Missed Nursing Care: Magnet vs. non-Magnet Hospitals Beatrice Kalisch, PhD, RN, FAAN Titus Professor of Nursing and Director, Innovation and Evaluation,
University of Michigan September, 2012 CANS
[email protected]
Presentation Outline – Previous Studies – Conceptual Framework – Study Questions – Study Methods – Findings – Discussion and Implications
What we DON’T know
…Any aspect of required patient care omitted or delayed
ERRORS OF OMISSION
PREVIOUS STUDIES
STUDY 1 Missed Care: A Qualitative Study
Kalisch B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21:4; 306-313.
Missed Care: A Qualitative Study 9 areas of missed care – Ambulation – Turning – Delayed or missed feedings – Patient education – Discharge planning – Emotional support – Hygiene – Intake and output documentation – Surveillance
7 themes for reasons for missed care
– Too few staff – Time required for a nursing intervention – Poor use of existing staff resources – “It’s not my job syndrome” – Ineffective delegation – Habit – Denial
STUDY 2 A Concept Analysis
B. Kalisch, G. Landstrom, & A. Hinshaw, (2009) “Missed Nursing Care: A Concept Analysis,” Journal of Advanced Nursing, 65(7), 1509-1517.
STUDY 3 MISSCARE Survey Development & Psychometric Testing Kalisch B & Williams R. (2009) The development and psychometric testing of a tool to measure missed nursing care (MISSCARE Survey). Journal of Nursing Administration. 39 (5). 211-219.
MISSCARE Survey Development & Psychometric Testing
Acceptability Validity – Content validity – Construct validity (EFA and CFA)
Reliability - Consistency: Cronbach’s alphas 0.88 to 0.64 - Test-retest: 0.87
STUDY 4 Missed Care and Reasons: 3 hospital study Kalisch B, G. Landstrom & R. Williams, (2009) . Missed Nursing Care: Errors of Omission, Nursing Outlook, 57(1), 3-9.
Missed Care and Reasons: 3 hospital study
Research questions – What and how much nursing care is missed? – What are the reasons for missing care?
Methods – 3 hospitals (459 RNs), 35 patient units – MISSCARE Survey , response rate 57%
Findings – Significant amount of missed care – Consistency across the 3 hospital sample in amount and specific elements of care as well as reasons
Study 5 MISSED NURSING CARE: An 11 HOSPITAL STUDY
5 Most Often Missed Nursing Care 100% 90% 76% Ambulation
80% 66% 70% 60%
64%
60%
59%
Interdisciplinary care conference attendance Mouth care
50% 40%
Timely medication administration
30%
Turning
20% 10% 0%
5 Most Least Missed Nursing Care 100% 90% 80% 70%
Patient assessment
60%
Glucose monitoring
50%
Discharge plan Vital sign
40% 24%
30% 20% 10% 0%
14% 9%
25%
26%
Focused reassessment
5 MOST OFTEN MISSED
5 LEAST MISSED CARE
Overall Reasons for Missed Care
92.8% 100.0%
89.6% 81.8%
80.0%
60.0%
40.0%
20.0%
0.0% Labor resources
Material resouces
Communication/Teamwork
CONCEPTUAL FRAMEWORK
THE MISSED NURSING CARE MODEL HOSPITAL CHARACTERISTICS
STAFF OUTCOMES
•Size •Teaching intensity •Magnet
e.g. Satisfaction, Turnover, intent to leave
UNIT CHARACTERISTICS Case mix index Nurse staffing (HPPD, RN HPPD skill mix) Type of nurse staffing (education, experience) Absenteeism Overtime Work schedules
TEAMWORK
MISSED NURSING CARE
PATIENT OUTCOMES e.g. Falls
RESEARCH QUESTIONS
RESEARCH QUESTIONS 1.
2. 3.
Controlling for staffing levels, case mix index, and type of unit, do Magnet designated hospitals have less missed nursing care than non-Magnet facilities? Do the reasons for missed nursing care differ between Magnet and non-Magnet facilities? Do staffing levels and type account for variations in amount and reasons for missed nursing care in Magnet vs. non-Magnet hospitals?
STUDY METHODS
Study Sample
Nursing staff on 124 adult patient care units (medical-surgical, rehabilitation, intermediate and intensive care units) in 11 hospitals. – Magnet: 62 units – Non-Magnet 62 units
4,412 nursing staff (3,349 RNs, 83 LPNs and 980 NAs) Return rate 57.3% (61.7% for RNs & LPNs, 53.4% for NAs)
Measures
The MISSCARE Survey From hospital administrative data
level variables)
– HPPD, RN HPPD, skill mix – Unit Case Mix Index (CMI)
(unit
STUDY FINDINGS Kalisch B & Lee, K. (in press). Missed Nursing Care: Magnet vs. Non-Magnet, Nursing Outlook.
Overall Missed Nursing Care: Magnet vs. non-Magnet Variable
Magnet Mean±SD
Non-Magnet Mean±SD
t
p
Overall Missed Nursing Care
1.50±.21
1.57±.15
2.20
.03
Missed Nursing Care: Magnet vs. non-Magnet Variable
Magnet Mean±SD
Non-Magnet Mean±SD
t
p
Overall missed nursing care
1.50±.21
1.57±.15
2.20
.03
Mouth care*
1.81±.32
1.93±.31
2.02
.05
Skin/Wound care
1.32±.26
1.39±0.15
1.99
.05
Feeding
1.65±.26
1.82±.30
3.34
.00
Meal set up
1.35±.27
1.47±.22
2.65
.01
Turning*
1.65±.31
1.77±.23
2.34
.02
Med effectiveness assessment
1.52±.25
1.63±.20
2.65
.01
IV/central line site care
1.32±.26
1.47±.18
3.79
.00
Call light response
1.54±.31
1.67±.29
2.38
.02
Patient teaching
1.62±.25
1.72±.22
2.24
.03
Full documentation
1.60±.29
1.73±.24
2.72
.01
Missed Nursing Care: Magnet vs. non-Magnet (continued)
Variable
Magnet Mean±SD
Non-Magnet Mean±SD
t
p
Ambulation*
2.03±.36
2.13±.28
1.57
.12
Attend interdisciplinary care conferences*
1.99±.28
2.05±.50
.83
.41
Timely medication administration*
1.76±.33
1.79±.24
.55
.58
Monitoring I/O
1.59±.40
1.65±.38
.78
.44
Assist with toileting
1.54±.24
1.60±.23
1.40
.17
Bathing
1.50±.27
1.56±.22
1.22
.22
Emotional support
1.47±.25
1.53±.22
1.53
.13
PRN meds administration
1.45±.25
1.52±.21
1.75
.08
Patient discharge planning^
1.29±.28
1.31±.14
.47
.64
Focused reassessments^
1.28±.27
1.29±.15
.18
.86
Vital signs^
1.27±.29
1.29±.17
.54
.59
Hand washing
1.27±.27
1.35±.19
1.88
.06
Glucose monitoring^
1.14±.32
1.17±.13
.90
.37
Assessment each shift^
1.11±.29
1.12±.10
.28
.78
Reasons for Missed Nursing Care: Magnet vs. Non-Magnet Hospitals Magnet Mean±SD
Non-Magnet Mean±SD
t
p
Communication
2.23±.18
2.32±.20
2.49
.014
Labor resources
3.00±.29
3.12±.18
3.31
.001
Material resources
2.56±.22
2.61±.23
1.37
.174
Actual Staffing Differences by Magnet Status Variable
Magnet Mean±SD
Non-Magnet Mean±SD
t
p
HPPD
10.94±.18
11.30±4.98
.44
.662
RN HPPD
8.71±4.17
8.86±4.58
.19
.847
Skill Mix
.781±.14
.780±.18
-.04
.969
Hierarchical regression result summary Variable
Coefficient
Robust S.E.
T ratio
P-value
1.530
0.040
37.775
.000
Experience
0.044
0.005
8.961
.000
Education (BSN or higher)
0.088
0.014
6.374
.000
Magnet (Magnet)
-0.074
0.030
-2.471
.015
Type of unit (ICU)
0.077
0.159
0.484
.629
HPPD
-0.022
0.012
-1.827
.070
CMI
-0.002
0.021
-0.104
.918
Intercept
Individual-level predictors
Unit-level predictors
Level-1 R2
4.6%
Level-2 R2
15.0%
Note. S. E. standard error.
Magnet units had less missed care after adjusting for other variables (γ01=-0.074, p=.015)
More experience was positively associated with missed nursing care Nurses with a BSN degree or higher identified more missed nursing care than staff that held an associate degree or less.
In summary…
Magnet hospitals have significantly less missed care. Magnet hospital staff report less staffing and communication problems. Yet there were no significant differences in staffing levels and type between Magnet and non-Magnet hospitals.
DISCUSSION
Discussion
The amount of missed nursing care represents errors of omission; standard ; nursing care not being completed Leads to negative patient outcomes – Failure to do mouth care
Leads to a reluctance to eat that in turn impacts risk of pressure ulcer development and/or pneumonia, particularly in ventilated patients.
– Failure to ambulate linked to:
New onset delirium Pneumonia Delayed wound healing Pressure ulcers increased length of stay and delayed discharge increased pain and discomfort muscle wasting and fatigue Physical disability
IMPLICATIONS
IMPLICATIONS
Ensure adequate staffing – Deal effectively with flows in patient acuity and volume
Conduct studies which measure other variables such as culture, leadership, teamwork, which may account for less missed care in Magnet Hospitals.
The End QUESTIONS?
