1
According to AHRQ ( 2019 ), missed nursing care is primarily a problem of time pressure and competing demands , and adequate nurse staffing is needed
to prevent it .
2
Organizational and unit culture influence missed nursing care .
3
The organization of nursing work and the organization of the supply chain that supports nursing work may contribute to preventing missed care . assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care , more research that uses objective staffing and outcome measures is required . Although nurses may exercise judgements in rationing care in the face of pressure , there are nonetheless adverse consequences for patients ( ranging from poor experience of care to increased risk of infection , readmissions and complications due to critical incidents from undetected physiological deterioration ). Hospitals should pay attention to nurses ’ reports of missed care and consider routine monitoring as a quality and safety indicator .”
Solutions to Missed Nursing Care
AHRQ ( 2019 ) emphasizes that missed nursing care can be “ best understood as a common safety and quality threat for which there is not yet strong evidence regarding effective solutions .” That said , the agency identifies predictors of missed nursing care .
First , according to AHRQ ( 2019 ), missed nursing care is primarily a problem of time pressure and competing demands , and adequate nurse staffing is needed to prevent it : “ Evaluation of organizational nurse staffing plans should include not just the average needs of nursing units , but also careful assessment of how frequently surges in demand or patient complexity affect the adequacy of staffing . Creativity and careful analysis may be required to develop mechanisms to nimbly deploy appropriately skilled nursing staff to clinical areas experiencing an influx of admissions , unexpectedly high numbers of complex patients , or unusually depleted staff .”
Second , organizational and unit culture influence missed nursing care . As AHRQ ( 2019 ) notes , “ Improvements in the work environment , unit safety climate , organizational culture , and teamwork skills should reduce the pressures that lead to missed nursing care . Qualitative research has found that adaptable teams can help mitigate missed care . In times of resource pressures and scarcity , such teams tend to orient themselves toward caring for the whole group of patients , mostly by assisting each other to complete needed care rather than focusing only on their own patient assignments . Cultivating cross-monitoring and cooperative problem-solving skills among staff may decrease the frequency of missed nursing care .”
Third , the organization of nursing work and the organization of the supply chain that supports nursing work may contribute to preventing missed care . As AHRQ ( 2019 ) explains , “ A well-organized , reliable supply chain for medications , clinical supplies , and equipment may contribute to nurses ’ capacity to complete all required care . Some authors suggest that moderate or radical rethinking of responsibilities may be required in nursing to meet the needs of patients and the profession . Specific to preventing missed nursing care , ambulation and turning — two aspects of care that are frequently missed — may be best addressed by reconfiguration of the medical – surgical nursing team to include full-time ambulation and turning assistants to ensure that patients are assisted to the bathroom and turned or repositioned every two hours . This has not been tested , but it might be an effective component of programs to eliminate missed nursing care .”
These factors , experts say , could likely result in improved work environments for nurses , which may augment patient outcomes by enhancing teamwork and reducing time pressure , cognitive load , and burnout . AHRQ ( 2019 ) points to the results from a study of Pennsylvania hospitals suggesting that more than 30 percent of nurses had high burnout scores , and higher burnout among nursing staff may explain the relationship between poorer nurse staffing and increased nosocomial infection rates . Several investigators suggest that addressing work environment issues and burnout among providers are essential to achieving safety , quality , and value in healthcare .
Ramifications of Missed Nursing Care for Infection Prevention
Adding nurses ’ unguarded perspectives to the conversation around missed care , Bail , et al . ( 2021 ) investigated their perceptions of missed infection control through in-depth interviews . Participants were asked whether nursing and hospital-wide care tasks fundamental to infection control were missed , and what were the underlying causes and contributing factors for these omissions .
The researchers found omission of infection control care at the individual clinician and organizational levels , as nurses described failure to perform standard precautions in addition to basic patient care . These nurses identified what researchers characterized as “ institutional and cultural factors which contributed to cascade iatrogenesis resulting in healthcare associated infections for patients .” These factors often existed outside nurses ’ control , including environmental cleanliness , nursing unit layout , ward culture , resourcing and staffing , integration of infection control into clinical governance , action following audit results , and review of evidence-based protocols .
They state , “ Care occurs in complex and conflicted settings , with prioritization essential . Potentially harmful practices are generally done with the intention of care . Nurses are key , but not sole performers in the creation of quality infection control .”
Mapping missed care related to infection control against standard frameworks of nursing practice revealed “ gaps in the chain of infection ” that contribute to the aforementioned “ cascade iatrogenesis ” that can lead to negative outcomes for patients .
As Bail , et al . ( 2021 ) state , “ Underpinning missed care is the assumption that the rationing of human and material resources means nurses prioritize some , usually medically ordered tasks , over other aspects of care . Similarly , Kalisch associates missed nursing care