospital and cited patient turnover, labor resource shortages, and unbalanced assignments as key, contributing factors. Inter-professional communication and teamwork effectiveness were not reported as contributing factors. Project results should inform nurse leaders’ efforts to devise interventions to safeguard patients, improve quality, and decrease cost. MISSED NURSING CARE 3 Background The Institute of Medicine(IOM), published Crossing the Quality Chasm: A New Health System for the 21 Century (2001), which called for the redesign of the healthcare delivery system. The call to action was based on the healthcare systems languor for re-engineering processes and strengthening care teams, necessary for managing increasingly complex and dynamic care delivery models and environments. In a subsequent report, Keeping Patients Safe: Transforming the Work Environment of Nurses (2004), the IOM highlighted the role nurses play in ensuring patient safety and recommended improvements to the nursing work environment to optimize health outcomes. The report explicitly advocated for; (a) an emphasis by governing boards and leadership on the promotion of patient safety, (b) strengthening inter-professional collaborations, (c) translating evidence-based practices into strategies and processes to instill an organizational safety culture, and (d) imploring nurse leaders to influence, transform, and sustain positive work environments to enhance patient safety (IOM, 2004). Registered Nurses (RNs) perform critical roles in achieving patient safety and quality because they provide the majority of bedside care and are well-positioned to recognize and prevent patient harm (Quigley & White, 2013). However, nursing care for patients may not be reliable or amply provided; care tasks can be missed, and care omissions can lead to adverse patient outcomes (Blackman et al., 2014). To date, efforts to improve healthcare quality and safety have intentionally emphasized the reduction of commission errors such as administering the wrong dose of medication to a patient because they are easier to detect and more frequently reported (Agency for Healthcare Research and Quality [AHRQ], 2016). Conversely, a failure to 1 The Institute of Medicine (IOM) changed its name to the National Academy of Medicine in April 2015, as part of a reorganization initiative to improve work integration with the National Academies of Science, Engineering, and Medicine (National Academies of Science, Engineering, and Science, 2018) MISSED NURSING CARE 4 perform recommended care or any portion thereof is an error of omission, which represents a more significant problem (AHRQ, 2016). Unfortunately, omission errors are difficult to recognize, and because of this, fewer investigations have explored and less is known about this phenomenon (AHRQ, 2016). Yet, omission errors can pose severe safety risks to patients and contribute to harm, reduce the quality of life (QOL), and cause deleterious cascading effects on healthcare outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). The concept of “missed nursing care” is analogous to omitted or delayed care (Kalisch, 2006). Missed nursing care is defined as “any aspect of standard, required nursing care, not provided to the patient” (Kalisch, 2015, p. 17). For instance, a failure to ambulate an older adult patient, which is an example of missed nursing care, can contribute to muscle deconditioning and functional decline. These losses can subsequently extend hospitalization, increase mortality, and increase the risk of hospital-acquired conditions (HACs), post-hospital rehabilitation, and nursing home placement (Callen, Mahoney, Grieves, Wells, & Enloe, 2004; Fisher et al., 2011). Failure to provide nourishment to an older adult patient by setting up or assisting with feeding is another form of missed nursing care. Insufficient nutritional intake can exacerbate poor or declining nutritional status which can increase the risk for pressure ulcers, delay healing, increase the risk for infection, prolong hospitalization, and increase patient mortality (Kagnasky & Berner, 2005). There are no cost estimates of missed nursing care. However, there are downstream monetary consequences for the patient and the hospital. For example, when missed care results in protracted recoveries or unexpected rehabilitation or long-term care, there are higher out-ofpocket costs for patients or more significant expenditures by the insurance industry (Meddings et al., 2015). Pappas (2008) found that an adverse event for a medical or surgical patient due to a MISSED NURSING CARE 5 fall, pneumonia, or pressure ulcers, had a combined cost per case increase of approximately $1,000, and if examined individually, ranged from $300 to $2,400 added cost per adverse event, but did not address the root cause for why the adverse event occurred or the relationship to missed nursing care. Under new policies, HACs are financially penalized, with a one-percent reduction in Medicare payments via the Hospital-Acquired Conditions Reductions Program and private insurer quality and value-based purchasing contracts (Castellucci, 2017; Meddings et al., 2015). To further illustrate this point on a national scale, there are over 1.7 million patients who experience a HAC annually, which contributes to more than 100,000 deaths; approximately onethird may be preventable (Roberts et al., 2010). Medicare pays an additional $145 million annually for HACs (Kandilov, Coomer, & Dalton, 2014). On average, the cost for an added inpatient day in a non-profit hospital in 2013 was $2,289, and the estimated expense for a hospital-acquired pressure ulcer was $17,000 with an increased mortality rate of 72 deaths per 1,000 patients (AHRQ, 2013; Rappleye, 2015). Ultimately, patients and families bear the burden of a decline in safety, the adverse human toll, and unintended patient suffering. Ergo, patient risk and cost could be significant when nursing care is omitted and have broader implications.