tti-092415audio
Cyber Seminar Transcript
Date: 9/24/15
Series: Timely Topics of Interest
Session: Errors of Omission: Missed Nursing Care
Presenter: Beatrice Kalisch
This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm.
Unidentified Female: At this time, I would like to introduce our speaker for today. We have Beatrice J. Kalisch. She is an RN, PhD, and FAAN. She is a Titus Distinguished Professor Emeritus of Nursing at the University Of Michigan School Of Nursing, located in Ann Arbor, Michigan. At this time, I am going to turn it over to Dr. Kalisch. Dr. Kalisch, please press the button that says Show My Screen. We are ready to go. Thank you.
Beatrice J. Kalisch: Thank you. I am pleased that you have invited me to present my research on missed nursing care. I look forward to the opportunity to work with some of you in studies. This is my presentation outline. I am going to start with what nursing care is missed. According to my studies over the last decade, and the reasons for missed nursing care, what the outcomes are for staff, what the outcomes are for patients, teamwork, which is a big contributor to missed nursing care, and strategies to reduce missed nursing care.
First, let’s do a poll question. To what extent is missed nursing care a problem in your organization? Not a problem at all? A minor problem? A significant problem? An epidemic? I have no idea? Those are your options.
Unidentified Female: Thank you Dr. Kalisch. As our attendees can see, that poll question is up on your slide right now. You can simply click the circle next to the answer option that you choose. We already have about 50% of our audience who has voted. The answers are still streaming in. we will give people some more time. These are anonymous responses and you are not being graded. Feel free to take an educated guess at that. It looks like we have about an 80% response rate, and a pretty good trend of what people think. I am going to go ahead and close the poll now. I will share those results. It looks like we have about one-quarter of our audience thinking it is a minor problem. About half of our audience thinks it is a significant problem. 4% would refer to it as an epidemic. About one-quarter of our audience says they have no idea. We are back onto your slides now Beatrice.
Beatrice J. Kalisch: Okay. We will talk about the results as we present the slides.
Missed nursing care I defined as any aspect of required standard patient care that is omitted or significantly delayed. These are errors of omission, as opposed to errors of commission. Errors of commission is giving the wrong medication. Errors of omission is not giving the medication at all. Those are just examples. The patient safety movement has largely focused on errors of commission, and the AHRQ has said that there are probably many more errors of omission than errors of commission.
This slide shows that you have nurse staffing on one side and patient outcomes on the other. We have over 150 studies that show us that the level and type of nurse staffing impact patient outcomes. We do not know what goes on between the nurse staffing or what else is involved in patient outcomes. Ten years ago, we began to see all these studies on patient outcomes related to staffing, and I decided that I wanted to conduct these studies into the process of nursing care. I call this a black box of nursing care as well, what goes on there and how that results in those outcomes. If we do not know, it is very hard to develop interventions to improve the situation.
The conceptual framework for my work is here. Missed nursing care is in the middle. This is going to be the structure process and outcomes. On the structure side, we have hospital characteristics. We have unit characteristics, _____ [00:05:00] index, staffing, outcomes, and so forth. I put teamwork down as a separate box because I have done a lot of studies of nursing teamwork. I feel like it is a big contributor, and my studies show that it is a big contributor to missed care and other quality issues. The outcomes are both staff and patients. The staff outcomes include satisfaction, turnover, and ____ [00:05:26]. Patient outcomes are falls, infections, readmissions, and so forth.
How much nursing are is being missed? Some of you said you did not know. We have not known. It has been a hidden secret. The first thing I did is a qualitative study. The hallmark came out of being a consultant, talking with nursing staff members and watching the work over a period of time in depth. I conducted a qualitative study to verify those findings, or to see if they were not correct. This involved 30 focus groups that we spoke with. The areas that emerged in the qualitative piece were ambulation, turning delays, missed feedings, patient education, discharge planning, emotional support, hygiene, intake and output documentation, and surveillance.
I thought that I would not get any attention to this if I did not quantify it. I developed a tool called the Missed Care Survey. I did all those psychometrics, susceptibility, validity, reliability, and so forth, so that we could use it to find out quantitatively what we were dealing with.
The first study I did was with three hospitals. The research questions were what nursing care was missed and what the reasons were. I had a Part 1 and a Part 2. The Part 1 was what was missed and Part 2 was the reasons missed. There were 35 patients units in this study, and the response rate was 57%. What I found in a nutshell was a lot of missed nursing care, more than I thought, more than most people thought.
The reasons clustered around three factors, labor or staffing, material resources including having the medications when they are needed to be given, and communication and teamwork. I thought all three of these hospitals were similar and I could not figure it out. Why were the nurses all missing the same things? I could give some ideas, but I thought this was really important. I thought these three hospitals were part of the same system, so maybe that was why. I did a big study then, with 11 hospitals. The questions were to what extent care was missed and if it varied by hospitals. What were the reasons for missing care? Did the reasons vary? Did missed nursing care vary by staff characteristics?
The study sample was 124 adult patients units in 11 hospitals, over, 4,000 nursing staff that included RNs, LPNs, and nursing assistants. They all were administered the survey and 57% returned. The hospitals ranged in size from 60 beds to 113 beds. 55% of the respondents, nursing and nursing assistants, were over 35 years old. 90% were female. 29% had a baccalaureate degree or higher. 54% had more than five years of experience. 73% of the sample was registered nurses, while the other was nursing assistants and LPNs. We divided employment status by 30 hours a week being full-time and 82% had 30 hours per week or more. 58% worked the day shift or rotated. Here are the measures.
I also had, in parallel, a real interest for years in teamwork. I had done some work. I developed another tool and did the psychometric testing for that. It is called the Nursing Teamwork Survey. I administered both to a certain group of patient care units. Once I got that done, I wondered if patients could tell us anything, and if it could be done accurately, validly, and reliably. That was my third instrument. I used it some of the studies. From a hospital administrative survey, I got turnover, HPPD or hours per patient day, ____ [00:10:18]. The unit level case mix index is a proxy for acuity. There was average daily census and fall rates as well.
To what extent is nursing care missed? This will show you that it is a lot. Ambulation three times a day was 76% missed. It was the highest one. Interdisciplinary rounds was 66%. Mouth care, medications on time, feeding patients while the food was still warm, patient teaching, response to call lights in five minutes, patient bathing, skin care, emotional support for patients and/or families were measured. There were many others, but these are the ones that were missed the most. These graphs show it in graph form. Ambulation is number one, and it seems to be number one everywhere, in every hospital. These studies have been done in seven other countries and ambulation is highest there too, although in the Asian countries it is lower to some extent because the family comes in and provides care while the patients are in the hospital.
The least missed are the patient assessments at the beginning of every shift. They do not miss that. We could talk about why, but the point is that if you are going to assess, it seems really nonsensical if you do not also provide the other elements of care that are needed. Discharge planning came out as least missed, and the reason I finally figured out through follow-up focus groups and so on is because nurses view the discharge activities as handing the patient the sheet that tells them what they are supposed to take for medications, who they are supposed to call if there is a problem, and so forth. It is not comprehensive discharge planning and implementation for the patient.
What can patients report? We knew right away that this was going to be a problem because the patients cannot tell what the nurse is doing or not. We did a qualitative study with interviews. We found three categories of elements of nursing care. Fully reportable, like they knew if they were bathed or had pain medication. There was partially reportable. Handwashing was partially reportable because they did not always see if the provider washed their hands. They could not always tell. I was a patient and I experienced this. There was patient education, they might be able to tell you if they were educated, but not if it was adequate. Not reportable was things they could not report on. I thought of looking at this again, because they can tell you quite a bit about IV care.
This is how the patient data came out. The overall column is the first one. It was up around 2. The basic care, which included bathing, mouth care, and all of those kinds of things we have called traditionally basic care, was the most missed. I think that would probably fit with your view and the world’s as well. Communication and teamwork were up there, as well as time to response. That is how the factors came out. Here is what was missed.
Mouth care was really important to them. It was missed by half. Mouth care just is not being done. There was ambulation, getting out of bed, and getting the information they need about what tests and procedures were going on, as well as bathing. Least missed was not listening. They felt they were listened. They felt like their call lights were answered. The nursing staff thought their call lights needed to be answered faster than the patients thought, I guess. There were not responding to beeping monitors and requests not fulfilled, and not being helped to the bathroom.
This shows you that if you drop down to mouth care, you can see the big discrepancy. The red is what the patients say and the grey is what the staff say. There is a big discrepancy there that the patients report not getting mouth care more than the nursing staff do. That is true of bathing and feeding. That is true of repositioning. Ambulation was equally identified. There is more to be said about this, but we do not have time today.
Does missed nursing care vary across hospitals? The summary answer really is no. this shows you ten of the hospitals, and you can see how close they are to one another in terms of the elements of nursing care. The red one is attended interdisciplinaries. That particular hospital was really emphasizing that. They recorded less missed care there. This is the least missed. All this is up here for is to show you how close these hospitals were in identifying what care was missed.
What does that tell us? It tells us that it is not an individual problem, it is a system problem. There are reasons that we will go over as to why nurses miss care. It is not because they do not want to do a good job. They want to do a good job.
What are the reasons for missed nursing care? It fell into these three buckets, nursing staffing, material resources including the medications, which is a major problem in some hospitals, having the medication when it needs to be given, and communication and teamwork. I did an analysis and found out that the reasons in my tool did not account for everything. I want to revise this tool, but here are some of the other reasons.
Last year, I was in Washington, DC. I had a whole year to work on this. I tried to find every possible study that would give me clues about why nurses did not complete the care, as well as other factors. Fatigue is one of the reasons. Long work hours and mandated overtime still exist in some organizations. Rotating shifts leads to diurnal rhythm problems. I found it is a little better now, but nurses do not take breaks, or they take a break while they are charting, something like that. About 5% of nurses have more than one job, according to the ANA. There is moral distress, which comes from seeing that something needs to be done, but they do not have the capacity to do it. That creates, inside them, a moral distress. That causes them to be more fatigued. There is burnout and compassion fatigue. Their compassion seems to edge away after this goes on day in and day out. They cannot do the care that they want to do and they think the patient needs.
Another reason is the interruptions and multitasking, as well as task switching. We did a study that showed nurses are interrupted at least five times an hour. If you think of yourself and you have to do X, Y, and Z, and you find that you are interrupted, you forget to go back and do A, B, or C. Cognitive biases are a big thing now in these studies. There is an omission bias that tells us it makes it more comfortable for nursing staff to not do something, rather than do something wrong. That is what is happening with immunizations. People would rather not have their child immunized than run the risk of them developing a problem because of it. That is omission bias. Nurses would rather not ambulate a patient than have the patient fall when they are ambulating.