Missed Nursing Care, Staffing, and Patient Falls

Reducing Pressure Injury Incidence Using a Turn Team Assignment: Analysis of a Quality Improvement Project

PURPOSE

The purpose of this study was to analyze outcomes of a quality improvement project that evaluated a turning intervention for prevention of facility-acquired pressure injuries.

DESIGN

A descriptive correlational study design examined the effectiveness of using a "turn team assignment" on pressure injury incidence and staff perceptions.

SUBJECTS AND SETTING

The study sample comprised RNs and patient care associates assigned to provide care for patients admitted on the first or any subsequent day of hospitalization to a surgical intensive care unit at a Midwest inner-city teaching hospital.

METHODS

Direct observation by expert clinicians occurred in 2-hour increments over a 14-day period using an 11-item, unit-designed process improvement tool. We collected information regarding cueing, concurrent turning, independent turning in lieu of the cue, staff support, and possible barriers to turning and repositioning. Staff perceptions were collected using an online tool via survey. The survey utilized a 14-item questionnaire, and a 5-point Likert Scale to identify staff perceptions and beliefs about the turn team intervention. Pressure injury occurrences were measured using data from our monthly prevalence study.

RESULTS

Pressure injury occurrences declined from 24.9% to 16.8% over the data collection period. There was a strong positive correlation between verbal cueing and turning (r = 0.815; P < .05). Staff perceptions supported preintervention education (64.3%) and cueing (93%; 78%) as effective interventions in completing patient turning.

CONCLUSIONS

Findings suggest that turn team assignments using verbal cueing are an effective intervention that decreases pressure injury occurrence. This intervention required no increase in staffing personnel, making this type of intervention reasonable and effective in improving frequency of repositioning and decreasing pressure injury prevalence rates.

Factors influencing the missed nursing care in patients from a private hospital

Objective:

to determine the factors that influence the missed nursing care in hospitalized patients.

Methods:

descriptive correlational study developed at a private hospital in Mexico. To identify the missed nursing care and related factors, the MISSCARE survey was used, which measures the care missed and associated factors. The care missed and the factors were grouped in global and dimension rates. For the analysis, descriptive statistics, Spearman’s correlation and simple linear regression were used. Approval for the study was obtained from the ethics committee.

Results:

the participants were 71 nurses from emergency, intensive care and inpatient services. The global missed care index corresponded to M=7.45 (SD=10.74); the highest missed care index was found in the dimension basic care interventions (M=13.02, SD=17.60). The main factor contributing to the care missed was human resources (M=56.13, SD=21.38). The factors related to the care missed were human resources (r_s=0.408, p<0.001) and communication (r_s=0.418, p<0.001).

Conclusions:

the nursing care missed is mainly due to the human resource factor; these study findings will permit the strengthening of nursing care continuity.

Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units

Missed nursing care is an emerging measure of front-line nursing care effectiveness in neonatal intensive care units (NICUs). Given Magnet® hospitals' reputations for nursing care quality, missed care comparisons with non-Magnet® hospitals may yield insights about how Magnet® designation influences patient outcomes. The purpose of this secondary analysis was to evaluate the relationship between hospital Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals. A random sample of certified neonatal intensive care unit nurses was invited to participate in a cross-sectional survey in 2012; data were analyzed from nurses who provided direct patient care (n=230). Logistic regression was used to model relationships between Magnet® designation and reports of the occurrence of and reasons for missed care while controlling for nurse and shift characteristics. There was no relationship between Magnet® designation and missed care occurrence for 34 of 35 types of care. Nurses in Magnet® hospitals were significantly less likely to report tensions and communication breakdowns with other staff, lack of familiarity with policies/procedures, and lack of back-up support from team members as reasons for missed care. Missed nursing care in NICUs occurs regardless of hospital Magnet® recognition. However, nurses' reasons for missed care systematically differ in Magnet® and non-Magnet® hospitals and these differences merit further exploration.

Patient Safety Incidents and Nursing Workload

Objective

to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile.

Method

quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation.

Results

879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload.

Conclusions

the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload.

Conformity of nurse prescribing to care needs: nurses' understanding

ABSTRACT Objective: investigate the understanding of nurses on nurse prescribing conformity to the care needs of hospitalized patients and factors associated with that conformity. Method: a descriptive study, with a quantitative approach, was conducted at 20 in-patient units of a teaching hospital in the state of São Paulo. The participants (N=139) answered a semi-structured questionnaire. Results: For 43 (30.9%) nurses, nurse prescribing is always in line with patients' care needs. The fields of body care and elimination, skin and mucosa care and investigation and monitoring were the most frequently addressed. Conclusion: in the perception of most nurses, nurse prescribing does not conform with patients' health heeds. The establishment of strategies to improve prescribing quality is recommended, as well as the development of permanent qualification programs and the systematic use of instruments for assessment of patients' care demands regarding nursing.

Correlates and predictors of missed nursing care in hospitals

AIMS AND OBJECTIVES

To identify the contribution of hospital, unit, staff characteristics, staffing adequacy and teamwork to missed nursing care in Iceland hospitals.

BACKGROUND

A recently identified quality indicator for nursing care and patient safety is missed nursing care defined as any standard, required nursing care omitted or significantly delayed, indicating an error of omission. Former studies point to contributing factors to missed nursing care regarding hospital, unit and staff characteristics, perceptions of staffing adequacy as well as nursing teamwork, displayed in the Missed Nursing Care Model.

DESIGN

This was a quantitative cross-sectional survey study.

METHODS

The samples were all registered nurses and practical nurses (n = 864) working on 27 medical, surgical and intensive care inpatient units in eight hospitals throughout Iceland. Response rate was 69·3%. Data were collected in March-April 2012 using the combined MISSCARE Survey-Icelandic and the Nursing Teamwork Survey-Icelandic. Descriptive, correlational and regression statistics were used for data analysis.

RESULTS

Missed nursing care was significantly related to hospital and unit type, participants' age and role and their perception of adequate staffing and level of teamwork. The multiple regression testing of Model 1 indicated unit type, role, age and staffing adequacy to predict 16% of the variance in missed nursing care. Controlling for unit type, role, age and perceptions of staffing adequacy, the multiple regression testing of Model 2 showed that nursing teamwork predicted an additional 14% of the variance in missed nursing care.

CONCLUSIONS

The results shed light on the correlates and predictors of missed nursing care in hospitals. This study gives direction as to the development of strategies for decreasing missed nursing care, including ensuring appropriate staffing levels and enhanced teamwork.

RELEVANCE TO CLINICAL PRACTICE

By identifying contributing factors to missed nursing care, appropriate interventions can be developed and tested.

Nurses' perceptions of their knowledge and barriers to ambulating hospitalized patients in acute settings

PURPOSE

The purpose of this study was to understand nurses' knowledge and perceptions of the importance of patient ambulation in acute care hospital settings. The data obtained from this survey will be used to create improvement initiatives that address patient ambulation.

METHOD

An exploratory, cross-sectional study using a self-administered survey was conducted in two different hospital sites, and was completed by 192 nurses. A modified version of the validated and reliable tool entitled "Missed Nursing Care Survey" was used. Multivariate regressions were used to determine the relationship of demographic and workplace variables to nurses' knowledge and perceptions regarding acute adult-inpatient ambulation.

RESULTS

The primary factors interfering with ambulating patients were inadequate number of staff (both clerical and nursing), urgent patient situations, and unexpected rises in patient volume and/or acuity on the unit. Small associations were found between knowledge of ambulation and years of experience, and shift worked.

CONCLUSION

Study findings add to the body of knowledge by providing insight into what variables influence urban nurses' knowledge and perceptions of barriers faced when ambulating acute adult-inpatients in acute hospitalized settings. The study results can be used to develop strategies and improvement initiatives that address acute adult-inpatient ambulation in acute settings and address the perceived barriers to this process. The ultimate goal is to improve the quality of care delivered, improve patient outcomes, and promote patient well-being. Implication for nursing practice, research and education will be discussed.

Nursing care missed in patients at risk of or having pressure ulcers

Objective:

to determine the nursing care missed as perceived by the nursing staff and its relation with the nursing care missed identified in the assessment of patients at risk of or having pressur ulcers.

Method:

descriptive correlation study. The participants were 161 nurses and 483 patients from a public hospital. The MISSCARE survey was used in combination with a Nursing Care Assessment Form for Patients at Risk of or having pressure ulcers. For the analysis, descriptive and inferential statistics were used.

Results:

the nursing staff indicated greater omission in skin care (38.5%), position change (31.1%) and the registration of risk factors for the development of pressure ulcers (33.5%). The nursing care missed identified in the assessment related to the use of pressure relief on bony prominences and drainage tubes interfering in the patient's movements (both with 58.6%) and the use of pneumatic mattresses (57.6%).

Conclusion:

a high percentage of nursing care missed was found according to the staff's perception. Nevertheless, the assessment of the nursing care missed was much higher. No significant relation was found between both. Therefore, it is a priority to reflect on the importance of objective patient assessments.

Missed Nursing Care and Unit-Level Nurse Workload in the Acute and Post-Acute Settings

This study replicates previous research on the nature and causes of missed nursing care and adds an explanatory variable: unit-level nurse workload (patient turnover percentage). The study was conducted in California, which legally mandates nurse staffing ratios. Findings demonstrated no significant relationship between patient turnover and missed nursing care.

An Evidence-Based Cue-Selection Guide and Logic Model to Improve Pressure Ulcer Prevention in Long-term Care

Pressure ulcers have consistently resisted prevention efforts in long-term care facilities nationwide. Recent research has described cueing innovations that-when selected according to the assumptions and resources of particular facilities-support best practices of pressure ulcer prevention. This article synthesizes that research into a unified, dynamic logic model to facilitate effective staff implementation of a pressure ulcer prevention program.

Analysis of nurse staffing and patient outcomes using comprehensive nurse staffing characteristics in acute care nursing units

Associations between comprehensive nurse staffing characteristics and patient falls and pressure ulcers were examined using negative binomial regression modeling with hospital- and time-fixed effects. A convenience sample was collected from 35 nursing units in 3 hospitals. Rates of patient falls and injury falls were found to be greater with higher temporary registered nurse staffing levels but decreased with greater levels of licensed practical nursing care hours per patient day. Pressure ulcers were not related to any staffing characteristics.

Using process improvement methodology to address the complex issue of falls in the inpatient setting

Falls in the acute care hospital are a significant patient safety issue. The purpose of this article was to describe the use of process improvement methodology to address inpatient falls on 5 units. This initiative focused on a proactive approach to falls, identification of high-risk patients, and a complete assessment of patients at risk. During the project timeframe, the mean total fall rate decreased from 3.7 to 2.8 total falls per 1000 patient days.

An Examination of Hospital Nurse Staffing and Patient Experience with Care: Differences between Cross-Sectional and Longitudinal Estimates

OBJECTIVE

To study the association between hospital nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

DATA SOURCES

State hospital financial and utilization reports, Healthcare Cost and Utilization Project State Inpatient Databases, HCAHPS survey, and American Hospital Association Annual Survey of Hospitals.

STUDY DESIGN

Retrospective study using cross-sectional and longitudinal models to estimate the effect of nurse staffing levels and skill mix on seven HCAHPS measures.

DATA COLLECTION/EXTRACTION METHODS

Hospital-level data measuring nurse staffing, patient experience, and hospital characteristics from 2009 to 2011 for 341 hospitals (977 hospital years) in California, Maryland, and Nevada.

PRINCIPAL FINDINGS

Nurse staffing level (i.e., number of licensed practical nurses and registered nurses per 1,000 inpatient days) was significantly and positively associated with all seven HCAHPS measures in cross-sectional models and three of seven measures in longitudinal models. Nursing skill mix (i.e., percentage of all staff who are registered nurses) was significantly and negatively associated with scores on one measure in cross-sectional models and none in longitudinal models.

CONCLUSIONS

After controlling for unobserved hospital characteristics, the positive influences of increased nurse staffing levels and skill mix were relatively small in size and limited to a few measures of patients' inpatient experience.

Problematising the problem: a critical interpretive review of the literature pertaining to older people with cognitive impairment who fall while hospitalised

This article presents a reflexive account by way of a critical interpretive review of the literature pertaining to falls of older people with cognitive impairment who have been hospitalised in an acute care setting. A key aim of this review was to use thematic analysis and problematisation to challenge assumptions underpinning the current falls literature and to bring into consideration alternate foci of research and new approaches to falls research. An innovative approach is used to generate descriptive and interpretive summaries of the literature which are presented graphically to reveal the prevailing themes and assumptions within. It is argued that currently, falls research in the context of cognitive impairment is constrained by scientism. Meta-paradigmatic approaches, which have the potential to provide a better understanding of why falls may or may not occur among this particular subgroup of older people, are proposed as an alternative.

The Impact of the Nursing Practice Environment on Missed Nursing Care

OBJECTIVES

Missed nursing care is an emerging problem negatively impacting patient outcomes. There are gaps in our knowledge of factors associated with missed nursing care. The aim of this study was to determine the relationship between the nursing practice environment and missed nursing care in acute care hospitals.

METHODS

This is a secondary analysis of cross sectional data from a survey of over 7.000 nurses from 70 hospitals on workplace and process of care. Ordinary least squares and multiple regression models were constructed to examine the relationship between the nursing practice environment and missed nursing care while controlling for characteristics of nurses and hospitals.

RESULTS

Nurses missed delivering a significant amount of necessary patient care (10-27%). Inadequate staffing and inadequate resources were the practice environment factors most strongly associated with missed nursing care events.

CONCLUSIONS

This multi-site study examined the risk and risk factors associated with missed nursing care. Improvements targeting modifiable risk factors may reduce the risk of missed nursing care.

Lower Nurse Staffing Levels Are Associated With Occurrences of Inpatient Falls at a Large Pediatric Hospital

No previous research has been published regarding the relationship between nurse staffing levels and inpatient pediatric falls, and previous research in the adult population has yielded conflicting results, probably due in many instances to suboptimal study design. The objective of this study was to examine the relationship between nurse staffing levels and pediatric patient falls in a large children's hospital. A case-control study design was used to compare the nurse staffing level during the shift of patient falls to the staffing level in the same units on shifts when patient falls did not occur. Nurse staffing levels were significantly lower in units when patient falls occurred, particularly during night shift. Targeted nurse staffing interventions in high-risk units could reduce the incidence of inpatient pediatric falls.

Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals

BACKGROUND

As nurses are the principal care provider in the hospital setting, the completion or omission of nursing care is likely to have a sizable impact on the patient care experience. However, this relationship has not been explored empirically.

AIM

To describe the prevalence and patterns of missed nursing care and explore their relationship to the patient care experience.

METHODS

This cross-sectional study used secondary nurse and patient survey data from 409 adult non-federal acute care US hospitals in four states. Descriptive statistics were calculated and linear regression models were conducted at the hospital level. Regression models included controls for hospital structural characteristics.

RESULTS

In an average hospital, nurses missed 2.7 of 12 required care activities per shift. Three-fourths (73.4%) of nurses reported missing at least one activity on their last shift. This percentage ranged from 25 to 100 across hospitals. Nurses most commonly reported not being able to comfort or talk with patients (47.6%) and plan care (38.5%). 6 out of 10 patients rated hospitals highly. This proportion ranged from 33% to 90% across hospitals. At hospitals where nurses missed more care (1 SD higher=0.74 items), 2.2% fewer patients rated the hospital highly (p<0.001); a coefficient equivalent to a one-quarter SD change.

CONCLUSIONS

Missed nursing care is common in US hospitals and varies widely. Most patients rate their hospital care experience highly, but this also varies widely across hospitals. Patients have poorer care experiences in hospitals where more nurses miss required nursing care. Supporting nurses' ability to complete required care may optimise the patient care experience. As hospitals face changing reimbursement landscapes, ensuring adequate nursing resources should be a top priority.

Missed Nursing Care in Hospitalized Patients

Objective: Determine missed nursing care in hospitalized patients and the factors related to missed care, according to the perception of the nursing staff and the patient. Method: Correlational descriptive study of a sample of 160 nurses and hospitalized patients, using the MISSCARE Nursing Survey. Results: Nursing personnel indicated there were fewer care omissions in continuous evaluation interventions (M=94.56; SD=11.10). The greatest number of omissions pertained to basic care interventions (M=80.2; SD=19.40). Patients mentioned there were fewer omissions in continuous evaluation interventions (M=96.32; SD=7.96), while the greatest number of omissions pertained to patient discharge and education (M=45.00; SD=23.22). The factors that contributed to missed nursing care, according to the nursing staff, were related to human resources (M=80.67; SD=17.06) and material resources (M=69.72; SD=23.45); patients mentioned human resources and communication. Conclusions: Nursing care that is not carried out according to the needs of the patient, or is omitted or delayed, was identified. This aspect is relevant, since nursing care is fundamental to the recovery of hospitalized patients.

Factors associated with rushed and missed resident care in western Canadian nursing homes: a cross-sectional survey of health care aides

AIMS AND OBJECTIVES

To describe the nature, frequency and factors associated with care that was rushed or missed by health care aides in western Canadian nursing homes.

BACKGROUND

The growing number of nursing home residents with dementia has created job strain for frontline health care providers, the majority of whom are health care aides. Due to the associated complexity of care, health care aides are challenged to complete more care tasks in less time. Rushed or missed resident care are associated with adverse resident outcomes (e.g. falls) and poorer quality of staff work life (e.g. burnout) making this an important quality of care concern.

DESIGN

Cross-sectional survey of health care aides (n = 583) working in a representative sample of nursing homes (30 urban, six rural) in western Canada.

METHODS

Data were collected in 2010 as part of the Translating Research in Elder Care study. We collected data on individual health care aides (demographic characteristics, job and vocational satisfaction, physical and mental health, burnout), unit level characteristics associated with organisational context, facility characteristics (location, size, owner/operator model), and the outcome variables of rushed and missed resident care.

RESULTS

Most health care aides (86%) reported being rushed. Due to lack of time, 75% left at least one care task missed during their previous shift. Tasks most frequently missed were talking with residents (52% of health care aides) and assisting with mobility (51%). Health care aides working on units with higher organisational context scores were less likely to report rushed and missed care.

CONCLUSION

Health care aides frequently report care that is rushed and tasks omitted due to lack of time.

RELEVANCE TO CLINICAL PRACTICE

Considering the resident population in nursing homes today--many with advanced dementia and all with complex care needs--health care aides having enough time to provide physical and psychosocial care of high quality is a critical concern.

Effectiveness of team training on fall prevention

A longitudinal, repeated-measures design with intervention and comparison groups was used to evaluate the effect of a training curriculum based on TeamSTEPPS with video vignettes focusing on fall prevention. Questionnaires, behavioral observations, and fall data were collected over 9 months from both groups located at separate hospitals. The intervention group questionnaire scores improved on all measures except teamwork perception, while observations revealed an improvement in communication compared with the control group. Furthermore, a 60% fall reduction rate was reported in the intervention group. Team training may be a promising intervention to reduce falls.

Effects of increasing nurse staffing on missed nursing care

BACKGROUND

Inadequate nurse staffing has been reported to lead nurses to omit required nursing care. In South Korea, to reduce informal caregiving by patient families and sitters and to improve the quality of nursing care, a public hospital operated by the Seoul Metropolitan Government has implemented a policy of increasing nurse staffing from 17 patients per registered nurse to 7 patients per registered nurse in 4 out of 13 general nursing units since January 2013.

AIM

The study aims to compare missed nursing care (omission of required care) in high-staffing (7 patients per nurse) units vs. low-staffing (17 patients per nurse) units to examine the effects of nurse staffing on missed care.

METHODS

A nurse survey conducted in July 2013 targeted all staff nurses in all four high-staffing and all nine low-staffing units; 115 nurses in the high-staffing units (response rate = 94.3%) and 117 nurses in the low-staffing units (response rate = 88.6%) participated. Missed nursing care was measured using the MISSCARE survey that included 24 nursing care elements. Nurses were asked how frequently they had missed each element on a 4-point scale from 'rarely' to 'always'.

RESULTS

Overall, nurses working in high-staffing units had a significantly lower mean score of missed care than those in low-staffing units. Seven out of 24 nursing care elements were missed significantly less often in high-staffing (vs. low-staffing) units: turning, mouth care, bathing/skin care, patient assessments in each shift, assistance with toileting, feeding and setting up meals.

CONCLUSION

The findings suggest that increasing nurse staffing is associated with a decrease in missed care. Less omission of required nursing care is expected to improve nursing surveillance and patient outcomes, such as patient falls, pressure ulcers and pneumonia.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Adequate nurse staffing should be ensured to reduce unmet nursing needs and improve patient outcomes.

Unfinished nursing care, missed care, and implicitly rationed care: State of the science review

OBJECTIVES

The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions.

METHODS

A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author).

RESULTS

Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave.

DISCUSSION & CONCLUSIONS

Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies.

The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals

INTRODUCTION

Threats to quality and patient safety may exist when necessary nursing care is omitted. Empirical research is needed to determine how missed nursing care is associated with patient outcomes.

AIM

The aim of this study was to examine the relationship between missed nursing care and hospital readmissions.

METHODS

Cross-sectional examination, using three linked data sources-(1) nurse survey, (2) patient discharge data from three states (California, New Jersey and Pennsylvania) and (3) administrative hospital data- from 2005 to 2006. We explored the incidence of 30-day readmission for 160 930 patients with heart failure in 419 acute care hospitals in the USA. Logistic regression was used to assess the effect of missed care on the odds of readmission, adjusting for patient and hospital characteristics.

RESULTS

The most frequently missed nursing care activities across all hospitals in our sample included talking to and comforting patients (42.0%), developing and updating care plans (35.8%) and educating patients and families (31.5%). For 4 of the 10 studied care activities, each 10 percentage-point increase in the number of nurses reporting having missed the activity was associated with an increase in the odds of readmission by 2-8% after adjusting for patient and hospital characteristics. However, missed nursing care was no longer a significant predictor of readmission once adjusting for the nurse work environment, except in the case of the delivery of treatments and procedures (OR 1.08, 95% CI 1.02 to 1.14).

CONCLUSIONS

Missed care is an independent predictor of heart failure readmissions. However, once adjusting for the quality of the nurse work environment, this relationship is attenuated. Improvements in nurses' working conditions may be one strategy to reduce care omissions and improve patient outcomes.

A descriptive study of nurse-reported missed care in neonatal intensive care units

AIMS

The aims of this study are to describe: (1) the frequency of nurse-reported missed care in neonatal intensive care units; and (2) nurses' reports of factors contributing to missed care on their last shift worked.

BACKGROUND

Missed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown.

DESIGN

A descriptive analysis of neonatal nurses' self-reports of missed care using data collected through a cross-sectional web-based survey.

METHODS

A random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach.

RESULTS

Nurses reported missing a range of patient care activities on their last shift worked. Nurses most frequently missed rounds, oral care for ventilated infants, educating and involving parents in care and oral feedings. Hand hygiene, safety and physical assessment and medication administration were missed least often. The most common reasons for missed care included frequent interruptions, urgent patient situations and an unexpected rise in patient volume and/or acuity on the unit.

CONCLUSION

We find that basic nursing care in the neonatal intensive care unit is missed and that system factors may contribute to missed care in this setting.

Nursing-sensitive indicators: a concept analysis

AIM

To report a concept analysis of nursing-sensitive indicators within the applied context of the acute care setting.

BACKGROUND

The concept of 'nursing sensitive indicators' is valuable to elaborate nursing care performance. The conceptual foundation, theoretical role, meaning, use and interpretation of the concept tend to differ. The elusiveness of the concept and the ambiguity of its attributes may have hindered research efforts to advance its application in practice.

DESIGN

Concept analysis.

DATA SOURCES

Using 'clinical indicators' or 'quality of nursing care' as subject headings and incorporating keyword combinations of 'acute care' and 'nurs*', CINAHL and MEDLINE with full text in EBSCOhost databases were searched for English language journal articles published between 2000-2012. Only primary research articles were selected.

METHODS

A hybrid approach was undertaken, incorporating traditional strategies as per Walker and Avant and a conceptual matrix based on Holzemer's Outcomes Model for Health Care Research.

RESULTS

The analysis revealed two main attributes of nursing-sensitive indicators. Structural attributes related to health service operation included: hours of nursing care per patient day, nurse staffing. Outcome attributes related to patient care included: the prevalence of pressure ulcer, falls and falls with injury, nosocomial selective infection and patient/family satisfaction with nursing care.

CONCLUSION

This concept analysis may be used as a basis to advance understandings of the theoretical structures that underpin both research and practical application of quality dimensions of nursing care performance.

A research protocol for testing relationships between nurse workload, missed nursing care and neonatal outcomes: the neonatal nursing care quality study

AIM

We describe an innovative research protocol to test the role of missed nursing care as a mediator of the association between nurse workload and patient outcomes in the neonatal intensive care unit.

BACKGROUND

Increases in nurses' workloads are associated with adverse patient outcomes in neonatal intensive care settings. Missed nursing care is a frequently hypothesized explanation for the association between workload and outcomes. Few studies to date have tested missed care as a variable that mediates the workload-outcomes relationship.

DESIGN

We use a longitudinal, observational study design.

METHODS

We will recruit approximately 125 nurses (80% of target population) providing direct patient care in one neonatal intensive care unit. Four, 6-week data collection cycles occur over 1 year. At the end of every shift, nurses report on their workloads and the frequency with which specific patient care activities were missed for each infant cared for during the shift. Infant-specific nurse reports of missed care are linked to shift-level infant outcomes data extracted from the electronic health record. Funding for the study began in July 2012; Research Ethics Committee approval was granted in December 2012.

DISCUSSION

Missed care may explain the effects of nurse workload on patient outcomes. This research will generate preliminary evidence regarding the causal relationships among nurses' workloads, missed care and infant outcomes that we will confirm in a future multi-site study.

Lost opportunities...the challenges of "missed nursing care"

Learn how to define, identify, and ultimately avoid missed nursing care within your organization.

Linking patient satisfaction with nursing care: the case of care rationing - a correlational study

BACKGROUND

Implicit rationing of nursing care is the withholding of or failure to carry out all necessary nursing measures due to lack of resources. There is evidence supporting a link between rationing of nursing care, nurses' perceptions of their professional environment, negative patient outcomes, and placing patient safety at risk. The aims of the study were: a) To explore whether patient satisfaction is linked to nurse-reported rationing of nursing care and to nurses' perceptions of their practice environment while adjusting for patient and nurse characteristics. b) To identify the threshold score of rationing by comparing the level of patient satisfaction factors across rationing levels.

METHODS

A descriptive, correlational design was employed. Participants in this study included 352 patients and 318 nurses from ten medical and surgical units of five general hospitals. Three measurement instruments were used: the BERNCA scale for rationing of care, the RPPE scale to explore nurses' perceptions of their work environment and the Patient Satisfaction scale to assess the level of patient satisfaction with nursing care. The statistical analysis included the use of Kendall's correlation coefficient to explore a possible relationship between the variables and multiple regression analysis to assess the effects of implicit rationing of nursing care together with organizational characteristics on patient satisfaction.

RESULTS

The mean score of implicit rationing of nursing care was 0.83 (SD = 0.52, range = 0-3), the overall mean of RPPE was 2.76 (SD = 0.32, range = 1.28 - 3.69) and the two scales were significantly correlated (τ = -0.234, p < 0.001). The regression analysis showed that care rationing and work environment were related to patient satisfaction, even after controlling for nurse and patient characteristics. The results from the adjusted regression models showed that even at the lowest level of rationing (i.e. 0.5) patients indicated low satisfaction.

CONCLUSIONS

The results support the relationships between organizational and environmental variables, care rationing and patient satisfaction. The identification of thresholds at which rationing starts to influence patient outcomes in a negative way may allow nurse managers to introduce interventions so as to keep rationing at a level at which patient safety is not jeopardized.

Errors of Omission: Missed Nursing Care

A series of studies on missed nursing care (i.e., required standard nursing care that is not completed) is summarized. Missed nursing care is substantial and similar levels are found across hospitals. Reasons for missed nursing care are staffing resources, material resources, and communication and these are also similar across hospitals. The higher the staffing levels, the fewer occurrences of missed nursing care. Magnet status and higher levels of teamwork are associated with less missed nursing care, and more missed care leads to a lower level of staff satisfaction. Missed nursing care has been found to be a mediator between staffing levels and patient falls. Patient identified missed nursing care predicts adverse events (i.e., falls, pressure ulcers, new infections etc.).

Monitoring the impact of the DRG payment system on nursing service context factors in Swiss acute care hospitals: Study protocol

Aims: With this study protocol, a research program is introduced. Its overall aim is to prepare the instruments and to conduct the first monitoring of nursing service context factors at three university and two cantonal hospitals in Switzerland prior to the introduction of the reimbursement system based on Diagnosis Related Groups (DRG) and to further develop a theoretical model as well as a methodology for future monitoring following the introduction of DRGs.

Background: DRG was introduced to all acute care hospitals in Switzerland in 2012. In other countries, DRG introduction led to rationing and subsequently to a reduction in nursing care. As result, nursing-sensitive patient outcomes were seriously jeopardised. Switzerland has the opportunity to learn from the consequences experienced by other countries when they introduced DRGs. Their experiences highlight that DRGs influence nursing service context factors such as complexity of nursing care or leadership, which in turn influence nursing-sensitive patient outcomes. For this reason, the monitoring of nursing service context factors needs to be an integral part of the introduction of DRGs. However, most acute care hospitals in Switzerland do not monitor nursing service context data. Nursing managers and hospital executive boards will be in need of this data in the future, in order to distribute resources effectively.

Methods/Design: A mixed methods design in the form of a sequential explanatory strategy was chosen. During the preparation phase, starting in spring 2011, instruments were selected and prepared, and the access to patient and nursing data in the hospitals was organized. Following this, online collection of quantitative data was conducted in fall 2011. In summer 2012, qualitative data was gathered using focus group interviews, which helped to describe the processes in more detail. During 2013 and 2014, an integration process is being conducted involving complementing, comparing and contrasting quantitative and qualitative findings.

Conclusion: The research program will produce baseline data on nursing service context factors in Swiss acute care hospitals prior to DRG introduction as well as a theoretical model and a methodology to support nursing managers and hospital executive boards in distributing resources effectively.

The study was approved by the ethics committees of Basel, Bern, Solothurn and Zürich.

Measuring Nursing Error: Psychometrics of MISSCARE and Practice and Professional Issues Items

Background and Purpose: Health care error causes inpatient morbidity and mortality. This study pooled the items from preexisting nursing error questionnaires and tested the psychometric properties of modified subscales from these item combinations. Methods: Items from MISSCARE Part A, Part B, and the Practice and Professional Issues were collected from 556 registered nurses. Principal component analyses were completed for items measuring (a) nursing error and (b) antecedents to error. Results: Acceptable factor loadings and internal consistency reliability (.70–.89) were found for subscales Acute Care Missed Nursing Care, Errors of Commission, Workload, Supplies Problems, and Communication Problems. Conclusions: The findings support the use of 5 subscales to measure nursing error and antecedents to error in various inpatient unit types with acceptable validity and reliability. The Activities of Daily Living (ADL) Omissions subscale is not appropriate for all inpatient unit types.

Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study

BACKGROUND

Little is known of the extent to which nursing-care tasks are left undone as an international phenomenon.

AIM

The aim of this study is to describe the prevalence and patterns of nursing care left undone across European hospitals and explore its associations with nurse-related organisational factors.

METHODS

Data were collected from 33 659 nurses in 488 hospitals across 12 European countries for a large multicountry cross-sectional study.

RESULTS

Across European hospitals, the most frequent nursing care activities left undone included 'Comfort/talk with patients' (53%), 'Developing or updating nursing care plans/care pathways' (42%) and 'Educating patients and families' (41%). In hospitals with more favourable work environments (B=-2.19; p<0.0001), lower patient to nurse ratios (B=0.09; p<0.0001), and lower proportions of nurses carrying out non-nursing tasks frequently (B=2.18; p<0.0001), fewer nurses reported leaving nursing care undone.

CONCLUSIONS

Nursing care left undone was prevalent across all European countries and was associated with nurse-related organisational factors. We discovered similar patterns of nursing care left undone across a cross-section of European hospitals, suggesting that nurses develop informal task hierarchies to facilitate important patient-care decisions. Further research on the impact of nursing care left undone for patient outcomes and nurse well-being is required.