‘Stop the pressure’, ‘Harm-free care’ and ‘Sign up to safety’ are just a few examples of evidence-based national quality improvement programmes that many of us have participated in as part of our harm-reduction programmes. The past 2 years have required our primary response to be focused on the pandemic. However, as we recover and reset our quality priorities, and there is more capacity to re-engage with our professional agenda of continuous improvement, I am concentrating on what one of my non-executive colleagues has termed ‘the stubborn indices’ of pressure damage, patient falls, and safety incidents relating to nutrition.
Having spent time with colleagues reviewing the root cause of local incidents, ‘omissions in care’ is an area that warrants further exploration. A primer from the Patient Safety Network (2019), the resource hosted by the US Agency for Healthcare Research and Quality, pointed out that although there is a well-established link between nurse staffing levels and some patient outcomes such as mortality and failure to rescue, there are other patient outcomes that are less well-understood. One proposed pathway is the amount of surveillance, or ongoing assessment and reassessment of patient condition, that can be provided under a given staffing structure. A related proposed pathway is missed nursing care, which is defined as ‘a subset of the category known as error of omission’ that refers to ‘needed nursing care that is delayed, partially completed, or not completed at all’ (Patient Safety Network, 2019)
Kalisch et al (2009) undertook a study with the aim of analysing the concept of missed nursing care. Their starting points were:
- Needed nursing care is sometimes omitted in everyday practice
- There are both errors of commission and omission
- Considerable attention has been paid to errors of commission, but little to errors of omission.
From their analysis, Kalisch et al (2009) developed a conceptual model of missed nursing care, identifying the factors or ‘antecedents’ and consequences that contribute to missed nursing care, namely labour resources, material resources and communication/teamwork. They reflected that when one or more of these factors is missing from an organisation or a particular shift, nurses need to prioritise their care activities and the stage is set for nursing care to be delayed or omitted. It is worth exploring these threats to patient care from Kalisch et al (2009) in a bit more detail.
Labour and material resources
Skill mix, care hours available and experience along with material resources (availability of necessary medications, supplies, and equipment) were felt to be factors. To take one of their examples: an inexperienced staff member may not recognise the importance of care left undone, they may not escalate to ensure that this care is ‘backed up’ by other team members, often when staff are overwhelmed, or team members ignore the one another's situation. It was also reflected that when the labour and material resources available conflict with the amount or timing of care to be provided, nurses must make choices or prioritise their work.
Communication and teamwork
Kalisch et al (2009) argued that the choice to complete, delay or omit items of patient care is influenced by four factors internal to a nurse, namely:
- Team norms: This refers to the way in which individuals operate concerning acceptable behaviour, and it may allow for a range of behaviours, including omissions of care, in order to conform and strengthen the sense of belonging to the team
- Decision-making processes: This is described within the context of balancing all other priorities of the shift, considering all demands on their time
- Internal values and beliefs: Individual nurses have internal values and beliefs about their roles as nurses, which influence their behaviour; even with external factors forcing them to make decisions about what care will be provided or omitted, personal values and beliefs may compel nurses to provide certain aspects of care, while deciding to omit others
- Habits: Perhaps the most worrying finding was that once care is missed, and there is no apparent detrimental effect on a patient, or no one notices, it is easier to decide to delay or omit that element of care the next time. It is suggested that these habits may become so deeply embedded, those nurses no longer make conscious decisions to omit the care. The pattern will simply continue with future patients, unless the omission is noticed and addressed in some way.
Gathering the available literature considering missed care has really encouraged me to research this area more extensively to enable a fuller exploration in my own organisation of the reasons that sit under the themes of omissions and what improvement interventions can be considered as part of our quality improvement programme.