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 bkalisch@umich.edu

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

PREVIOUS STUDIES

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.

MISSCARE Survey Development & Psychometric Testing 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

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

MISSED NURSING CARE: An 11 HOSPITAL STUDY

5 Most Often Missed Nursing Care

5 Most Least Missed Nursing Care

5 MOST OFTEN MISSED ambulation (84%) -assess RX effect (83%) -turning (82%) -mouth care (82%) -pt. teaching (80%) -timely PRN RXs (80%) 16

5 LEAST MISSED CARE Patient assessment each shift Glucose monitoring Vital signs Discharge planning Focused reassessments 17

Overall Reasons for Missed Care

CONCEPTUAL FRAMEWORK

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

RESEARCH QUESTIONS

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?

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 (unit level variables) HPPD, RN HPPD, skill mix Unit Case Mix Index (CMI)

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 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 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 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 IV/central line site care 1.47±.18 3.79 Call light response 1.54±.31 1.67±.29 2.38 Patient teaching 1.62±.25 1.72±.22 2.24 Full documentation 1.60±.29 1.73±.24 2.72

Missed Nursing Care: Magnet vs. non-Magnet (continued) Variable Magnet Mean±SD Non-Magnet 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

Reasons for Missed Nursing Care: Magnet vs. Non-Magnet Hospitals Mean±SD Non-Magnet 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 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 Intercept 1.530 0.040 37.775 .000 Individual-level predictors Experience 0.044 0.005 8.961 Education (BSN or higher) 0.088 0.014 6.374 Unit-level predictors 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 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?