Missed Nursing Care: Errors Of Omission

Missed Nursing Care:Errors of OmissionBeatrice Kalisch, PhD, RN, FAANTitus Professor of Nursing and ChairUniversity of MichiganNursing Business and Health SystemsPresented at the NDNQI annual meetingMiami, FloridaJanuary, 2011bkalisch@umich.edu

Presentation Outline–––––Previous StudiesConceptual FrameworkStudy QuestionsStudy MethodsFindings Missed nursing care: 11 hospitalsMissed nursing care and staffing levelsMissed nursing care and satisfactionMissed nursing care and intent to leave andturnoverMissed nursing care and teamworkMissed nursing care and patient falls– Implications

What we DON’T know

Any aspect of requiredpatient care omitted or delayedERRORS OF OMISSION

PREVIOUSSTUDIES

STUDY 1Missed Care:A Qualitative StudyKalisch B. (2006). Missed nursing care: A qualitative study. Journalof Nursing Care Quality, 21:4; 306-313.

Missed Care:A Qualitative Study9 areas of missed layed or missed feedingsPatient educationDischarge planningEmotional supportHygieneIntake and output documentationSurveillance7 themes for reasons for missed care–––––––Too few staffTime required for a nursing interventionPoor use of existing staff resources“It’s not my job syndrome”Ineffective delegationHabitDenial

STUDY 2A Concept AnalysisB. Kalisch, G. Landstrom, & A. Hinshaw, (2009) “MissedNursing Care: A Concept Analysis,” Journal of AdvancedNursing, 65(7), 1509-1517.

STUDY 3MISSCARE SurveyDevelopment & PsychometricTestingKalisch B & Williams R. (2009) The development andpsychometric testing of a tool to measure missed nursing care(MISSCARE Survey). Journal of Nursing Administration. 39 (5).211-219.

STUDY 4Missed Care and Reasons: 3hospital studyKalisch B, G. Landstrom & R. Williams, (2009) . Missed Nursing Care:Errors of Omission, Nursing Outlook, 57(1), 3-9.

Missed Care and Reasons:3 hospital study Research questions– What and how much nursing care is missed?– What are the reasons for missing care? Methods– 3 hospitals (459 RNs), 35 patient units– MISSCARE Survey , response rate 57% Findings– Significant amount of missed care– Consistency across the 3 hospital sample in amount and specificelements of care as well as reasons

MISSED NURSING CARE:11 HOSPITAL STUDY

CONCEPTUALFRAMEWORK

THE MISSED NURSINGCARE MODELHOSPITALCHARACTERISTICSSTAFFOUTCOMES Size Teaching intensity Magnete.g. Satisfaction,Turnover,intent to leaveUNIT CHARACTERISTICS Case mix index Nurse staffing (HPPD,RN HPPD skill mix) Type of nurse staffing(education, experience) Absenteeism Work .g. Falls

RESEARCHQUESTIONS

Research Questions To what extent is nursing care missed? How does missed nursing care varyacross hospitals? What are the reasons for missed nursingcare? Do reasons for missed care vary acrosshospitals? Do nurse staffing levels predict missedcare?

Research Questions(continued) Does missed nursing care predict jobsatisfaction? Does missed nursing care predict intentto leave and/or turnover? Does teamwork predict missed nursingcare? Does missed nursing care mediate therelationship between staffing levels andpatient falls?

STUDY METHODS

Study Sample Nursing staff on 124 adult patient care units(medical-surgical, rehabilitation,intermediate and intensive care units) in 11hospitals.4,412 nursing staff (3,349 RNs, 83 LPNs and980 NAs)Return rate 57.3% (61.7% for RNs & LPNs,53.4% for NAs)

Study 0433479913330Unitsinstudy52151168229141814Total number of patient care units 124

Study Sample (continued)Predominantly female (90.0%)Over 35 years of age (53.5%)Working full time (81.0%)RNs baccalaureate degree (53.9%)RNs more than 10 years of experience (35.1%)

Measures The MISSCARE SurveyNursing Teamwork Survey (NTS)– Kalisch, B., Lee, H., & Salas, E. (2010). The development and testing ofthe nursing teamwork survey. Nursing Research, 59(1): 42-50. From hospital administrative data (unitlevel variables)––––Actual turnoverHPPD, RN HPPD, skill mixUnit Case Mix Index (CMI)Average daily census

STUDYFINDINGS

Research Question 1To what extent is nursingcare missed?

5 Most Often MissedNursing terdisciplinary careconference attendanceMouth care40%Timely medicationadministration30%Turning20%10%0%

5 Most Least MissedNursing Care100%90%80%70%Patient assessment60%Glucose monitoring50%Discharge planVital sign40%24%30%20%10%0%9%14%25%26%Focused reassessment

Extent of missed nursing careElements of Nursing CareAmbulation three times per day or as orderedAttend interdisciplinary care conference whenever heldMouth careMedications administered within 30 minutes before orafter scheduled timeTurning patient every 2 hoursFeeding patient when the food is still warmPatient teaching about procedures, tests and otherdiagnostic studies76%66%64%Full documentation of all necessary data54%60%59%57%55%

Extent of missed nursing care(continued)Elements of Nursing Care%Response to call light is initiated within 5 minutes50%Monitoring intake/output49%Assess effectiveness of medications49%Assist with toileting needs within 5 minutes of request49%Patient bathing/skin care45%PRN medication requests acted on within 15 minutes43%Emotional support to patient and/or family42%Setting up meals for patients who feed themselves35%

Extent of missed nursing care(continued)Elements of Nursing CareIV/central line site care and assessments according tohospital policySkin/wound care%34%32%Hand washingFocused reassessments according to patientcondition27%Vital signs assessed as orderedTeach patient about plans for their care afterdischarge and when to call after dischargeBedside glucose monitoring as ordered25%Patient assessments performed each shift9%26%24%14%

Staff Characteristics by MissedNursing Care Gender: No differenceAge: Under 35 reported less missed care than those over 36Education: No differenceExperience: less than 6 months reported the least amount ofmissed careWork schedules:– Night shifts reported less missed– Less than 12 hour shift reported less missed careAbsenteeism: Staff missing more shifts, reported moremissed care

Research Question 2Does missed care varyacross hospitals?Kalisch, B., Tschannen, D., Lee, H., & Friese, C. (in press). Hospitalvariation in missed nursing care. American Journal of MedicalQuality.

Elements of Care Most- andLeast- Frequently Missed The solid bars represent the means across all hospitals, and the rangelines indicate the standard deviations

Research Question 3:What are the reasons formissed nursing care?

Overall Reasons for Missed abor resourcesMaterial resoucesCommunication/Teamwork

Reasons For Missed CareLabor resources ‐ Overall92.8(Level of staffing) Inadequate number of staff91Urgent patient situations (e.g. a patient's condition worsening)92Unexpected rise in patient volume and/or acuity on the unit95Inadequate number of assistive personnel (e.g. nursing assistants,techs, unit secretaries etc.)94Heavy admission and discharge activity93

Reasons For Missed Care(continued)Material resources – Overall89.6Medications were not available when needed95Supplies/equipment not available when needed90Supplies/equipment not functioning properly when needed84

Reasons For Missed Care(continued)Communication – Overall81.8(The method of making patient assignments) Unbalanced patientassignmentsInadequate hand‐off from previous shift or sending unitOther departments did not provide the care needed (e.g. physicaltherapy did not ambulate)Lack of back up support from team membersTension or communication breakdowns with otherancillary/support departmentsTension or communication breakdowns within the nursing team76Tension or communication breakdowns with the medical staff82Nursing assistant did not communicate that care was not done85Caregiver off unit or unavailable709188858080

Research Question 4How do reasons for missedcare vary across hospitals?

Reasons for Missed Care across11 Hospitals1234567891011LaborResources(Total: rces(Total: (Total: 82%)79%75%80%79%80%83%84%78%84%83%82%

Research Question 5Do nurse staffing levelspredict missed care?Kalisch B., Tschannen D., & Lee K. (under review). Does nursestaffing predict missed nursing care? International Journal ofQuality in Healthcare.

Actual Nurse Staffing and Missed Care Bivariate analyses Higher Hours Per Patient Day (HPPD) wasassociated with less missed care (r -0.32,p 0.01) Higher RN Hours Per Patient Day (RNHPPD)associated with less missed care (r -0.27,p 0.01) Skill mix no significant relationship

Actual Nurse Staffing andMissed Care (continued) Multivariate analysis– The overall model accounted for 29.4% of thevariation in missed nursing care (p .001).– The higher the HPPD, the lower the level ofmissed nursing care (β -.45, p .002).– Other variables in the model were not significantpredictors of the dependent variable, missednursing care.

Research Question 6Does missed nursing carepredict job satisfaction andoccupation satisfaction?Kalisch, B., Tschannen, D., & Lee, H., (in press). Does missednursing care predict job satisfaction? Journal of HealthcareManagement.

Missed nursing care and jobsatisfaction (continued) Satisfaction with current position– 4 independent variables were significantlyrelatedMissed nursing care (r -.32, p .01) Age (r -.32, p .05) Perceptions of staffing adequacy (r .33, p .01) Type of unit (F 15.462, p .003)

Missed nursing care and jobsatisfaction (continued)Predictors of Satisfaction with Current Position (n 4074)Independent VariablesMissed Care Overall meanCoefficientRobust Std. Err.P-0.4830.0610.000Age0.111Staff AdequacyType of unitMedical-Surgical (R)IntermediateIntensive e: R2 0.224, F (18, 109) 55.22, p 0.001. (R) is the reference variable.

Missed nursing care and jobsatisfaction (continued) The overall model accounted for 22.4% of the variation (F[18, 109] 55.22, p 0.001).3 independent variables were significant predictors of satisfactionwith current position– The more missed nursing care, the higher thedissatisfaction level with their current position (p 0.001).– The more staff felt staffing was inadequate, the higher themissed nursing care (p 0.001).– The type of unit: ICUs: higher levels of satisfaction (p 0.05) Rehabilitation units: lowest levels of satisfaction (p 0.05).

Missed nursing care andoccupation satisfaction (continued) Satisfaction with occupation– Based on preliminary analysis, this modelincluded 5 independent variables–––––Missed nursing care (r -.16, p .01)Gender (t 3.36, p .01)Job title (t 8.57, p .01)Education (F 5.42, p .01)Perceptions of staffing adequacy (r .20, p .01)

Missed nursing care andoccupation satisfaction (continued) The overall model accounted for 6.47% of the variation, based onthe pseudo R2 (X2[16] 252.71, p 0.001).Staff who reported less missed care were more satisfied withoccupation (OR 0.57, 95% CI 0.41 – 0.80).When staffing perceived to be inadequate, the higher thelevel of occupation dissatisfaction (OR 1.49, 95% CI 1.35 - 1.64).Males less satisfied (OR 0.69, 95% CI 0.53 - 0.90)NAs less satisfied than RNs (OR 0.28, 95% CI 0.20 - 0.40).ADN nurses more satisfied than BSN nurses (OR 1.12, 95% CI 0.12 –0.90).

Research Question 7Does missed nursing carepredict intent to leaveand/or turnover?Tschannen, D., Kalisch, B., & Lee, K. (in press). Missed nursing careand nurse turnover and intent to leave Canadian Journal of NursingResearch.

Missed nursing care andturnover Nurse turnover– In bivariate analysis, 5 variables weresignificantly associated with turnover–––––Missed care (r .23, p .05)Skill mix (r .32, p .01)Gender (Female) (r -.20, p .05)Absenteeism (r .35, p .01)Intent to leave (r .30, p .01)

Missed nursing care and turnover(continued) Model accounted for 46.5% of the variation innurse turnover (p .0001).A greater percentage of females on the unitassociated with lower turnover rates (β -.235, p .010).Missed care not significant