1. 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

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

5. PREVIOUS STUDIES

6. Missed Care: A Qualitative Study
Kalisch B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21:4;

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),

9. 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)

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

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

18. Overall Reasons for Missed Care

19. CONCEPTUAL FRAMEWORK

20. 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

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
Variable
Magnet
Mean±SD
Non-Magnet t p
Overall Missed Nursing Care
1.50±.21
1.57±.15
2.20
.03

28. 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

29. 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

30. 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

31. 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

32. 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.

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 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

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?