Missed Nursing Care and Declining Patient Safety
Making the case for ‘missed nursing care’ as a safety issue
While the immediate effect of the COVID-19 omicron variant on the healthcare workforce is the pressing issue, there were serious concerns about staff shortages and the effect of “missed nursing care” on patients well before the pandemic.
Missed nursing care is defined as delaying, omitting, or rationing care by nursing staff, said Lynda Enos, RN, BSN, MS, COHN-S, CPE, an occupational health nurse in Oregon with more than 25 years of work and consulting experience. Enos addressed the issue of rationed care and the worsening effect of the pandemic on the nursing shortage at a recent webinar1 held by the Association of Occupational Health Professionals in Healthcare.
Two Tasks Often Missed
“What some of the data are telling us is that missed nursing care, if we can identify it on a unit, may be an early warning indicator before we have increased adverse events and patient deaths,” she said. “The two most common tasks that are missed are ambulation from the bed and turning or repositioning in bed.”
Enos emphasized just those two commonly neglected tasks can cause a cascade of adverse events, including ventilator-associated pneumonia, new-onset delirium, hospital-associated infections, falls, longer lengths of stay, and more readmissions.
“Patients [missing nursing care] have increased pain and discomfort, and ultimately die sooner. That’s what I tell the nurses,” Enos explained. “If you miss care, your patient’s quality of life declines dramatically. There’s a lot of evidence to support this. There was a review2 of 42 studies on missed nursing care, and 55% to 99% of nurses reported missing care in the prior shift that they worked. What they missed varies from facility to facility, and we do see there’s less missed nursing care in magnet facilities in the U.S. But when they asked how often you were missing the care, 76% said they were missing ambulating three times a day, and 60% of nurses said they missed turning care.”
COVID-19, Insufficient Faculty Are Factors
Unfortunately, this is a problem that is likely to get worse before it improves.
“COVID has had a huge impact on worker safety, on psychological stress, on burnout,” Enos said. “We have one in three healthcare workers thinking about leaving healthcare. We’re going to be short 1.2 million nurses by next year, just from retirement alone.”
Compounding the problem is insufficient faculty in medical schools to train the needed number of new nurses to fill the gap.
“Then, when they’re in school, we can’t send them on clinical rotation because of the COVID restrictions,” Enos said. “Here in Oregon at our teaching hospital, we’ve had to cut the number of students who can go on clinical rotation because of the social distancing.”
Indeed, missed nursing care is certainly looking like a problem that will continue indefinitely and create broad adverse risk to patients.
“Most of the evidence right now is in ICUs, but we’re starting to see research in med-surg units and long-term care as well, because this doesn’t just affect hospitals,” Enos said. “Obviously, if we don’t turn our patients, there’s the increased risk of pressure ulcers and declining function. We know that missed care is directly related to a higher likelihood of patient death and lower patient experience ratings. As we all know, if there’s not a good patient experience, that patient can go to a different hospital next time, and that results in lost revenue.”
Safety Culture Needed
Of course, understaffing will lead to missed care, but why does it still occur even with adequate staff?
“The first reason we have missed nursing care is culture,” Enos said. “Is there teamwork? Do we focus on patient and worker safety? What is the culture within the organization vs. the unit culture? Are we a high-reliability organization, or do we have very hierarchical leadership?”
There are competing demands on nurses’ time. They might be more reluctant to perform tasks such as turning or mobilizing a patient if safe lifting equipment is not readily accessible.
“Safe patient handling can really help mitigate missed nursing care, promote early mobilization, prevent falls and pressure injuries,” Enos said. “Communication and relationship factors between physical therapists and nurses are very important. Because when we don’t have a good dynamic between those two professions, our patients don’t get moved well and safely.”
The reality is nursing is a hard profession, and it may be difficult or impossible to meet all needs and expectations every day.
“I was teaching a group of nurses — they’re new hires within the last three months — and I asked them, ‘Have you ever seen missed nursing care occur?’ They all said, ‘yes,’” Enos said. “I asked, when does it occur? They said at the end of a 12-hour shift when they’re really tired, and of course we’re all short-staffed right now. This is actually a very serious issue. See if it’s occurring in your facility, and then try to use safe patient handling to mitigate it.”
- Enos L. Enhancing patient safety and outcomes: The safe patient handling connection. Association of Occupational Health Professionals in Healthcare. Aug. 11, 2021.
- Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud 2015;52:1121-1137.
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