Missed Nursing Care: Magnet vs. non-Magnet Hospitals

1. Missed Nursing Care: Magnet vs. non-Magnet Hospitals Beatrice Kalisch, PhD, RN, FAANTitus Professor of Nursing and Director, Innovation and Evaluation, University of Michigan September, 2012 CANS bkalisch@umich.edu

2. Presentation Outline • Previous Studies • Conceptual Framework • Study Questions • Study Methods • Findings • Discussion and Implications

3. What we DON’T know

4. …Any aspect of required patient care omitted or delayed ERRORS OF OMISSION MISSED NURSING CARE

5. PREVIOUS STUDIES

6. 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.

7. 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

8. 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.

9. 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.

10. 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

11. 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.

12. 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

13. Study 5 MISSED NURSING CARE: An 11 HOSPITAL STUDY

14. 5 Most Often Missed Nursing Care

15. 5 Most Least Missed Nursing Care

16. 5 MOST OFTEN MISSED

17. 5 LEAST MISSED CARE

18. Overall Reasons for Missed Care

19. CONCEPTUAL FRAMEWORK

20. THE MISSED NURSING CARE MODEL • HOSPITAL CHARACTERISTICS • Size • Teaching intensity • Magnet STAFF OUTCOMES e.g. Satisfaction, Turnover, intent to leave MISSED NURSING CARE PATIENT OUTCOMES e.g. Falls • UNIT CHARACTERISTICS • Case mix index • Nurse staffing (HPPD, RN HPPD skill mix) • Type of nurse staffing (education, experience) • Absenteeism • Overtime • Work schedules TEAMWORK

21. RESEARCH QUESTIONS

22. RESEARCH QUESTIONS • 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?

23. STUDY METHODS

24. 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)

25. Measures • The MISSCARE Survey •  From hospital administrative data (unit level variables) • HPPD, RN HPPD, skill mix • Unit Case Mix Index (CMI)

26. STUDY FINDINGS Kalisch B & Lee, K. (in press). Missed Nursing Care: Magnet vs. Non-Magnet, Nursing Outlook.

27. Overall Missed Nursing Care: Magnet vs. non-Magnet

28. Missed Nursing Care: Magnet vs. non-Magnet

29. Missed Nursing Care: Magnet vs. non-Magnet (continued)

30. Reasons for Missed Nursing Care: Magnet vs. Non-Magnet Hospitals

31. Actual Staffing Differences by Magnet Status

32. Hierarchical regression result summary Note. S. E. standard error.

33. 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.

34. 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.

35. DISCUSSION

36. 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 ambulatelinked 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

37. IMPLICATIONS

38. 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.

39. The End questions?