Missed Care in Nursing

Nurses are charged with the duty of planning, coordinating, providing and evaluating care to meet various patient needs in different health care systems. This care may sometimes fall below the desired standards. Often, missed care comes up in different healthcare settings and leads to reduced healthcare provisions in meeting the diverse needs of patients. Some of the major contributors to missed care in nursing include challenges with the equipment used in the hospitals, limitations in the human resources, failed communication, a poor relationship among the nurses and those that assist them, and inappropriate prioritization. When the required nursing care is omitted partially or entirely, patient mortality and morbidity occur. The result is patients falls, skin impairment, wrong medication and nosocomial infections (Kalisch & Lee, 2012) Additionally, patient satisfaction relatively reduce due to missed nursing care (Bittner & Gravlin,2009) to achieve quality patient outcomes, nurses have to provide all the required care by carrying out different interventions which are prescribed by other providers to treat illness and treat complications.

          The working environment is a key determinant of how nurses execute patient care. Interruptions and complex workloads have a negative effect on job satisfaction, patient mortality, medication errors, and burnout (Clark & Flanders, 2012). When nurses are given complex workloads, they are put in a position of making difficult choices on which care elements to consider first. There are several structural factors that contribute to missed care in nursing. These factors include material resources in the form of availability of all the necessary medications, proper equipment, and supplies. At some point, the nurses do not receive enough drugs as and when necessary. The equipment required to perform various specific nursing care activities are sometimes unavailable for use while other vital supplies are either delayed or lack completely.            The other factor is labor resources which involve the type and number of nurses available, their competency level, experience, and level of education. When there is an urgent patient situation, missed care is likely to occur because most of the nurses may be fully occupied thus the urgent situation will have to wait. This waiting may be for long hours, and so nursing care will be missed. The education and experience represent the nurse-sensitive indicators which are associated directly with missed care. It is essential for the experienced nurses to offer guidance to the novice nurses to boost the outcome of whatever activity they undertake. Lack of proper training and education will lower the confidence of a nurse, and thus the nurse will not be able to respond well while faced with a certain problem (Winters & Neville, 2012). On the other hand, lack of experience for nurses will lead to underperformance where a nurse does not provide full services as required. Limited knowledge on the importance of some of the nursing care interventions can make the nurses ignore or fail to do some tasks by considering them useless. Where there is insufficient staff, the nurses are overworked hence the required nursing care is not fully met. Additionally, several nurse sensitive indicators showcase of missed nursing care. When novice nurses are put together to work without the guidance of the experienced nurses, there is a great possibility of the novice nurses failing to provide the desired nursing care most likely due to lack of knowledge or simply being ignorant In some other situations, the nurses receive an unexpectedly high number of patients thus the work burden increases (Kalisch & Lee 2010). Weak interprofessional collaboration is a nurse-sensitive indicator that is process oriented and is likely to lead to missed care in nursing. When the healthcare professionals do not work hand in hand with the nurses in addressing the needs of the patients, some crucial interventions are left out resulting in poor patient’s satisfaction. Consequently, the use of nursing care plans is a process-based nurse sensitive indicator that influences missed nursing care. When a nurse plans and uses the plan effectively, no activity is bypassed at all. However, when a plan is drafted but not put to proper use while offering care to the patients, it becomes easy to skip some nursing interventions. Documentation of care is another factor that influences missed care. When a nurse documents a wrong thing, the continuity of care will be compromised thus missed care occurs. In some cases, some nurses are negligent, and the outcome of their negligence is missed nursing care. When a patient becomes a victim of the negligence of a nurse, medical negligence ensues.                                                                                                                          The third structural factor is teamwork and communication. The communication may be between nurses and physicians, between nurses and members in the support staff or among the available          patient care team members. When a nurse is not available when called on by a patient, the result is missed care. In other cases, errors in communication and tension also cause missed care. In most cases, nurses lack back up support which everyone who is working needs. In most cases, when things like electricity fail, a backup generator is used to ensure continuity of a smooth running which includes communication from patient to nurses and from nurses to other nurses. Some assistants fail to communicate with the nurses when something is not in order. Without the information, the nurse cannot be able to offer the services required. In a healthcare center, there exist distinct departments with each having some specific duties to perform. At some point, all the departments need to work hand in hand with each other to ensure that a patient is given the desired care and specifically in case of an emergency. However, failure by other departments to at least provide some care for patients because it is the duty of nurses can lead to missed care. Other problems related to communication include unbalanced assignments, where care is not done, caregiver off unit and tension with the ancillary department. When an organization is lacking one or more of these resources, nurses have to prioritize their different care activities, and there is a high possibility of either delayed or omitted nursing care (Pearson et al., 2006)

          Whenever a nurse faces a problem relating to limited resources, they end up using the nursing process at their disposal to determine the clinical priorities and thus decide whether to omit or delay specific aspect of care. Four factors influence the decision process. The first one is the judgment of the nurse about the importance of some of the aspects of care about the conditions of many patients that the nurse is responsible. Secondly, the perception of the nurse on group norms, the other factor is the nurses’ beliefs, attitudes and values and lastly the usual practice used by the nurse. Any of the four listed elements lead to prioritization thus the outcome is missed nursing care.

          More routine consequences such as delayed medication fall, ventilation associated pneumonia, increased level of stay, pressure ulcers, deconditioning and decreased patient satisfaction are all caused by missed care in nursing. Many of the missed care are those related to psychological and emotional needs (Jones, Hamilton and Murray, 2015). For example, ambulation is among the most lost aspects of care together with mouth care and turning.

Missed nursing care may be in different forms including delayed or lack of feeding, emotional support, patient teaching, intake, and output documentation, call light response, skin/wound care, ambulation, turning and mouth care (Stimpfel, Sloanne & Aiken, 2012). Breaking down each element of care, the lack of patient ambulation is the most common element of missed care in many healthcare facilities. It takes a lot of time before patients get ambulances and in some cases, nurses are dependent on other individuals to assist them in ambulating patients since they consider it not important.

          Nursing care can be incorporated into different dimensions. The dimensions include individual needs, primary care, discharge planning, and education, and care with continuous assessments. Nurses generally use their knowledge and skills they have gained to treat people’s human reactions and not the health problems and consequently use the person’s willingness to enhance self-care and offer support which in most cases is emotional. Through discharge planning and the education provided, the patients and family members are able to improve their participation thus they are equipped with the knowledge to help them while making informed decisions about the care. Nursing care with continuous assessment is concerned with constant monitoring process and constant evaluation of the care provided which assist in identifying whether there is any change in the patient’s health status and therefore make decisions on the process of care.

Nurses are responsible for the care quality provided. Therefore, when a nursing staff identifies care omissions and other factors relating to those omissions, they should take relevant action in changing the structure of nursing services thus bringing a solution to the problem of missed nursing care.

          Missed nursing care is a significant hindrance to the realization of health care goals (Kalisch & Lee, 2010) When these goals are not realized, the quality of care accorded to patients in different health institutions goes down and thus there is an adverse effect on continuous quality improvement. The implementation of desired changes is limited by the lack of constant quality improvement due to missed care. Interprofessional health teams that are involved in promoting continuous quality improvements are discouraged by the missed care in nursing.

Interruptions and multitasking is also a contributor to missed care where a nurse is interrupted mostly by a call light or another person and thus leaves what they are doing to attend to an emergency. Multitasking, on the other hand, lowers the quality of work done by a nurse since the concentration is divided into several parts hence missed care occurs. So many errors result from interruptions and multitasking.

          Missed care is a standard safety and quality threat which has no specific solution. The following conclusions can, however, be drawn based on the missed nursing care. First, missed care in nursing is a problem of time pressure and demands that are competing. To prevent the problem of time pressure, adequate nurse staffing is needed. Nurse staffing plans should be evaluated and should include the universal need of the nursing unit, and a careful assessment of patient complexity affect the adequacy of staffing. Careful assessment and creativity are required to ensure the best nurses are the ones recruited and assigned work in areas that have tendencies of receiving many patients. Second, the unit and organization culture influence missed care in nursing. Improvements in unit safety climate, teamwork skills, organizational culture, and work environment should reduce the pressure that leads to missed nursing care. Adaptive teams can further be used to minimize missed attention. When there are scarcity and resource pressure, such organizations cater for the whole group of patients by mainly assisting one another to complete the necessary care instead of focusing on their patient assignments (Kalisch & Tschannen, 2011b). Advocating for cross-monitoring and cooperation skills among the staff members may lower the frequency of missed care in nursing. Third, when the nursing work is organized, and the supply chain is organized as well, there will be cooperation, and that will prevent missed nursing care. When the supply chain responsible for medications, clinical supplies and equipment is well organized and reliable, the nurses are able to complete all the required care. To meet the needs of different patients, the commonly missed care activities which are ambulation and turning should be addressed by restructuring the medical-surgical nursing team to constitute a team of full-time nurses responsible for ambulation and turning assistants who will make sure the patients are assisted to the bathroom and turned or repositioned after every set duration of time. By putting all the listed factors into consideration, there is a possibility of achieving improved work environment for nurses which will trickle down to the patient outcomes as a result of reduced time pressure and enhanced teamwork.

          Missed nursing care represent any care that is omitted during a patient’s stay at any hospital. Greater omissions are mainly reported during intervention for primary care, patient education, and planning of discharge. Missed care is associated with human resource factors, material resources, and communication. There is a direct relationship that exists between human factors and patient care. To cater for the care demands that are available in hospitals, nursing managers need to manage and have sufficient and competent nursing staff and further strengthen communication between nursing professionals and all the other clinical staff involved in care so as to strengthen nursing care and raise the quality of hospital care.

References

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Clark, A. P., & Flanders, S. (2012). Interruptions and medication errors: part II. Clinical Nurse Specialist, 26(5), 239-243.

Jones, T. L., Hamilton, P., & Murry, N. (2015). Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International journal of nursing studies, 52(6), 1121-1137.

Kalisch, B. J., & Lee, K. H. (2010). The impact of teamwork on missed nursing care. Nursing outlook, 58(5), 233-241.

Kalisch, B. J., & Lee, K. H. (2012). Missed nursing care: Magnet versus non-Magnet hospitals. Nursing outlook, 60(5), e32-e39.

Kalisch, BJ, Tschannen, D, & Lee, KH (2011b). Do staffing levels predict missed nursing care? International Journal for Quality in Health Care, 23(3), 302–308.

Kalisch, B. J., Doumit, M., Lee, K. H., & El Zein, J. (2013). Missed nursing care, level of staffing, and job satisfaction: Lebanon versus the United States. Journal of Nursing Administration, 43(5), 274-279.

Pearson,A,Pallas,LO,Thomson,D,Doucette,E,Tucker,D,Wiechula,R,...Jordan,Z(2006). Systematic review of evidence on theimpactofnursingworkloadandstaffingonestablishing healthy work environments. International Journal of Evidence Based Healthcare, 4(4), 337–384.

Stimpfel, AW, Sloane, DM, & Aiken, LH (2012). The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Affairs, 31(11), 2501–2509. http://dx.doi.org/10.1377/hlthaff.2011.1377.

Winters, R., & Neville, S. (2012). Registered nurse perspectives on delayed or missed nursing cares in a New Zealand Hospital. Nursing Praxis in New Zealand, 28(1).