Relationship between missed care and urinary tract infections in nursing homes

First-line managers´ perceptions of missed nursing care in community health care for older people-A phenomenographic study

INTRODUCTION

First-line managers in Swedish communities have responsibility for that care to older people is provided, staffing is sufficient and the budget is balanced in their unit. It is a struggle with limited resources due to a growing population in need of care. This can lead to missed nursing care. The aim was to describe first-line managers´ perceptions of missed nursing care in community health care for older people.

METHODS

A qualitative design with a phenomenographic approach, interviewing 24 first-line managers. Ethics approval for the study was received from the Research Ethics Committee at Karlstad University (Dnr HNT 2020/566).

RESULTS

The results are shown in six descriptive categories containing 15 perceptions. The descriptive categories are 'occurrence of missed nursing care', 'becoming aware of missed nursing care', 'reasons for missed nursing care', 'missed nursing care has consequences for the older persons', 'missed nursing care has consequences for the staff' and 'taking action to decrease missed nursing care'.

CONCLUSIONS

It is important for first-line managers to become aware of the existence and reasons for missed nursing, as it has consequences for older people and staff. Managers need to take missed nursing care seriously in order to work with improvements for maintaining good quality of care and patient safety.

Care quality and safety in long-term aged care settings: A systematic review and narrative analysis of missed care measurements

AIM

To critically evaluate missed care measurement approaches and their application in long-term aged care (LTAC) settings.

DESIGN

Systematic review using Tawfik's guideline.

DATA SOURCES

PubMed, Scopus, Web of Science, CINAHL and ProQuest were searched. Supplemental searching was from reference lists of retrieved records, first authors' ORCID homepages and Google advanced search for grey literature. Search limitations were English language, published between 1 January 2001 and 31 December 2022.

REVIEW METHOD

COVIDENCE was utilized for screening, data extraction and quality appraisal. JBI Critical Appraisal Tools and COSMIN Risk of Bias Tool were used for quality appraisal. Data were summarized and synthesized using narrative analysis.

RESULTS

Twenty-four publications across 11 regions were included, with two principal methods of missed care measurement: modified standard scales and tailored specific approaches. They were applied inconsistently and generated diverse measurement outcomes. There were challenges even with the most commonly used tool, the BERNCA-NH, including absence of high-quality verification through comparative analysis against an established 'gold standard', reliance on self-administration, incomplete assessment of constructs and inadequate exploration of psychometric properties.

CONCLUSION

Globally, there are deficiencies in the effectiveness and comprehensiveness of the instruments measuring missed care in LTAC settings. Further research on theoretical and practical perspectives is required.

IMPLICATIONS

Findings highlighted a critical need to establish a standardized, validated approach to measure missed care in LTAC settings. This review calls for collaborative efforts by researchers, clinical staff and policymakers to develop and implement evidence-based practices as a way of safeguarding the well-being of older clients living in LTAC settings.

IMPACT

Measurements of missed care in LTAC settings rely on adapting acute care tools. There is a critical gap in measuring missed care in LTAC settings. Developing a new tool could improve care quality and safety in LTAC settings globally.

REPORTING METHOD

Adhered to PRISMA guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Associations between nursing home care environment and unfinished nursing care explored. Secondary analysis of cross-sectional data

Understanding unfinished nursing care and its relationship with modifiable care environment factors is crucial for the service delivery to long-term frail patients. This secondary analysis aimed to explore the associations between characteristics of the care environment and unfinished nursing care, as reported by nursing care workers in Norwegian nursing homes. Of 931 respondents (37% response rate) from 66 nursing homes, six care environment characteristics correlated with at least two types of unfinished nursing care. Resources and Multidisciplinary collaboration showed a positive association with all four unfinished care categories. Input and acknowledgement, Professional, or Interpersonal leadership were not associated to unfinished care. In summary, our findings suggest that nursing care workers reporting positive care environment descriptions also reported lower frequencies of unfinished nursing care. This study offers insights crucial for human resource management which ultimately can be used to improve patient outcomes in nursing homes.

Prioritization decision-making of care in nursing homes: A qualitative study

BACKGROUND

Prioritization decision-making arises when nurses encounter intricate situations that demand ethically challenging judgments about care. This phenomenon has rarely been studied in nursing homes. Prioritization decision-making may lead to instances where individuals in social and healthcare may not receive all services they need. Making prioritization decisions and awareness of their consequences can increase nurses' workload.

AIM

To describe prioritization decision-making regarding unfinished nursing care in nursing homes.

RESEARCH DESIGN

A qualitative descriptive study conducted through individual theme interviews. Participants were recruited through social media. The data was analyzed using inductive content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Nurses (n = 23) working in nursing homes for the elderly people in Finland. Data were collected between June 2022 and February 2023.

ETHICAL CONSIDERATIONS

Finnish legislation does not mandate an ethical review or research permits, as the participants took part as private individuals. [ask authors to make reference here to informed consent process and anonymity].

FINDINGS

Nurses stated that the need for prioritization decision-making arises from challenges associated with nurses' engagement with person-centered care, the culture of the work community, the burden due to workload and challenges associated with the leadership. Prioritization decision-making was based on the interests of residents, striving for an efficient workflow and nurse's personal interests. Nurses did not receive support for decision-making regarding unfinished care, and protocols for prioritization had not been established in their work communities. Prioritization decision-making and unfinished care were concealed and left unspoken.

CONCLUSION

Nursing leaders should address this hidden phenomenon, making it visible through discussions with nurses and by involving them in the development of protocols. The findings can be utilized for developing new approaches to support nurses and reduce their workload and for enhancing the quality and person-centeredness of nursing care in nursing homes.

Flanders Nursing Home (FLANH) project: Protocol of a multicenter longitudinal observational study on staffing, work environment, rationing of care, and resident and care worker outcomes

BACKGROUND

While the demand for high quality of care in nursing homes is rising, it is becoming increasingly difficult to recruit and retain qualified care workers. To date, evidence regarding key organizational factors such as staffing, work environment, and rationing of care, and their relationship with resident and care worker outcomes in nursing homes is still scarce. Therefore, the Flanders Nursing Home (FLANH) project aims to comprehensively examine these relationships in order to contribute to the scientific knowledge base needed for optimal quality of care and workforce planning in nursing homes.

METHODS

FLANH is a multicenter longitudinal observational study in Flemish nursing homes based on survey and registry data that will be collected in 2023 and 2025. Nursing home characteristics and staffing variables will be collected through a management survey, while work environment variables, rationing of care, and care worker characteristics and outcomes will be collected through a care worker survey. Resident characteristics and outcomes will be retrieved from the Belgian Resident Assessment Instrument for long-Term Care Facilities (BelRAI LTCF) database. Multilevel regression analyses will be applied to examine the relationships between staffing variables, work environment variables, and rationing of care and resident and care worker outcomes.

CONCLUSION

This study will contribute to a comprehensive understanding of the nursing home context and the interrelated factors influencing residents and care workers. The findings will inform the decision-making of nursing home managers and policymakers, and evidence-based strategies to optimize quality of care and workforce planning in nursing homes.

Accuracy of infection reporting in US nursing home ratings

OBJECTIVE

To assess the accuracy of nursing home-reported data on urinary tract infections (UTIs), which are publicly reported on Nursing Home Care Compare, and pneumonia, which are not publicly reported.

DATA SOURCES AND STUDY SETTING

We used secondary data for 100% of Medicare fee-for-service beneficiaries in the United States between 2011 and 2017.

STUDY DESIGN

We identified Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017 and admitted to a hospital with a primary diagnosis of UTI or pneumonia. After linking these hospital claims to resident-level nursing home-reported assessment data in the Minimum Data Set, we calculated the percentages of infections that were appropriately reported and assessed variation by resident- and nursing home-level characteristics. We developed a claims-based nursing home-level measure of hospitalized infections and estimated correlations between this and publicly reported ratings.

DATA EXTRACTION METHODS

Medicare fee-for-service beneficiaries who were nursing home residents and hospitalized for UTI or pneumonia during the study period were included.

PRINCIPAL FINDINGS

Reporting rates were low for both infections (UTI: short-stay residents 29.1% and long-stay residents 19.2%; pneumonia: short-stay residents 66.0% and long-stay residents 70.6%). UTI reporting rates increased when counting additional assessments, but it is unclear whether these reports are for the same versus a newly developed UTI. Black residents had slightly lower reporting rates, as did nursing homes with more Black residents. Correlations between our claims-based measure and publicly reported ratings were poor.

CONCLUSIONS

UTI and pneumonia were substantially underreported in data used for national public reporting. Alternative approaches are needed to improve surveillance of nursing home quality.

Unfinished nursing care in nursing homes

This study aimed to describe unfinished nursing care activities in nursing homes. The study was conducted as a cross-sectional survey and employed the BERNCA-NH-instrument and one open-ended question. The participants were care workers (n=486) in nursing homes. The results showed that an average of 7.3 nursing care activities out of 20 were unfinished. A large share of the unfinished activities were related to residents' social care and the documentation of care. Female gender, age, and the amount of professional experience were found to increase the likelihood of unfinished nursing care. The unfinished care was the result of insufficient resources, residents' characteristics, unexpected situations, non-nursing activities, and challenges in organizing and leading care. The results indicate that all of the necessary care activities are not performed in nursing homes. Unfinished nursing activities might affect residents' quality of life and diminish the visibility of nursing care. Nursing home leaders have a significant role to play in decreasing unfinished care. Future research should address how to reduce and prevent unfinished nursing care.

Consequences of Nurse Presenteeism in Switzerland and Portugal and Strategies to Minimize It: A Qualitative Study

Nurses exhibit higher rates of presenteeism than other professionals, with consequences for the quality of care and patient safety. However, nurses’ perceptions of these issues have been poorly explored. This study investigated the perceptions and experiences of frontline nurses and nurse managers in Switzerland and Portugal about the consequences of presenteeism and strategies to minimize it in different healthcare settings. Our qualitative study design used video focus groups involving 55 participants from both countries. Thematic analysis of their transcribed discussions revealed six themes surrounding the consequences of presenteeism: the personal impact on nurses’ health and wellbeing, on their family relationships, and on professional frustration and dissatisfaction; the professional impact on work dynamics; the social impact on the quality of care and patient safety and on society’s impressions of the profession. At the individual, collective, and institutional levels, six strategies were evoked to minimize presenteeism: encouraging professionals’ self-knowledge; creating a positive work atmosphere; facilitating communication channels; developing a positive organizational culture; implementing preventive/curative institutional interventions; identifying and documenting situations linked to presenteeism. Nurses’ perceptions and experiences provided a deeper understanding of their presenteeism and revealed underused pathways toward preventing and minimizing presenteeism via bottom-up approaches.

Factors Associated With Missed Nursing Care in Nursing Homes: A Multicentre Cross-sectional Study

BACKGROUND

Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care.

METHODS

In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs' judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner.

RESULTS

Younger RNs (P=.026), freelance RNs (P=.046), RNs with a permanent contract (P=.035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P<.012). Public ownership (odds ratio [OR]=9.88; 95% CI 2.22-44.03; P=.003), a higher proportion of residents with severe clinical conditions (OR=2.45; 95% CI 1.12-5.37; P=.025), a lower proportion of RNs (OR=2.24; 95% CI 1.10-4.54; P=.026), and perceived lack of time to care for residents (OR=2.33; 95% CI 1.04-5.26; P=.041) were statistically significantly associated with missed nursing care.

CONCLUSION

Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.

Increasing implicit rationing of care in nursing homes: A time-series cross-sectional analysis

BACKGROUND

Implicit rationing of nursing care is a socio-ecological problem where care workers, due to lack of resources, have to leave necessary nursing care activities undone. Cross-sectional studies on implicit rationing of nursing home care revealed associations with organizational and work environment characteristics. However, little is known on how implicit rationing of nursing care varies over time in nursing homes.

OBJECTIVE

This study's purpose was to describe changes in levels and patterns of implicit rationing of nursing care in Swiss nursing homes over time, while accounting for key explanatory factors related to organizational, work environment, and individual characteristics.

DESIGN

Time-series cross-sectional analysis.

SETTING

Nursing homes in Switzerland.

PARTICIPANTS

A convenience sample of 47 nursing homes and 3269 care workers from all educational levels participating in two multicenter cross-sectional studies (the Swiss Nursing Home Human Resources Project) conducted in 2013 and 2018.

METHODS

To quantify implicit rationing of nursing care, care workers' data were collected via the nursing home version of the Basel Extent of Rationing of Nursing Care instrument. To control for leadership ability, staffing and resource adequacy, we used the Nursing Work Index-Practice Environment Scale. Objective measures including turnover, staffing and skill mix levels were aggregated at the nursing home level. Our analyses included multiple linear mixed models, using time as a fixed effect and nursing home as a random effect.

RESULTS

We found overall increases of rationing of care activities over the five-year period studied, with documentation and social activities most rationed at both measurement points (overall coefficients varied between 0.11 and 0.23, as well as the 95%-confidence intervals between 0.05 and 0.30). Moreover, a considerable increase in rationing of activities of daily living (coefficient of 0.47 in 2013 and 0.63 in 2018) was observed.

CONCLUSIONS

Alongside long-term deterioration of staff resources, increases in rationing of nursing care are a worrying development, particularly given their potential negative impacts both on residents and on care workers. To assess nursing home care quality and to determine adequate staffing levels and skill mixes, policy makers and nursing home managers should consider regular monitoring of rationing of nursing care.

TWEETABLE ABSTRACT

Time-series cross-sectional analysis reveals increasing rationing of nursing care activities in Swiss nursing homes from 2013 to 2018.

Prevalence, type, and reasons for missed nursing care in municipality health care in Sweden – A cross sectional study

Background

With an ageing population, there is an increasing need for care, both as home care and in nursing homes. However, some needed care is not carried out for different reasons, which can affect patient safety. The aim of the study was to describe prevalence, type, and reasons for missed nursing care in home care and nursing homes, from nurses’ perspective.

Methods

A cross sectional design with quantitative and qualitative approach. A Swedish version of Basel Extent of Rationing of Nursing Care for nursing homes and 15 study specific questions were answered by 624 registered nurses, enrolled nurses, or nurse assistants. Both descriptive and analytical, independent-samples t-test, analyses were used. Qualitative content analysis was used for the open-ended question.

Results

The care activity most often missed in home care was: ‘set up or update care plans’ (41.8%), and in nursing homes: ‘scheduled group activity’ (22.8%). Reasons for missed nursing care were lack of preparedness for unexpected situations, obstacles in a deficient work environment, unsatisfactory planning in the organisation, and/or shortcomings related to the individual.

Conclusion

Not all care activities needed are performed, due to reasons such as lack of time or organisational issues. Missed nursing care can lead to adverse events and affect patient safety. It is important to be aware of missed nursing care and the reasons for it, which gives a possibility to initiate quality improvement work to ensure patient safety.

The short-term effect of a modified comprehensive geriatric assessment and regularly case conferencing on neuropsychiatric symptoms in nursing homes: a cluster randomized trial

Aims

To investigate the short-term effect of implementing a modified comprehensive geriatric assessment and regularly case conferencing in nursing homes on neuropsychiatric symptoms.

Background

Neuropsychiatric symptoms are common and may persist over time in nursing home residents. Evidence of effective interventions is scarce.

Design

A parallel cluster-randomised controlled trial.

Methods

The intervention was monthly standardised case conferencing in combination with a modified comprehensive geriatric assessment. The control group received care as usual.

Main outcome measure.

The total score on the short version of the Neuropsychiatric Inventory (NPI-Q, 12-items).

Results

A total of 309 residents at 34 long-term care wards in 17 nursing homes (unit of randomisation) were included. The intervention care units conducted on average two case conference-meetings (range 1–3), discussing a mean of 4.8 (range 1–8) residents. After 3 months, there were no difference of NPI-Q total score between the intervention (-0.4) and the control group (0.5) (estimated mean difference = -1.0, 95% CI -2.4 to 0.5, p = 0.19). There was a difference in favour of the intervention group on one of the secondary outcome measures, the apathy symptoms (-0.5 95% CI: -0.9 to -0.1, p = 0.03).

Conclusion

In this study there were no short-term effect of case conferencing and modified comprehensive geriatric assessments after three months on the total score on neuropsychiatric symptoms. The intervention group had less apathy at 3 months follow-up compared to those receiving care as usual. The findings suggest that a more comprehensive intervention is needed to improve the total Neuropsychiatric symptoms burden and complex symptoms.

Trial registration

Due to delays in the organisation, the study was registered after study start, i.e. retrospectively in Clinicaltrials.gov # NCT02790372 at https://clinicaltrials.gov/; Date of clinical trial registration: 03/06/2016.

Work interruptions and missed nursing care: A necessary evil or an opportunity? The role of nurses' sense of controllability

AIM

To explore nurses' experiences with work interruptions (WIs) through the lens of missed nursing care (MNC).

DESIGN

A qualitative descriptive design.

METHODS

Eleven small focus groups involving 34 nurses (three nurses per group on average) from acute-care hospital wards were conducted. Nurses shared their experiences with WIs (sources, reactions and decisions) from the MNC perspective. Data analysis was conducted via content analysis.

RESULTS

A preponderant theme emerged-the dynamic of controllability. Nurses who perceived a sense of controllability felt that they could decide whether to accept or reject the WI, regardless of WI type, and emotions of anger emerged. Conversely, nurses who did not perceive sense of controllability attended the secondary task: MNC occurred, and distress emotions emerged. Results emphasized that nurses are active agents prioritizing whether to omit or complete care in the face of WIs. Controllability, accompanied by active negative emotions, perpetuate a prioritization process that makes it less probable that MNC occurs.

Missed Nursing Care in a Sample of High-Dependency Italian Nursing Home Residents: Description of Nursing Care in Action

OBJECTIVE

The aim of the study was to describe omitted or delayed nursing care (i.e., missed nursing care [MNC]) in a sample of Italian nursing homes (NHs).

METHODS

Nurses from 50 NHs located in Northern Italy selected the 20 most dependent residents in their care and reported instances of MNC for three to five consecutive shifts. They described the type of MNC, its cause(s), management, recurrence, and severity of possible consequences for the resident. Information on the residents and the NH was also collected. The instances of MNC were classified as potentially avoidable/preventable or not.

RESULTS

Overall, 266 (85.3%) of 312 nurses participated and 1000 residents were observed during 381 shifts (164 mornings, 164 afternoons, and 53 nights); 101 (38%) nurses reported 223 instances of MNC among 175 residents (17.5%). Ninety-seven omissions and 109 delays occurred during the day shift (56 omissions were delegated to the next shift). The most frequent MNC was drug administration (n = 71, 34.5%). In 24 (44.4%) of 54 instances of delayed drug administration, the delay was less than 30 minutes. Nurses rated approximately 20% of MNC (n = 41) as highly severe because of the discomfort caused to the resident, the clinical impact, or the repetitiveness of the situation. Nurses ascribed almost half of MNC (n = 100, 48.5%) to inadequate staffing, and they categorized 26 (11.6%) instances of MNC as unavoidable.

CONCLUSIONS

The number of nurse-reported instances of MNC we reported was much lower than that previously collected with available instruments. Most MNC did not impact the comfort and safety of residents. A certain proportion of MNC was unavoidable.

Staffing, teamwork and scope of practice: Analysis of the association with patient safety in the context of rehabilitation

Aims

To describe the organization of nursing services (staffing, scope of practice, teamwork) and its association with medication errors and falls, in rehabilitation units.

Background

The healthcare system is greatly impacted by the ageing population and the complexity of care associated with chronic diseases. It is therefore necessary to have enough staff who are using their full scope of practice and who are operating in a favourable working environment. However, these conditions are not always met, which can lead to threats to patient safety.

Design

A correlational descriptive study.

Methods

Staffing data and reported safety incidents were collected by shift from 01 October 2019 until 15 January 2020 in five rehabilitation units. In addition, a total of 75 nursing staff members responded to a missed care and teamwork survey. Descriptive analysis and logistic regression analysis were performed.

Results

The mean staff hours per patient shift was 1.39 (SD = 0.60). The teams reported a global missed care score as ‘rarely missed’ at 1.14 (SD = 0.07) and a moderate teamwork score at 3.36 (SD = 0.58) on a five‐point scale. The safety incidents decreased 10‐fold with a predominance of bachelor compared with technician nurses and decreased by 67% when there was an increase of 1 h of care per patient shift.

Conclusions

This study showed that the organization of nursing services in the observed rehabilitation units is characterized by a moderate staffing intensity, a moderate perception of teamwork level and a relatively low level of missed care. It indicated the key role of the staffing in reducing the risk of occurrence of safety incidents. Future research specific to rehabilitation hospitals are greatly needed to improve patient outcomes in this setting.

Impact

Nurse Managers should consider all the aspects of the organization of nursing services (staffing, scope of practice and teamwork) in their efforts to improve patient safety in rehabilitation settings. A central finding of this study is that the staffing intensity, the proportion of bachelor prepared nurses and the proportion of agency staff were positively associated with a reduction of safety incidents.

Residents' and Relatives' Experiences of Acute Situations: A Qualitative Study to Inform a Care Model

Background and Objectives

As new models of care aiming to reduce hospitalizations from nursing homes emerge, their implementers must consider residents’ and relatives’ needs and experiences with acute changes in the residents’ health situations. As part of the larger INTERCARE implementation study, we explored these persons’ experiences of acute situations in Swiss nursing homes.

Research Design and Methods

3 focus groups were conducted with residents and their relatives and analyzed via reflexive thematic analysis.

Results

The first theme, the orchestra plays its standards, describes experiences of structured everyday care in nursing homes, which functions well despite limited professional and competency resources. The second theme, the orchestra reaches its limits, illustrates accounts of acute situations in which resources were insufficient to meet residents’ needs. Interestingly, participants’ perceptions of acute situations went well beyond our own professional view, that is, changes in health situations, and included situations best summarized as “changes that might have negative consequences for residents if not handled adequately by care workers.” Within the third theme, the audience compensates for the orchestra’s limitations, participants’ strategies to cope with resource limitations in acute situations are summarized.

Discussion and Implications

Our findings suggest differences between care providers’ and participants’ perspectives regarding acute situations and care priority setting. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning and meeting individual residents’ and relatives’ needs. Implications for the development and implementation of a new nurse-led model of care are discussed.

Factors associated with urinary tract infection in a Nursing Home

OBJECTIVE

to analyze the factors associated with urinary tract infection occurrence in institutionalized elderly.

METHODS

this is a cross-sectional, analytical, quantitative study with 116 elderly people from a Nursing Home. Urinary tract infection diagnosis was carried out through urine culture and clinical assessment. Demographic data and associated factors were obtained from medical records. Statistical analysis included bivariate analysis and logistic regression models.

RESULTS

the factors associated with urinary tract infection (p<0.05) were being female; wheelchair user; diaper use; diuretic use; urinary and bowel incontinence; type 1 diabetes; benign prostatic hyperplasia; dehydration.

CONCLUSION

this study revealed that it is important to consider non-modifiable factors such as sex and clinical comorbidities; however, dehydration, a modifiable factor, increased the chances of developing urinary tract infections by 40 times among institutionalized elderly and demands greater attention from the health team.

The impact of "missed nursing care" or "care not done" on adults in health care: A rapid review for the Consensus Development Project

Aim

To identify outcomes of missed nursing care for adult patients.

Design

A five‐stage rapid review process was conducted as follows: refining the question, retrieving relevant studies, determining the studies to be included, organizing the data and synthesizing the results.

Methods

Papers published between 2010–2020 that focused on the UK, Europe, the USA and Oceania were searched for keywords in the title and abstract in major databases. The articles that identified the impact of missed nursing care on adults in health care were selected.

Results

Seventeen articles met the criteria. Major impacts of missed care in adult settings were increases in mortality, adverse events and failure to maintain. These same studies also identified a range of causative factors linked to ward environment, inadequate staffing levels and skills mix although are inconclusive. Solutions include continuing education, ward and work re‐design, and appropriate skill level.

Systematic review of missed nursing care or nursing care left undone

Comprehensive nursing cares are important to provide total healthcare for the patient. However, there are miss nursing cares that nurses left to be done. This research is aim to discover the varieties of missed nursing care and to understand their possible impacts on nurses and patients. A systematic review was utilized. Data were collected from six databases: ScienceDirect, ProQuest, Scopus, SAGE, PubMed, and Wiley, from 2015 to 2019. Search results from the six databases (n=2934) sorted into 18 collected articles emphasized on three categories: missed nursing care, influencing factors, and impact of nursing care. The factors of missed nursing care are nurses' perception on patient safety, self-accountability, etc. The possible effects are patient and nurse satisfactions decline, and cost swell. Planning, intervention, and documentation are notoriously often missed by nurses. The reasons behind this issue are nurses' characteristics, HR problems, communication, workspace, and manager influence. These will have a great impact on patient satisfaction and nurse job satisfaction. Therefore, the role of nursing managers is large in improving missed nursing care.

A scoping review-Missed nursing care in community healthcare contexts and how it is measured

Aim

To examine the extent and nature of missed nursing care in elderly care in community healthcare contexts from the perspective of healthcare staff, and to identify instruments used to measure missed nursing care and the content of these instruments.

Design

Scoping review.

Methods

Searches were conducted in the CINAHL, PubMed, Scopus and Google Scholar databases in March 2020. The selection process followed the PRISMA flow diagram.

Results

Sixteen research papers were found from nine countries. The instruments used in the studies were Basel Extent of Rationing of Nursing Care for nursing homes (BERNCA‐NH), modified MISSCARE survey and study‐specific instruments or items. The item content differed, as did the number of items, which was between one and 44. The studies reported values for missed nursing care, as well as described reasons for and/or the relation between missed nursing care and organization, working climate and patient outcomes.

Unfinished Care in Residential Aged Care Facilities: An Integrative Review

BACKGROUND AND OBJECTIVES

When workload demands are greater than available time and resources, staff members must prioritize care by degree of importance and urgency. Care tasks assigned a lower priority may be missed, rationed, or delayed; collectively referred to as "unfinished care." Residential aged care facilities (RACFs) are susceptible to unfinished care due to consumers' complex needs, workforce composition, and constraints placed on resource availability. The objectives of this integrative review were to investigate the current state of knowledge of unfinished care in RACFs and to identify knowledge gaps.

RESEARCH DESIGN AND METHODS

We conducted a search of academic databases and included English-language, peer-reviewed, empirical journal articles that discussed unfinished care in RACFs. Data were synthesized using mind mapping techniques and frequency counts, resulting in two categorization frameworks.

RESULTS

We identified 17 core studies and 27 informing studies (n = 44). Across core studies, 32 types of unfinished care were organized under five categories: personal care, mobility, person-centeredness, medical and health care, and general care processes. We classified 50 factors associated with unfinished care under seven categories: staff member characteristics, staff member well-being, resident characteristics, interactions, resources, the work environment, and delivery of care activities.

DISCUSSION AND IMPLICATIONS

This review signifies that unfinished care in RACFs is a diverse concept in terms of types of unfinished care, associated factors, and terminology. Our findings suggest that policymakers and providers could reduce unfinished care by focusing on modifiable factors such as staffing levels. Four key knowledge gaps were identified to direct future research.

Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation: Multicenter Cross-sectional Survey Study

BACKGROUND

Nursing homes (NHs) are increasingly implementing electronic health records (EHRs); however, little information is available on EHR use in NH settings. It remains unclear how care workers perceive its safety, quality, and efficiency, and whether EHR use might ease the burden of documentation, thereby reducing its implicit rationing.

OBJECTIVE

This study aims to describe nurses' perceptions regarding the usefulness of the EHR system and whether sufficient numbers of computers are available in Swiss NHs, and to explore the system's association with implicit rationing of nursing care documentation.

METHODS

This was a multicenter cross-sectional study using survey data from the Swiss Nursing Homes Human Resources Project 2018. It includes a convenience sample of 107 NHs, 302 care units, and 1975 care workers (ie, registered nurses and licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the level of implicit rationing of nursing care documentation, their perceptions of the EHR system's usefulness and of how sufficient the number of available computers was, staffing and resource adequacy, leadership ability, and teamwork and safety climate. For analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, the care workers perceived the EHR systems as useful; ratings ranged from 69.42% (1362/1962; guarantees safe care and treatment) to 78.32% (1535/1960; allows quick access to relevant information on the residents). However, less than half (914/1961, 46.61%) of the care workers reported sufficient computers on their unit to allow timely documentation. Half of the care workers responded that they sometimes or often had to ration the documentation of care. After adjusting for work environment factors and safety and teamwork climate, both higher care worker ratings of the EHR system's usefulness (β=-.12; 95% CI -0.17 to -0.06) and sufficient numbers of computers (β=-.09; 95% CI -0.12 to -0.06) were consistently associated with lower implicit rationing of nursing care documentation.

CONCLUSIONS

Both the usefulness of the EHR system and the number of computers available were important explanatory factors for care workers leaving care activities (eg, developing or updating nursing care plans) unfinished. NH managers should carefully select and implement their information technology infrastructure with greater involvement and attention to the needs of their care workers and residents. Further research is needed to develop and implement user-friendly information technology infrastructure in NHs and to evaluate their impact on care processes as well as resident and care worker outcomes.

Unmet care needs of older people: A scoping review

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O'Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals' experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients' expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.

The Effect of Virtual Nursing and Missed Nursing Care

This article describes the impact of a Virtually Integrated Care team on missed nursing care as defined by the MISSCARE survey. This multisite project reported that the most common missed cares and reasons for missed cares were consistent with other reported results in earlier literature. However, when evaluating missed cares that were directly impacted by the virtual nurses' roles and responsibilities, 1 of the 2 sites demonstrated a decrease in missed nursing care during the project. The virtual nurses with in the team were constantly monitoring care, and even though the second site did not demonstrate a similar finding, the authors felt it was due to the virtual nurses bringing a heightened awareness of missed cares to the team.

The consistency between planned and actually given nursing care in long-terminstitutional care

Continuous information exchange between healthcare professionals is facilitated by individualized care plans. Compliance with the planned care as documented in care plans is important to provide person-centered care which contributes to the continuity of care and quality of care outcomes. Using the Nursing Interventions Classification, this study examined the consistency between documented and actually provided interventions by type of nursing staff with 150 residents in long-term institutional care. The consistency was especially high for basic (93%) and complex (79%) physiological care. To a lesser extent for interventions in the behavioral domain (66%). Except for the safety domain, the probability that documented interventions were provided was high for all domains (≥ 91%, p > 0.05). NAs generally provided the interventions as documented. Findings suggest that HCAs worked beyond there scope of practice. The results may have implications for the deployment of nursing staff and are of importance to managers.

Nursing care left undone in community settings: Results from a UK cross-sectional survey

AIM

To demonstrate the prevalence of care left undone and its relationship to registered nurse staffing levels within community nursing.

BACKGROUND

Much research has been completed on nursing care left undone in the acute sector. Little has been done in the community nursing context.

METHOD

Secondary analysis from a cross-sectional survey of 3,009 registered nurses working in the community and care home sector was completed. Measures reported are 'care left undone', 'nurse staffing levels' and 'type of shift'.

RESULTS

Only 37% of community respondents, and 81% of care home staff, reported having the planned number of nurses on their last shift. Prevalence of care left undone was 34% in the community sector, 33% in the care home sector and 23% in primary care. Care left undone increased as the proportion of registered nurses fell below planned numbers.

CONCLUSION

Care left undone is a significant issue across the community nursing context and is related to registered nurse staffing levels.

IMPLICATIONS FOR NURSING MANAGEMENT

This work is the first to look directly at the relationship of registered nurse staffing levels to care left undone in the community. Current policy on safe staffing needs to ensure consideration of the community nursing context.

Adaptation, modification, and psychometric assessment of a Norwegian version of the Basel extent of rationing of nursing care for nursing homes instrument (BERNCA-NH)

Background

To our knowledge, no instrument has been developed and tested for measuring unfinished care in Norwegian nursing home settings. The Basel Extent of Rationing of Nursing Care for Nursing Homes instrument (BERNCA-NH) was developed and validated in Switzerland to measure the extent of implicit rationing of nursing care in nursing homes. The BERNCA-NH comprises a list of nursing care activities in which a care worker reports the frequency to which activities were left unfinished over the last 7 working days as a result of lack of time. The aim of this study was to adapt and modify a Norwegian version of the BERNCA-NH intended for all care workers, and assess the instruments’ psychometric properties in a Norwegian nursing home setting.

Methods

The BERNCA-NH was translated into Norwegian and modified to fit the Norwegian setting with inputs from individual cognitive interviews with informants from the target population. The instrument was then tested in a web-based survey with a final sample of 931 care workers in 162 nursing home units in different parts of Norway. The psychometric evaluation included score distribution, response completeness and confirmatory factor analysis (CFA) of a hypothesised factor structure and evaluation of internal consistency. Hypothesised relation to other variables was assessed through correlations between the subscale scores and three global ratings.

Results

The Norwegian version of BERNCA-NH comprised four subscales labelled: routine care, ‘when required’ care, documentation and psychosocial care. All subscales demonstrated good internal consistency. The CFA supported the four-factor structure with fit statistics indicating a robust model. There were moderate to strong bivariate associations between the BERNCA-NH subscales and the three global ratings. Three items which were not relevant for all care workers were not included in the subscales and treated as single items.

Conclusions

This study found good psychometric properties of the Norwegian version BERNCA-NH, assessed in a sample of care workers in Norwegian nursing homes. The results indicate that the instrument can be used to measure unfinished care in similar settings.

Registered Nurse Burnout, Job Dissatisfaction, and Missed Care in Nursing Homes

OBJECTIVES

To examine the relationship between registered nurse (RN) burnout, job dissatisfaction, and missed care in nursing homes.

DESIGN

Cross-sectional secondary analysis of linked data from the 2015 RN4CAST-US nurse survey and LTCfocus.

SETTING

A total of 540 Medicare- and Medicaid-certified nursing homes in California, Florida, New Jersey, and Pennsylvania.

PARTICIPANTS

A total of 687 direct care RNs.

MEASUREMENTS

Emotional Exhaustion subscale of the Maslach Burnout Inventory, job dissatisfaction, and missed care.

RESULTS

Across all RNs, 30% exhibited high levels of burnout, 31% were dissatisfied with their job, and 72% reported missing one or more necessary care tasks on their last shift due to lack of time or resources. One in five RNs reported frequently being unable to complete necessary patient care. Controlling for RN and nursing home characteristics, RNs with burnout were five times more likely to leave necessary care undone (odds ratio [OR] = 4.97; 95% confidence interval [CI] = 2.56-9.66) than RNs without burnout. RNs who were dissatisfied were 2.6 times more likely to leave necessary care undone (OR = 2.56; 95% CI = 1.68-3.91) than RNs who were satisfied. Tasks most often left undone were comforting/talking with patients, providing adequate patient surveillance, patient/family teaching, and care planning.

CONCLUSION

Missed nursing care due to inadequate time or resources is common in nursing homes and is associated with RN burnout and job dissatisfaction. Improved work environments with sufficient staff hold promise for improving care and nurse retention. J Am Geriatr Soc 67:2065-2071, 2019.

Cognitive and Initial Psychometric Testing of the Errors of Care Omission Survey: A New Patient Safety Tool for Primary Care

BACKGROUND AND PURPOSE

Most patient safety studies focus on errors of commission rather than on errors of omission. No tools measure errors of omission in primary care. We developed the Errors of Care Omission Survey (ECOS) and present its cognitive and psychometric testing.

METHODS

Twenty-six primary care providers (PCPs) participated in cognitive interviews, which were audiotaped, transcribed, and analyzed. ECOS was also pilot tested with 37 PCPs. Item analysis and reliability testing w conducted.

RESULTS

Interviewees agreed that ECOS measures errors of omission and items were clear. The response categories were revised. All items were correlated and subscales had high internal consistency reliability.

CONCLUSIONS

ECOS can measure errors of omission in primary care.

The effect of a teamwork intervention on staff perception of teamwork and patient care on a medical surgical unit

As a result of the ever-changing health care environment and patient complexity, it is difficult for nursing teams to provide safe quality care and complete all tasks, also known as missed nursing care. Missed nursing care is a global health care issue and defined as any aspect of care missed in part, in whole, or delayed. Teamwork has been found to not only positively impact the performance of a team, but also patient outcomes. Teamwork strategies are needed to help nursing teams provide the best care to their patients. Inpatient nursing teams work in complex environments and handle many patient issues making it difficult to find one workable solution. The purpose of this study was to determine if a teamwork intervention would impact the nursing team's perception of teamwork and missed nursing care on a medical surgical unit. In this quasi-experimental design study there was an increase in both teamwork and missed nursing care pretest and posttest survey scores. Despite the increase not being statistically significant, based on the staff feedback, the intervention shows promise to be a viable teamwork strategy. Future studies should include larger sample size and longer duration.

Nurses' and Care Workers' Perception of Care Quality in Japanese Long-Term Care Wards: A Qualitative Descriptive Study

Despite the growing importance of long-term care for older adults, there has been limited attention to its quality assurance issues in Japan. To start planning the initiation of continuous quality improvement in long-term care hospitals, we explored how nurses and care workers themselves perceived current approaches to quality assurance and improvement on their ward. We interviewed 16 licensed nurses and nine care workers, transcribed and analyzed data using qualitative content analysis techniques, and derived six categories: keeping clients alive is barely possible, the absence of a long-term care practice model, the lack of quality indicators, long-term care hospitals as places for castaways, client quality of life as a source of satisfaction, and conflict between staff and client well-being. To develop continuous quality improvement in Japanese long-term care hospitals, it may be first necessary to introduce a practice model of long-term care and mechanisms to evaluate quality.

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Background

Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism.

Objectives

This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship.

Design

Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors.

Setting and participants

A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015.

Main outcomes

Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations.

Data sources

Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations.

Results

Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays.

Limitations

This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life.

Conclusions

Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety.

Future work

More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration.

Trial registration

This study is registered as ISRCTN17930973.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.

Description and Factors Associated With Missed Nursing Care in an Acute Care Community Hospital

OBJECTIVE

The aims of this study are to describe and evaluate the factors associated with missed nursing care in an acute care community hospital.

BACKGROUND

Despite RNs' accountability for high-quality patient care in hospitals, missed nursing care is widespread, jeopardizing patient safety and health system costs. Better understanding of the factors associated with missed nursing care may provide nurse leaders with opportunities for improvement.

METHODS

Using a cross-sectional correlational study design, 138 RNs were randomly sampled during May-June 2017.

RESULTS

The extent of missed nursing care is consistent with other studies, was greater on medical-surgical and telemetry units compared with specialty units, and was negatively associated with staffing/resources, satisfaction with current position, and collegial nurse-physician relationships.

CONCLUSION

Findings suggest urgent nurse leader action and future research.

Does Missed Care in Isolated Rural Hospitals Matter?

Missed care is associated with adverse outcomes such as patient falls and decreased nurse job satisfaction. Although studied in populations of interest such as neonates, children, and heart failure patients, there are no studies about missed care in rural hospitals. Reducing care omissions in rural hospitals might help improve rural patient outcomes and ensure that rural hospitals can remain open in an era of hospital reimbursement dependent on care outcomes, such as through value-based purchasing. Understanding the extent of missed nursing care and its implications for rural populations might provide crucial information to alert rural hospital administrators and nurses about the incidence and influence of missed care on health outcomes. Focusing on missed care within rural hospitals and other rural health care settings is important to address the specific health needs of aging rural U.S. residents who are isolated from high-volume, urban health care facilities.

What impact does nursing care left undone have on patient outcomes? Review of the literature

Aims and objectives

Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes.

Background

A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear.

Design

Systematic review.

Methods

We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses’ aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review.

Results

Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged.

Conclusions

The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self‐reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required.

Relevance to clinical practice

Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses’ reports of missed care and consider routine monitoring as a quality and safety indicator.

Evidence on the validity and reliability of the German, French and Italian nursing home version of the Basel Extent of Rationing of Nursing Care instrument

AIM

To develop and test psychometrically the Basel Extent of Rationing of Nursing Care for Nursing Homes instrument, providing initial evidence on the validity and reliability of the German, French and Italian-language versions.

BACKGROUND

In the hospital setting, implicit rationing of nursing care is defined as the withholding of nursing activities due to lack of resources, such as staffing or time. No instrument existed to measure this concept in nursing homes.

DESIGN

Cross-sectional study.

METHODS

We developed the instrument in three phases: (1) adaption and translation; (2) content validity testing; and (3) initial validity and reliability testing. For phase 3, we analysed survey data from 4748 care workers collected between May 2012-April 2013 from a randomly selected sample of 162 nursing homes in the German-, French- and Italian-speaking regions of Switzerland to provide evidence from response processes (e.g. missing), internal structure (exploratory factor analysis), inter-item inconsistencies (e.g. Cronbach's alpha) and interscorer differences (e.g. within-group agreement).

RESULTS

Exploratory factor analysis revealed a four-factor structure with good fit statistics. Rationing of nursing care was structured in four domains: (1) activities of daily living; (2) caring, rehabilitation and monitoring; (3) documentation; and (4) social care. Items of the social care subscale showed lower content validity and more missing values than items of other subscales.

CONCLUSION

First evidence indicates that the new instrument can be recommended for research and practice to measure implicit rationing of nursing care in nursing homes. Further refinements of single items are needed.