About Missed Nursing Care

Background

The European Commission's 2016 report Costs of unsafe care and cost effectiveness of patient safety programmes (Zsifkovits et al., 2016) found that between 4% and 17% of patients admitted to hospital experience complications, 44% to 50% of which could have been avoided. It is estimated that on average between 0.2% and 6% of total healthcare expenditure is consumed by the consequences of these complications each year. The authors point to the multiple consequences of unsafe care on the quality of life, clinical condition and even death of patients. In addition, it is reported that patients and health care workers lose their trust in the health care system when avoidable complications occur during the treatment process (Zsifkovits et al., 2016).

Nurses play an important role in interprofessional work in hospitals in dealing with patient risks and preventing complications. They are the professional group with the highest and most intensive patient:inpatient contact in terms of time and bear great responsibility for identifying risks and implementing and evaluating prophylactic measures (Kocks, Michaletz-Stolz, Feuchtinger, Eberl & Tuschy, 2014).

Inadequate framework conditions in the hospital

The constant demographic, epidemiological and economic changes in society result in significant challenges for the planning and implementation of nursing care in hospitals. These challenges come about as a result of the "increasingly compressed and intensified framework conditions" in the health care system (Kocks et al., 2014, p. 19). Hospitals are subjected to ongoing process optimisation and cost reduction in the interests of economisation. The increasingly ageing population, the rise in chronic and mental illnesses and the increased morbidity, which at the same time go hand in hand with numerous possibilities for diagnosis and therapy, lead to an increased workload and a significantly higher risk of errors in hospitals (Kocks et al., 2014).

One consequence of this is that nurses are unable to carry out necessary nursing activities in the context of prioritising patient care, or can only do so partially or too late. This phenomenon is described as missed nursing care (Hübsch et al., 2020; Stemmer & Schubert, 2019). The high prevalence of Missed Nursing Care is identified as a key outcome in the literature.

In the studies conducted, between 55% and 98% of caregivers report that they were unable to provide or complete necessary care activities (Jones et al., 2015).

Nursing activities that are most frequently described as implicitly rationed are mobilisation of patients, gait training, changing bed position (Brown et al., in Kalisch et al., 2009), patient education, discharge planning (Ball et al., 2014; Jones et al., 2015), emotional support and patient conversations (Ball et al., 2014), updating the care plan (Ball et al., 2014) and timeliness of care (Jones et al., 2015). Activities performed in the context of infection prevention, medical and therapeutic care, food intake or elimination are mentioned least frequently (Jones et al., 2015).

Although differences between hospitals, ward types, caregiver and teamwork-related characteristics were observed, for Jones et al. (2015) there are aspects that these implicitly rationed care activities have in common:

[They] address the emotional and psychological needs of patients rather than the physiological needs; their effect on patient health is indirect and less immediate; they require relatively more time to complete and/or require an unpredictable amount of time to complete; and they are less likely to be audited (Jones et al., 2015, S. 1132).

The negative consequences of implicit rationing of nursing activities on nursing-sensitive patient outcomes in the acute setting are manifold. These include reduced patient satisfaction, medication errors, falls, nosocomial infections or pressure ulcers, and even increased patient mortality (Kalisch et al., 2012; Blackman et al., 2018).

Undesirable consequences have also been addressed at the level of nursing staff, including increased turnover and absenteeism rates and job dissatisfaction (Kalisch et al., 2011; Tschannen et al., 2010).

Jones, Hamilton and Murry (2015) summarise the results of several international studies and report a high cross-national, but also local variance in the frequency of implicitly rationed care and patient outcomes, as well as different weightings for identified influencing factors. In interpreting this variation, the authors emphasise that the different contextual, professional and economic aspects in the practice of the nursing professions are of central importance for the phenomenon of implicit rationing. In other words, although implicit rationing is a general phenomenon, there is evidence that its manifestation is context-dependent.

There is therefore a need - complementary to the quantitative determination of the dimension of the phenomenon - for an exploration of the local significance of specific influences on implicit rationing of care activities from common experiences of caregivers.

Further links

The Missed Nursing Care Model

Kalisch, B., Landstrom, G., Hinshaw, A.(2009) Missed nursing care: a concept analysis. Journal of advanced nursing. 65(7):1509-17. doi:10.1111/j.1365-2648.2009.05027.x

PubMed Link: https://pubmed.ncbi.nlm.nih.gov/19456994/

The MISSCARE Survey

Kalisch, B., Williams, R. (2009) Development and psychometric testing of a tool to measure missed nursing care. The Journal of nursing administration. 39(5):211-9. doi: 10.1097/NNA.0b013e3181a23cf5

PubMed Link: https://pubmed.ncbi.nlm.nih.gov/19423986/

The revised MISSCARE Survey

Dabney, B., Kalisch, B., Clark, M. (2019) A revised MISSCARE survey: Results from pilot testing. Applied nursing research: ANR. 50:151202. doi:10.1016/j.apnr.2019.151202

PubMed Link: https://pubmed.ncbi.nlm.nih.gov/31668895/