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What are we missing?

Section Editor(s): Raso, Rosanne MS, RN, NEA-BC, FAAN

doi: 10.1097/01.NUMA.0000575332.78206.1f
Department: Editorial
Free

Editor-in-Chief, Vice President and CNO, NewYork-Presbyterian/Weill Cornell, New York, N.Y.

Those of us in leadership positions know the frustrations of not having enough time to do what we want/need to do.

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We all have robust quality programs for our unit(s) to ascertain and improve various process and outcome patient care indicators. Generally, when we're greater than 90%, we celebrate and if we're less than 90%, we work on correction. Is that enough? Don't groan already under the weight of onerous monitoring, concerned yet another audit is coming your way. Or worry we'll argue that 90% isn't good enough—that isn't where we're going with this story. We're headed to missed care and its implications.

Missed care is any omission, or even delay, of an aspect of care. We've seen a lot in the literature about it, including a huge study published last year involving nine countries. Nurses were asked, “On your most recent shift, which of the following activities were necessary but left undone because you lacked the time to complete them?” The list wasn't only clinical work, it also included activities such as documentation and interdisciplinary rounding. As expected, there were numerous instances of missed care, and the way this question was asked pointed squarely at staffing.

Logically, staffing makes sense, from being chronically underbudgeted or having a high turnover to daily situations such as high acuity or callouts. We could go deeper into the causality of these conditions, but the bottom line is time. Sometimes there really isn't enough time to do everything you want and need to do for a patient. Those of us in leadership positions also know the frustrations of not having enough time to do what we want/need to do. Defining adequate staffing is individual to the unit patient population, day/shift, geography, nurse competencies, support, and more. Right staffing can be determined locally by nursing leadership, administration, and staff, with all of the factors taken into consideration.

There are probably other causes besides time. What about lack of knowledge or priority setting? Another possibility is the manager's expectations or the unit's culture. Personal belief about care aspects can be compromised. And research has even identified shift type and nurses' satisfaction with their current job as variables.

So, what's the effect? The literature tells us that unfinished care is a predictor of decreased nurse-reported care quality, patient satisfaction, and job satisfaction, as well as increased adverse events, turnover, and intent to leave. These are big problems and leave patients with unmet needs. Even worse is the increased odds of patient morbidity and mortality.

We must stop ourselves from a judgmental response to missed care. The evidence is that it's ubiquitous, especially in medical-surgical settings. Nurses shouldn't have to choose between administering medications and comforting a dying patient/family or between ambulation and discharge teaching. Having to make those choices may be the start of moral distress, another unwelcome outcome. However, there are few, if any, intervention studies to address missed care.

We can't take our eye off the ball from both the quality and workforce perspectives. Knowing what we're missing is just too important to our staff and our patients.

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