Missed Nursing Care: Magnet
vs. non-Magnet Hospitals
Beatrice Kalisch, PhD, RN, FAAN
Titus Professor of Nursing and
Director, Innovation and Evaluation,
University of Michigan
September, 2012
CANS
bkalisch@umich.edu
Presentation Outline
– Previous Studies
– Conceptual Framework
– Study Questions
– Study Methods
– Findings
– Discussion and Implications
What we DON’T know
…Any aspect of required
patient care omitted or delayed
ERRORS OF OMISSION
PREVIOUS
STUDIES
STUDY 1
Missed Care:
A Qualitative Study
Kalisch B. (2006). Missed nursing care: A qualitative study. Journal
of Nursing Care Quality, 21:4; 306-313.
Missed Care:
A Qualitative Study
9 areas of missed
care
– Ambulation
– Turning
– Delayed or missed
feedings
– Patient education
– Discharge planning
– Emotional support
– Hygiene
– Intake and output
documentation
– Surveillance
7 themes for
reasons for
missed care
– Too few staff
– Time required for a nursing
intervention
– Poor use of existing staff
resources
– “It’s not my job syndrome”
– Ineffective delegation
– Habit
– Denial
STUDY 2
A Concept Analysis
B. Kalisch, G. Landstrom, & A. Hinshaw, (2009) “Missed
Nursing Care: A Concept Analysis,” Journal of Advanced
Nursing, 65(7), 1509-1517.
STUDY 3
MISSCARE Survey
Development & Psychometric
Testing
Kalisch B & Williams R. (2009) The development and psychometric testing of a
tool to measure missed nursing care (MISSCARE Survey). Journal of Nursing
Administration. 39 (5). 211-219.
MISSCARE Survey
Development & Psychometric Testing


Acceptability
Validity
– Content validity
– Construct validity (EFA and CFA)

Reliability
- Consistency: Cronbach’s alphas 0.88 to 0.64
- Test-retest: 0.87
STUDY 4
Missed Care and Reasons: 3
hospital study
Kalisch B, G. Landstrom & R. Williams, (2009) . Missed Nursing Care:
Errors of Omission, Nursing Outlook, 57(1), 3-9.
Missed Care and Reasons:
3 hospital study

Research questions
– What and how much nursing care is missed?
– What are the reasons for missing care?

Methods
– 3 hospitals (459 RNs), 35 patient units
– MISSCARE Survey , response rate 57%

Findings
– Significant amount of missed care
– Consistency across the 3 hospital sample in amount and specific
elements of care as well as reasons
Study 5
MISSED NURSING CARE: An 11
HOSPITAL STUDY
5 Most Often Missed
Nursing Care
100%
90%
76%
Ambulation
80%
66%
70%
60%
64%
60%
59%
Interdisciplinary care
conference attendance
Mouth care
50%
40%
Timely medication
administration
30%
Turning
20%
10%
0%
5 Most Least Missed
Nursing Care
100%
90%
80%
70%
Patient assessment
60%
Glucose monitoring
50%
Discharge plan
Vital sign
40%
24%
30%
20%
10%
0%
14%
9%
25%
26%
Focused reassessment
5 MOST OFTEN MISSED
5 LEAST MISSED CARE
Overall Reasons for Missed Care
92.8%
100.0%
89.6%
81.8%
80.0%
60.0%
40.0%
20.0%
0.0%
Labor resources
Material resouces
Communication/Teamwork
CONCEPTUAL
FRAMEWORK
THE MISSED NURSING
CARE MODEL
HOSPITAL
CHARACTERISTICS
STAFF
OUTCOMES
•Size
•Teaching intensity
•Magnet
e.g. Satisfaction,
Turnover,
intent to leave
UNIT CHARACTERISTICS
Case mix index
Nurse staffing (HPPD,
RN HPPD skill mix)
Type of nurse staffing
(education, experience)
Absenteeism
Overtime
Work schedules
TEAMWORK
MISSED
NURSING
CARE
PATIENT
OUTCOMES
e.g. Falls
RESEARCH
QUESTIONS
RESEARCH QUESTIONS
1.
2.
3.
Controlling for staffing levels, case mix index, and
type of unit, do Magnet designated hospitals have
less missed nursing care than non-Magnet
facilities?
Do the reasons for missed nursing care differ
between Magnet and non-Magnet facilities?
Do staffing levels and type account for variations
in amount and reasons for missed nursing care in
Magnet vs. non-Magnet hospitals?
STUDY METHODS
Study Sample

Nursing staff on 124 adult patient care units
(medical-surgical, rehabilitation,
intermediate and intensive care units) in 11
hospitals.
– Magnet: 62 units
– Non-Magnet 62 units


4,412 nursing staff (3,349 RNs, 83 LPNs and
980 NAs)
Return rate 57.3% (61.7% for RNs & LPNs,
53.4% for NAs)
Measures


The MISSCARE Survey
From hospital administrative data
level variables)
– HPPD, RN HPPD, skill mix
– Unit Case Mix Index (CMI)
(unit
STUDY
FINDINGS
Kalisch B & Lee, K. (in press). Missed Nursing Care:
Magnet vs. Non-Magnet, Nursing Outlook.
Overall Missed Nursing Care:
Magnet vs. non-Magnet
Variable
Magnet
Mean±SD
Non-Magnet
Mean±SD
t
p
Overall Missed
Nursing Care
1.50±.21
1.57±.15
2.20
.03
Missed Nursing Care: Magnet
vs. non-Magnet
Variable
Magnet
Mean±SD
Non-Magnet
Mean±SD
t
p
Overall missed nursing care
1.50±.21
1.57±.15
2.20
.03
Mouth care*
1.81±.32
1.93±.31
2.02
.05
Skin/Wound care
1.32±.26
1.39±0.15
1.99
.05
Feeding
1.65±.26
1.82±.30
3.34
.00
Meal set up
1.35±.27
1.47±.22
2.65
.01
Turning*
1.65±.31
1.77±.23
2.34
.02
Med effectiveness
assessment
1.52±.25
1.63±.20
2.65
.01
IV/central line site care
1.32±.26
1.47±.18
3.79
.00
Call light response
1.54±.31
1.67±.29
2.38
.02
Patient teaching
1.62±.25
1.72±.22
2.24
.03
Full documentation
1.60±.29
1.73±.24
2.72
.01
Missed Nursing Care: Magnet
vs. non-Magnet
(continued)
Variable
Magnet
Mean±SD
Non-Magnet
Mean±SD
t
p
Ambulation*
2.03±.36
2.13±.28
1.57
.12
Attend interdisciplinary care
conferences*
1.99±.28
2.05±.50
.83
.41
Timely medication administration*
1.76±.33
1.79±.24
.55
.58
Monitoring I/O
1.59±.40
1.65±.38
.78
.44
Assist with toileting
1.54±.24
1.60±.23
1.40
.17
Bathing
1.50±.27
1.56±.22
1.22
.22
Emotional support
1.47±.25
1.53±.22
1.53
.13
PRN meds administration
1.45±.25
1.52±.21
1.75
.08
Patient discharge planning^
1.29±.28
1.31±.14
.47
.64
Focused reassessments^
1.28±.27
1.29±.15
.18
.86
Vital signs^
1.27±.29
1.29±.17
.54
.59
Hand washing
1.27±.27
1.35±.19
1.88
.06
Glucose monitoring^
1.14±.32
1.17±.13
.90
.37
Assessment each shift^
1.11±.29
1.12±.10
.28
.78
Reasons for Missed Nursing Care:
Magnet vs. Non-Magnet Hospitals
Magnet
Mean±SD
Non-Magnet
Mean±SD
t
p
Communication
2.23±.18
2.32±.20
2.49
.014
Labor resources
3.00±.29
3.12±.18
3.31
.001
Material resources
2.56±.22
2.61±.23
1.37
.174
Actual Staffing Differences
by Magnet Status
Variable
Magnet
Mean±SD
Non-Magnet
Mean±SD
t
p
HPPD
10.94±.18
11.30±4.98
.44
.662
RN HPPD
8.71±4.17
8.86±4.58
.19
.847
Skill Mix
.781±.14
.780±.18
-.04
.969
Hierarchical regression
result summary
Variable
Coefficient
Robust S.E.
T ratio
P-value
1.530
0.040
37.775
.000
Experience
0.044
0.005
8.961
.000
Education
(BSN or higher)
0.088
0.014
6.374
.000
Magnet (Magnet)
-0.074
0.030
-2.471
.015
Type of unit (ICU)
0.077
0.159
0.484
.629
HPPD
-0.022
0.012
-1.827
.070
CMI
-0.002
0.021
-0.104
.918
Intercept
Individual-level predictors
Unit-level predictors
Level-1 R2
4.6%
Level-2 R2
15.0%
Note. S. E. standard error.
Magnet units had less missed care after adjusting for other
variables (γ01=-0.074, p=.015)
More experience was positively associated with missed
nursing care
Nurses with a BSN degree or higher identified more
missed nursing care than staff that held an associate
degree or less.
In summary…



Magnet hospitals have significantly
less missed care.
Magnet hospital staff report less
staffing and communication problems.
Yet there were no significant
differences in staffing levels and type
between Magnet and non-Magnet
hospitals.
DISCUSSION
Discussion


The amount of missed nursing care
represents errors of omission; standard ;
nursing care not being completed
Leads to negative patient outcomes
– Failure to do mouth care

Leads to a reluctance to eat that in turn impacts risk of pressure ulcer
development and/or pneumonia, particularly in ventilated patients.
– Failure to ambulate linked to:








New onset delirium
Pneumonia
Delayed wound healing
Pressure ulcers
increased length of stay and delayed discharge
increased pain and discomfort
muscle wasting and fatigue
Physical disability
IMPLICATIONS
IMPLICATIONS

Ensure adequate staffing
– Deal effectively with flows in patient acuity and
volume

Conduct studies which measure other
variables such as culture, leadership,
teamwork, which may account for less
missed care in Magnet Hospitals.
The End
QUESTIONS?