Patient Safety Tip of the Week
May 9, 2017
Missed Nursing Care and Mortality Risk
Many studies have
demonstrated a relationship between nursing staffing levels and patient
mortality and complications. High levels of nursing staffing are associated
with lower mortality and lower levels are associated with higher mortality. In
our November 26, 2013 Patient Safety Tip of the Week “Missed
Care: New Opportunities?” we also noted that adverse patient outcomes may
be related to missed nursing care (also known as “care left undone”). Now a new
study appears to connect the dots and demonstrate that much of the excess
mortality related to poor nursing staffing is due to missed nursing care. Jane
Ball, in a thesis using data from the RN4Cast study, found that a 10%
increase in the amount of care left undone by nurses was associated with a 16%
increase in the likelihood of a patient dying within 30 days of admission following
common surgical procedures (Ball
2017).
Lack of time is the major
reason that care gets left undone. This, in turn, may be due to nursing
staffing shortages or to disparities between nursing staffing levels and complexity
of care required or overall task load.
In several of our
columns we’ve discussed findings that have come out of the RN4Cast study. That is a collaborative
study of nurse staffing at hospitals in fifteen European countries, though the
data in the Ball study came from a subset of hospitals in England, Sweden, and
nine countries.
In the Ball study missed
care (aka care left undone) was measured using the “Basel Extent of Rationing
of Nursing Care (BERNCA)”instrument (Schubert
2009). Nurses were asked ‘On your most recent shift, which of the following
activities were necessary but left undone because you lacked the time to
complete them?’ Respondents were presented with a list of 13 nursing care
activities and asked to tick all that applied. The list included activities
such as timely medication administration, skin care, oral care, comforting
patients, care documentation, pain management,
changing a patient’s position, care planning, discharge preparation, patient
surveillance, and patient/family education.
It was not uncommon
for necessary nursing care to be left undone by RNs on a shift due to lack of
time. Ball found that 86% of RNs surveyed in England and 74% in Sweden reported
that they left some care undone on their last shift.
Interestingly, higher
support worker staffing levels (eg. nursing aides)
were not associated with better outcomes. But see our comments below about the
potential relationship with non-nursing staffing.
Nurse-rated quality
of care and patient safety environment scores were also significantly related
to differences in care left undone. But the striking finding was that a 10%
increase in the amount of care left undone by nurses was associated with a 16%
increase in the 30 day mortality rate.
In our November 26,
2013 Patient Safety Tip of the Week “Missed
Care: New Opportunities?” we noted that the concept of missed care
as a potential contributor to adverse patient events can largely be attributed
to Beatrice Kalisch, RN, PhD. In 2006 (Kalisch
2006) she first brought examples of commonly missed nursing care
that have been associated with adverse patient outcomes. (Make no mistake: the
root causes of missed nursing care extend well beyond nursing and those factors
put nurses in the position of having to prioritize care, leaving some care
undone or delayed). Prior to 2006 there was virtually nothing in the literature
about missed nursing care and its occurrence was described as “undiscussable” (Kalisch
2009a). Kalisch did qualitative studies of hospital nursing staff
using focus group interviews and developed a tool, the MISSCARE survey, to
measure missed nursing care (Kalisch
2006, Kalisch 2009a). We are not talking here about
occasionally missed or delayed nursing care but rather regularly missed nursing
care. We refer you back to our November
26, 2013 Patient Safety Tip of the Week “Missed
Care: New Opportunities?” for a discussion of the individual
elements of missed care and the themes as to the reasons for missed care.
While understaffing is an obvious root cause for missed care
or care left undone, don’t just look at nurse:patient staffing ratios. Even when nurse:patient ratios are
“acceptable” there may be additional factors that prevent nurses from carrying
out all regular aspects of nursing care. In our numerous columns on “the
weekend effect” we’ve noted the many additional activities nurses get stuck
doing on weekends because of inadequate non-nursing staffing. Sometimes the nurses end up doing tasks such as transporting patients or
even mopping floors. There is also less dietary and nutrition support, pharmacy
and imaging services, physical therapy, patient teaching, and social services. They
may spend more time on the phone trying to track down doctors on weekends. So
nurses end up doing many more tasks that they do not normally perform during
regular “day” hours and they do not have as much time to do patient care and
bedside nursing.
It’s interesting that the Ball study did not find use of higher support worker staffing levels to
be of any mortality benefit. We have often recommended having dedicated “teams” of appropriately
trained individuals for regular turning of patients at risk for decubiti, or
for ambulating patients, or for feeding patients. These could perhaps free up
nurses to perform some of the other activities that require more professional
backgrounds. Such may be more practical at larger hospitals and may not be
feasible at small hospitals.
But the Ball study did not find evidence that the
availability of nursing support staff increased the ability of RNs to complete
their work. They also note some prior studies have shown that higher support
staff levels in certain contexts may even be associated with increased mortality
rates. So the jury is still out on what, if any, specific activities currently
done by nurses might be done by support personnel to free nurses up for those
activities more closely tied to outcomes.
Kalisch has also pointed out that
experience levels of staff may vary from shift to shift and that issues with
orientation and handoffs may also be contributing factors. In a subsequent
concept paper (Kalisch
2009b) Kalisch and colleagues developed a
Missed Nursing Care Model which highlights teamwork and communication issues as
one of three major antecedents to missed care.
Missed nursing care has also recently been implicated in
some disparities of care in the US (Brooks-Carthon 2016). Looking at older patients admitted with
acute myocardial infarction, the researchers found that unmet nursing care was
associated with a higher risk of 30-day readmission for older black patients
but not older white patients. Older black patients were 18% more likely to
experience a readmission after adjusting for patient and hospital
characteristics and more likely to be in hospitals where nursing care was often
left undone. Factors identified as contributing to this phenomenon were when
nurses were unable to talk/comfort patients, complete documentation, or
administer medications in a timely manner.
Missed nursing care or care left undone is still a
relatively new concept in the patient safety world. The striking finding by
Ball that a 10% increase in the amount
of care left undone by nurses was associated with a 16% increase in mortality
is a wakeup call that tells us we must begin to address the issue. Using
tools like the BERNCA instrument or the
MISSCARE survey to identify what aspects of care are not being
completed, trending them over time and, most importantly, identifying and
ameliorating the root causes could result in significant improvement in patient
outcomes.
References:
Ball JE. Nurse Staffing Levels, Care Left Undone, &
Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm 2017
RN4CAST Study.
Schubert M., Clarke SP, Glass TR, et al. Identifying
thresholds for relationships between impacts of rationing of nursing care and
nurse- and patient-reported outcomes in Swiss hospitals: a correlational study.
International Journal of Nursing Studies 2009; 46(7): 884-893
http://www.sciencedirect.com/science/article/pii/S0020748908002800
Kalisch BJ. Missed Nursing Care: A
Qualitative Study. Journal of Nursing Care Quality 2006; 21(4): 306–313
Kalisch BJ, Williams RA.
Development and Psychometric Testing of a Tool to Measure Missed Nursing Care.
J Nurs Admin 2009; 39(5): 211-219
Kalisch BJ, Landstrom
GL, Hinshaw AS. Missed nursing care: a concept
analysis. Journal of Advanced Nursing 2009; 65(7): 1509–1517
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2009.05027.x/pdf
Brooks-Carthon JM, Lasater KB, Rearden J, et al. Unmet Nursing Care Linked to Rehospitalizations Among Older Black AMI Patients: A
Cross-Sectional Study of US Hospitals. Medical Care 2016; 54(5): 457-465, May
2016
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