Whenever I attend national meetings, I come away impressed by what many nurses are doing—research that's leading to better clinical outcomes, quality improvement projects that are enhancing patients’ experiences, and initiatives to increase patient safety and the quality of care.
But what I recall most from these meetings are the conversations over coffee and in hallways that often provide insight into important issues. Recently I spoke with other nurses about our personal experiences with hospitalization and those of family members, and the conversation turned to disappointment with nursing practice and nursing care. In fact, whenever I've asked, every colleague has disclosed a similar experience. Some say that they'd never leave a family member alone in a hospital.
We need to acknowledge that there is a disconnect between what we know to be good practice and what is often the reality—even in facilities with Magnet accreditation. There are far too many instances in which nursing practice is substandard.
Many breakdowns seem to involve failures of individualized care, particularly the failure to reassess patients as conditions change. Here are some examples from nurses who were themselves patients in various U.S. facilities. In one case, because vital signs had been ordered every four hours, a nurse didn't see a need to retake a neurosurgery patient's blood pressure sooner, even though the most recent reading had shown a marked increase. In another, a nurse continued to administer prescribed pain medication to a patient who couldn't stay awake long enough to eat. In a third, a new postoperative patient was left in a room behind a closed door with no way to call for assistance; no one checked on her for three hours. And then there was the nurse who gave a patient a four-page printout of discharge instructions, yet hadn't read them and couldn't clarify contradictory medication instructions. The nurse told this patient to “call the doctor's office” when she got home. What were these nurses thinking? Or is the problem that they weren't?
This is not new information. In November 1996, we published Judith Shindul-Rothschild's analysis of AJN’s Patient Care Survey of 7,500 nurses. One finding was that two-fifths of the respondents said they wouldn't want their families to be patients in the hospitals where they worked. And then there is Beatrice Kalisch's 2006 research into “missed nursing care,” which described various aspects of nursing care that were delayed or neglected altogether. Many were areas essential to basic nursing practice, including patient surveillance, positioning and ambulation, intake and output documentation, patient teaching, emotional support, and hygiene. Kalisch also noted that once an aspect of care is neglected, it's easier to continue neglecting it. (To read Kalisch's account of experiencing missed care as a patient herself, visit http://bit.ly/cxGhGS.)
Many reasons may underlie omissions of care—insufficient staffing and resources; scheduling patterns that make ensuring continuity of care difficult; the rapid turnover of older, more complex patients; mandated checklists that can divert attention from aspects of care that then aren't measured; inexperienced nurses who lack critical thinking or organizational skills; and job burnout. Regardless, we cannot continue to ignore the basic tenets of good nursing care and expect our patients to excuse us. We cannot claim to provide patient-centered care when that care is rote, when what the system values is a completed checklist.
If we're to maintain the public's trust, we must address this discrepancy between what is and what we strive for. Perhaps the first step is to recognize that those missed aspects of care have real value and warrant our attention. Perhaps we should address missed care much as organizations have addressed medication errors—with an open, nonpunitive approach, based on the assumption that nurses want to provide high-quality care but face many barriers. Then the barriers can be addressed one by one. We also need to look at how nurses are being taught to provide care—are we missing something?
I hope nurses whose organizations have addressed this successfully will write and share with us how it can be done. Our patients’ lives depend on it.