Missed nursing care, low value activities and cultures of busyness
Debra Jackson
Abstract
Nurses hold an important role in society and an essential role in healthcare delivery. Nurses are a trusted workforce-it is nurses who people rely on when they are sick, injured, incapacitated and when seeking various forms of health care. As nurses, we know the value and vital importance of skilled, empathic nursing and of strong nurse advocacy for patients, families and communities. In most settings, nursing services are funded by the public purse (sometimes with the additional contribution of those in receipt of services). Members of the public often fund these services through the taxation system and want to believe that quality and skilled nursing care will be available to them, if they or a family member become ill, incapacitated or injured, or find themselves in any situation in which health care is needed. However, there is increasing and compelling evidence that many patients experience missed nursing care. Since Kalischs's (2006) seminal work, missed care has become a growing area of interest to researchers, and research findings show that missed care is widespread in many settings, including hospitals (Ball et al., 2016) and community settings (Phelan et al., 2018) and affects patients across the lifespan, including neonates and children (Bagnasco et al., 2019; Tubbs-Cooley et al., 2015). In a concept analysis, Kalisch et al. (2009, p. 1509) defined missed nursing care as ‘any aspect of required patient care that is omitted (either in part or in whole) or delayed’. These authors linked missed care to patient safety and positioned missed care as an error of omission. Missed care occurs much more frequently than we might think. A systematic review reported that ‘care left undone on the last shift ranged from 75% in England, to 93% in Germany, with an overall estimate of 88% across 12 European countries’ (Griffiths et al., 2018, p. 1475). This review also provides important and detailed information on the nature of missed nursing care and shows that all manner of care is liable to being missed, including personal hygiene, skin care, oral care, discharge preparation, assistance with food and hydration, medications and infusions and hand hygiene. Blackman et al. (2022) focused on issues around infection control and found that 13 variables exerted influence on missed infection control care, including methods used to prevent hospital-acquired infections, surveillance and hand hygiene practices. Clearly, omission of care to this extent and across this range of areas can affect patient outcomes, experience and satisfaction. In a review of literature on the impact of missed care on patient outcomes, Recio-Saucedo et al. (2018) identified nine studies that reported associations between missed care and outcomes such as pressure injury, medication errors, hospital-acquired infection, falls, unplanned 30-day readmission, critical incidents and mortality. For these reasons alone, it is imperative that nursing responds to findings of this nature and seeks to interrogate and resolve the antecedents to and consequences of missed care. Kalisch et al. (2009) suggest that the decision to either attend, delay or omit patient care activities is affected by factors internal to the nurse. These factors are named as team norms; decision-making processes; internal values and beliefs and habits. However, there are also many factors external to the nurse that play a role in missed care. Findings by Dutra and Guirardello (2021) suggest a link between the nursing work environment, quality of leadership and missed care. Missed care has also been associated with other factors including austerity, interruptions, pressures associated with patient acuity and numbers, high staff turnover, labour and resource limitations and sub-optimal staffing (Dutra & Guirardello, 2021; Griffiths et al., 2018; Tubbs-Cooley et al., 2015; Willis et al., 2017). These factors also contribute to cultures of busyness, in which nurses may be too busy or pressured to complete all patient care activities, meaning that nurses must respond to what they consider the most pressing patient needs to be. The area of missed care has many complexities and clearly is multi-factorial. In their daily work, nurses are continually prioritizing and reprioritizing activities in response to changing patient need, meaning that intended or planned care activities may be relegated to a lower priority. However, missed care is an issue of critical concern and is increasingly being viewed as a care quality indicator (Recio-Saucedo et al., 2018). If nurses are unable to provide nursing care, for whatever reason, there is an imperative to carefully consider what this means and to identify and implement strategies to mitigate (or at least reduce the frequency of) missed care. Busyness is frequently referred to in relation to nursing and missed care—to the point it has become a mantra that is almost uncritically accepted as truth, and oft-times spoken of as a truth that is not amenable to change. Busyness has become the ‘go-to’ response to queries about care quality and in discussions about changing practices in any way, it is often not long before the issue of nurse busyness is raised as a barrier to change. However, we cannot continue to cite busyness (and its antecedents) as a reason for missed care without interrogating the context and nature of this busyness and bringing a solution-focused stance to the issue. This means a critical evaluation of processes, practices and contextual factors that shape the nursing workplace. For a start there is a need to really listen and respond to nurses when they say they are too busy to provide optimal patient care and have to omit or delay care activities. There may be a need to critically re-evaluate models of care—if nurses are trapped in relentless cycles of busyness and care activities are not being delivered to patients, then surely there is a need to reconsider the models and frameworks for care that are in use. Because these models may be ineffective, and not work well for patients or for nurses. There is also a need to reconsider skill mix in the nursing workforce. The review by Griffiths et al. (2018) suggests that the presence of support workers did ‘not generally reduce the level of missed nursing care and may even increase it where skill mix is diluted’ (p. 1485). In the face of widespread missed nursing care, there is a need to better understand why strategies such as adding support workers are not effective and how (or if) these workers can be better integrated to reduce missed care. It may be that increased advocacy for prescribed staff-to-patient ratios would be a more successful and appropriate way forward. There is also a need to rigorously interrogate low value activities that may be taking up nursing time, often at the expense of care that will be of benefit to patients. Low value care refers to activities that do not benefit patients, can even harm patients, and use up resources. Low value care takes the time and energy of healthcare professionals and is potentially a contributing factor to cultures of busyness and missed care. Reducing low value care could have a significant and positive impact on cultures of busyness in health care and could transform health care through cost savings and reducing missed care (Rietbergen et al., 2020). In several countries, ‘Choosing Wisely’ lists of low value nursing care have been created and it is important we promote these to our colleagues and students (Rietbergen et al., 2020). It is also useful to scrutinize policies and practices in our own organizations with a view to identifying and reducing low value activities (Osorio et al., 2019). Much of the published work on missed nursing care is survey-data based on retrospective self-report by nurses, and while this is very useful work and certainly provides important insights into missed care, it is also important that we engage with patients and carers to better understand their views on missed care and the implications of missed care to them and their health trajectory. Qualitative research with all key stakeholders could also provide crucial additional insights, including why it is that additional support workers do not reduce (and may even increase) the frequency of missed care. It is also important to have access to patient views on low value activities and their support for de-implementation processes (Osorio et al., 2019). The culture of busyness does not serve us well. It can mean that we may not be able take the time to step back, reflect on practice, and consider how things could be done differently to improve care for patients, enhance the nursing work environment and reduce the frequency of missed care. Collectively, we must come to terms with damaging cultures of busyness that contribute to the unacceptably high levels of missed care that are reported in the literature. This is not only an essential issue for patient care and patient safety but is linked to job satisfaction for nurses—a factor in nurse retention. In coming to terms with missed care and its antecedent factors, we could potentially not only better meet our social mandate, through improved patient experiences of care and patient outcomes but contribute to a more robust and sustainable workforce through improvements to nurse job satisfaction and potentially, enhanced nurse retention.