Missed nursing care: Its impact on nurses working in intensive care

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Missed nursing care:

Its impact on nurses working in

Intensive Care.

A Masterate Thesis

presented in partial fulfilment of the requirements for the degree of

Master of Nursing

at the

Eastern Institute of Technology Hawke’s Bay, New Zealand

Amy Frechtling

2018

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Declaration of originality

I declare that the work presented in this thesis, “Missed nursing care: Its impact on nurses working in Intensive Care (IC) is, to the best of my knowledge and belief, original and my own work, except as acknowledged in the text and reference pages.

Signed: Date: 8 May 2018

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Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author.

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Acknowledgements

Firstly, I must thank and acknowledge my three children, Jacob, Zoe and Alexander, for their support over the last year. Without their support, encouragement and enthusiasm to continue on this journey, I might have lost hope of completing this thesis. Their patience in providing me with the time needed, away from their own needs, to help me continue with my study is remarkable.

Secondly, I must thank the six participants for their support and time spent with me through the interview process and follow-up discussions. I feel incredibly grateful to have had the opportunity to share their feelings and experiences throughout this thesis. Without the support and participation of those six people, I would not have been able to achieve and accomplish this research thesis.

Further acknowledgements must be given to my supervisors, Shona Thompson and Alexa Hantler, for all the encouragement, expert advice and time spent reviewing and discussing the finer elements of the content details with me, thank you. I would also like to acknowledge, Joanna Johnston for her editorial assistance throughout the thesis.

I would like to thank my employer for proving me with the encouragement and support to undertake this venture and also, I would like to thank my friends, colleagues, and family who have listened to me stress, celebrate and converse with them about my thesis.

I would also like to acknowledge, Joanna Johnston for her editorial assistance throughout the thesis.

The journey throughout the research thesis for the researcher has been one of significant challenges to satisfaction. The amount of vital academic knowledge that was gained from this experience cannot be described in words, overwhelming at times through to a feeling of great achievement. The topic of missed nursing care reflects a huge body of inquiry and investigation and, when choosing my research question, I may have overlooked the sheer complexity and broadness of the topic. However, the results and findings of this study have unfocused my determination and passion for this topic, which have added quality, rich, informative research into the body of knowledge we currently have about this topic.

Nothing is impossible – even the word says ‘Im – possible’

(Audrey Hepbun)

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Abstract

Background: Missed nursing care continues to have a presence throughout New Zealand (NZ) hospitals. Missed nursing care can be a controversial and politically sensitive topic. Nurses are aware of these issues and the patient outcomes when care is missed, and it is their responses to this concern that the research explores. How missed nursing care impacts on the nurse currently suggests that nurses question their professional integrity and job satisfaction, and have feelings of guilt, concerns about patient safety, and ethical feelings of remorse. When nursing care is missed in the IC environment, patients are exposed to a much higher incidence of severe complications of that missed care. Many outsiders may look at the nature of the environment and its name Intensive Care and believe that missed nursing care is less expected in this area of nursing.

Research Aim: The aim of this research was to explore the impact on nurses working in IC units in NZ hospital settings when nursing care is missed, delayed or omitted. The aim of this

research is to move away from the why and how of missed nursing care and to investigate the topic from the nurses’ perspective regarding the impact when nursing care is missed.

Methodology: This qualitative research used a descriptive approach, based on the

interpretation and experiences of nurses working in IC. Narrative data were collected from the population group of six nurses working in an IC environment under the phenomenon study, missed nursing care. The nurses were asked to describe how missed nursing care impacted on their nursing practice.

Results: The results of this research indicate that missed nursing care also happens in IC. The factors that impact on the nurses include intensifying workloads, time allocation and having an experienced workforce. The professional dilemmas indicated by the participants include the key impacts, namely prioritising of patient care, the reporting of missed care in IC and how a team works together in IC, along with the unit’s culture. The impact of personal emotional stress was felt by many of the participants, indicating that they felt feelings of moral stress, and they discussed the responsibilities they felt towards missed nursing care. The results indicated that, for many nurses, missed nursing care had become a norm in practice, with individual nurse’s attitudes being factors in that normalisation. The participants stated that nurses had become idle in their care and had lost the art of prioritising of nursing care.

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Chapter Two: Literature Review

2.0 Introduction……….13

2.1 Search methods……….13

2.2 The issues of missed nursing care……….13

2.3 Job satisfaction, staffing levels and organisational factors……….15

2.4 Missed nursing care in IC………..18

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2.5 NZ research………21

2.6 Summary of the review……….23

Chapter Three: Methodology

3.1 Research methodology……….25

3.2 Research recruitment……….26

3.3 Research participants………27

3.4 Demographics of the participants………...28

3.5 Data collection……….……….29

3.6 Data analysis: Thematic analysis……….………….30

3.7 Ethics approval……….……….31

3.8 Respect for autonomy, privacy and confidentiality beneficence and non- maleficence ……….…….31

3.9 Respect for cultural diversity……….32

3.10 Summary of chapter……….……….32

Chapter Four: Results

4.0 Introduction………...33

4.1 Theme one: Missed care also happens in IC………34

4.1A Nursing care most likely to be missed………..…..34

4.1B Time allocation and intensifying workloads………...37

4.1C Staffing impacts in IC, patient care and need for an experienced workforce……….39

4.1D Summary of theme one………42

4.2 Theme two: Professional dilemmas……….43

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4.2A Prioritising patient care………..….44

4.2B Reporting of missed care ………45

4.2C Teamwork and unit culture………47

4.2D Summary of theme two………48

4.3 Theme three: Personal emotional stress………..…..49

4.3A Moral stress………..……50

4.3B Responsibilities nurses feel towards missed nursing care……….51

4.3C Coping with emotional stress……….52

4.3 D Summary of theme three………..……….53

4.4 Theme four: Normalisation of missed nursing care……….54

4.4A Missed nursing care a norm in practice……….……..54

4.4B Individual attitudes……….56

4.4C Technology………57

4.4D Summary of theme four……….58

4.5 Summary of chapter……….58

Chapter Five: Discussion

5.1 Missed care also happens in IC………60

5.2 Professional dilemmas………61

5.3 Personal and emotional stress……….64

5.4 Normalisation of missed nursing care……….67

5.5 Chapter summary………..68

Chapter Six: Conclusion

6.0 Conclusion………69

6.1 Strengths of the research………..70

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6.2 Limitations of the research……….71

6.3 Recommendations……….71

References

References………..73

Appendices

Appendix A Research interview questions………80

Appendix B Research Consent Form……….81

Appendix C Information for Research Participants……….83

Appendix D EIT Ethics approval………86

Appendix E Undertaking as to Non-Disclosure of information form………..87

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Abbreviations List

ACC Accident Compensation Corporation CCDM Care Capacity Demand Management DHB District Health Board

HDS Health and Disability Services

HQSCNZ Health Quality and Safety Commission of New Zealand IC Intensive Care

ICU Intensive Care Unit NZ New Zealand

NZNO Nursing Council of New Zealand NZNO New Zealand Nurses Organisation MOH Ministry of Health

MDT Multidisciplinary Team RN Registered Nurse

SAS Severity Assessment Scale VAP Ventilation acquired pneumonia

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Chapter One Introduction

1.0 Introduction

The aim of this research was to explore the impact on nurses working in IC wards in NZ hospital settings when nursing care is missed, delayed or omitted. This chapter will give an overview of what is missed nursing care, including the factors related to missed nursing care from a patient safety perceptive, and will explore the influences that may contribute to missed nursing care. The reporting of missed nursing care and its effects on nurses will be discussed, including their moral obligation to report missed nursing care and their

experiences when nursing care is missed. The purpose of the study will be outlined in this chapter, with details including the researcher’s special interest in the topic and the significance of missed nursing care in the IC environment. Missed nursing care in the IC environment is a concern because it has implications for patient health outcomes. For example, patients can develop pressure injuries when they are not turned regularly. Patient mouthcare that is missed may result in ventilation acquired pneumonia (VAP), and nursing care such as failure to mobilise patients effectively will impact on the patients’ length of IC stay, delay wound healing, and increase the risk of pneumonia and delirium (Leditschke, Green, Irvine, Bissett, & Mitchell, 2012; Sedwick, Lance-Smith, Reeder, & Nardi, 2012).

Nurses are aware of these issues and the patient outcomes when care is missed, and it is their responses to this concern that the research explores. The research question aims to draw out new evidence on the impact on the nurses when they miss care. This chapter outlines the background of missed nursing care in practice and then describes the purpose of this study, outlining the writer’s interest in missed nursing care. Following this

information, the IC environment will be discussed in relation to missed nursing care, providing a background about missed care practices.

1.1 Missed nursing care overview

The term ‘missed nursing care’ refers “to any aspect of required patient care that is omitted by the nursing staff, either in part or in whole, and includes delayed care” (Kalisch,

Landstrom, & Hinshaw, 2009. p,1512). In this thesis, ‘missed care’ will refer to nursing care that is missed, delayed or omitted. The term ‘omitted care’ refers to nursing care that is

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deliberately left undone, usually due to nursing workload pressures. Nursing care in these circumstances is omitted by the nurse when other nursing care takes priority or is thought to be more important to the patient’s health needs (Harvey, Buckley, Forrest, Roberts, Searle, Meyer & Thompson, 2015; Winters & Neville, 2012). Delayed nursing care stems from the same factors as omitted care; however, nursing care is delayed rather than not provided (Kalisch, 2006; Kalisch & Hee Lee, 2011).

What types of nursing care are typically missed? This question is complex as missed care can include any nursing care that is considered obligatory for the welfare of the patient but is not provided by the nurse caring for that patient. A literature review conducted by Kalisch and Hee Lee (2011) indicated that the most common types of nursing care that are not completed or that are regularly missed are basic nursing care. Basic nursing care is nursing tasks that nurses usually provide for patients to assist them with activities required for daily living. Examples of basic nursing tasks are ambulation and turning of patients, patient mouthcare, and general patient hygiene care. Also included are nutrition requirements of patients, medication administration, and patient education. Kalisch and Hee Lee (2011) broke down the missed care activities and showed the frequency of missed care occurrence as a percentage of the time this task was missed: ambulation (84%), turning (82%),

mouthcare (82%), patient teaching and education (80%), and delays in medications (80%).

Many of the terms used when referring to the types of missed care can vary according to published literature. Some researchers term basic ‘nursing care’ as ambulation, turning, mouthcare, and personal grooming as one term, ‘basic nursing care’. However, as stated above, is a term used to describe any aspect of care that is not provided to a patient when needed or as required by the nurse to perform when providing care to that patient (Kalisch

& Hee Lee, 2011).

Missed nursing care is a topic that is rarely discussed openly within the healthcare

profession. What makes this topic difficult to discuss amongst nurses is the fact that errors of omission or care that is delayed or missed can have severe healthcare outcomes for patients (Kalisch, 2006; Winters & Neville, 2012; Ulrich, 2016). For that reason, many health professionals avoid the subject due to the fear of blame being laid on individual nurses, and their being held responsible for negative outcomes. Historically, because of the way the investigations are undertaken into why and how missed nursing care happens in practice, missed nursing care would reflect the practice of the individual nurse without consideration of factors arising from outside influences, such as nurse workloads, access to resources, and organisation restraints (Kalisch, 2006). Research conducted by Kalisch (2006) exposed the

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background behind why and how missed nursing care happens. Discussions were held by health professionals into the causes and factors that contributed to missed nursing care, which have suggested that the primary nurse was not always to blame (Kalisch, 2006).

Recent evidence, supported by literature, suggests that issues related to missed nursing care are much more complex than can be directly attributed to incompetent nursing, and that it generally happens due to factors beyond an individual nurse’s control (Blackman, et al., 2015; Ulrich, 2016). Research suggests that healthcare organisations play a fundamental role in the amount of nursing care that is missed. These factors include unsafe nursing work levels, understaffed work environments, high patient- to- nurse staffing ratios, poor

teamwork and delegation, and poor communication. Critically, patients have reported fewer positive experiences of care in hospitals where more nursing care is left undone (Kalisch, 2006; Kalisch et al., 2009; Kalisch, Tschanen & Lee, & Salsgiver, 2011; Ulrich, 2016 Winters &

Neville, 2012).

1.2 Purpose of the study

The aim of this research was to explore the impact on nurses working in IC in NZ hospitals, when nursing care is missed, delayed or omitted, and to investigate how missing care affects the individual nurse. It involved interviewing nurses who have worked in IC, in order to provide a snapshot of the impact of missed nursing care in this environment. The reason for collecting this form of qualitative data was to better understand the impact on nurses when their ability to provide adequate nursing care was compromised or reduced in some way.

Previous research has investigated why and how missed nursing care happens. However, research into how nurses are directly impacted by this missed care is somewhat limited.

Information on how missed nursing care impacts on the nurse suggests that nurses question their professional integrity and job satisfaction, and have feelings of guilt, concerns about patient safety, and ethical feelings of remorse (Blackman et al., 2015; Harvey et al., 2015;

Kalisch, 2012). The aim of this research was to move away from the why and how of missed nursing care and to investigate the topic from the nurses’ perspective regarding the impact when nursing care is missed.

1.3 Researcher’s special interest

While the phenomenon of missed nursing care is well researched, and it is well known that missed care happens in nursing, much nursing care seems to still be missed. Also, there is limited understanding of how the impact felt by the nurse delivering patient care affects

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their practice. The researcher has a wealth of experience in the IC environment and notes that missed nursing care is not isolated to just one nursing care environment. The

researcher’s special interest in the topic of missed nursing care and her clinical nurse experience in the IC environment prompted this research enquiry. Missed nursing care can be a controversial and politically sensitive topic. However, it is a topic that needs to be investigated in the light of nursing professional development and organisational insight.

When nursing care is missed in the IC environment, patients are exposed to a much higher potential for severe complications resulting from that missed care. Patients in IC have a complex medical status and are the most critically ill patients in the hospital. Many outsiders may look at the nature of the environment, and its name Intensive Care, and believe that missed nursing care is less expected in this area of nursing.

1.4 Patient safety and organisation factors

Patient safety and expected healthcare outcomes are the standard goal that any healthcare professional sets when involved in any aspect of patient care. When nursing care is missed or delayed at any level, evidence suggests that the patient’s health outcome will be affected in some way and always to the detriment of the patient (Harvey et al., 2015; Winters & Neville, 2012). Evidence already suggests that there are overwhelming financial costs to health care organisations due to the adverse effects of missed nursing care (Kalisch, 2012). Patient safety is compromised, with possible fatal effects to patient’s healthcare outcomes because of missed nursing care. The consequences of missed nursing care present actual threats to patient safety and the quality of care that they receive. All patients have the basic human right to optimum care that is not missed and to safe nursing practice (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014; Blackman et al., 2015; Winters & Neville, 2012). Despite this, Kalisch and Hee Lee (2011) reported that organisational factors, such as unsafe staff workloads and lack of resources such as equipment needed to perform nursing tasks, were two of the main reasons why a patient’s health and safety might be compromised.

In the research conducted by Winters and Neville (2012), a common theme that emerged was the suggestion that state organisation restraints were having the highest influence on nurses when delivering patient care and were impacting on the quality of care patients received. When staffing levels are low, staff are under-resourced and under-managed, and have no strong leadership from experienced nursing staff, basic nursing care is often missed (Kalisch, 2006; Kalisch et al., 2009; Kalisch et al., 2011; Winters & Neville, 2012). The

pressures on nurses to work in hospital environments where there may be extremely high

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patient workloads result in nurses having to prioritise nursing care, attending to medications and complex procedures, with simply no time available to attend to basic nursing care.

However, missing basic nursing care may result in increased incidences of hospital

infections, patients with pressure injuries and increased lengths of stay in hospital (Kalisch, 2006; Kalisch et al., 2009; Kalisch et al., 2011; Winters & Neville, 2012).

In NZ, the obligations for healthcare providers are driven by the Health and Disability Services (HDS) (Safety) Act 2001, which clearly states the following in the content of standard:

In the case of hospital care or rest home care, a means by which there can be ascertained minimum numbers of nursing and other care staff who must be on duty (at any time, or at different times) in premises in which the care is being provided (p, 21 1g).

The Health Quality and Safety Commission of NZ (HQSCNZ) provides frameworks and policy for service providers to meet the obligations of the Health and Disability Services (Safety) Act (2001). Currently, the Commission is working on care rationing guidelines with the New Zealand Nurses Organisation (NZNO) to reduce nursing care deficits in relation to staffing shortfalls (NZNO, 2017). Care rationing is a term used when nurses withhold or fail to carry out necessary tasks due to staffing levels or lack of time. Care rationing is a form of missed nursing care in some nurses’ views. However, the NZNO does not clearly term care rationing as missed care The NZNO (2017) states that care rationing is both a service issue and a quality and safety issue in our hospitals. When nursing care is rationed patients, are at higher risk of falls, infections, pressure injury, and longer stays in hospital, and rationing can even cause irreversible harm or death (NZNO, 2017). The purpose of the NZNO’s enquiry into care rationing is to achieve safer staffing levels and healthy working environments, and to prevent care rationing in practice. The recommendation to healthcare services was to implement a programme known as Care Capacity Demand Management (CCDM) (NZNO, 2017). CCDM is active in many District Health Boards (DHB) in NZ, which have implemented CCDM after considering the evidence-based practice from literature and recommendations from government agencies such as the Ministry of Health (MOH) of NZ, HQSCNZ and NZNO (HQSCNZ, 2012; 2017; NZNO, 2017). It could be argued that CCDM is an effective step toward addressing the care deficits in nursing care that are commonly missed due to the high workloads of nurses who have no choice but to withhold or prioritise nursing care.

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1.5 Reporting of missed care

Many healthcare organisations have focused on improving strategies to reduce missed, delayed or omitted care by requiring nurses or other healthcare professionals to report occurrences of missed care through the organisation’s incidence reporting (HQSCNZ, 2017).

However, evidence would suggest that many incidences go unreported due to nurses’ fear of repercussions, and that the actual occurrences of missed nursing care causing incident to the patient are possibly much higher than reported (Jones, Hamilton, & Murry, 2015; Kalisch

& Hee Lee, 2011). The HQSCNZ National Adverse Events Reporting Policy (2017) is a document guideline to support a national approach to reporting and reviewing adverse events that have been reported by healthcare staff. It is a learning tool to enable health professionals to learn from events and near misses. Near misses are events that are reported using the tool, to highlight such things as staffing issues and possible influences that result in a near miss of care. An example would be one nurse looking after two ventilated patients in IC, when best practice states that ventilated patients require one-to- one nursing care. The doubled workload of nursing two ventilated patients then will put the patient at higher risk of an adverse event happening and is called reporting care as a near miss. An event with negative or unfavourable reactions due to the example stated above could result in an unintended, unexpected or unplanned event and is also referred to an

‘incident’ or ‘reportable event’. In practice this is most often understood as an event that results in harm or has the potential to cause harm to the consumer (HQSCNZ, 2017). The guideline requires the person reporting the event to rate the event according to a Severity Assessment Scale (SAS) from severe to minimal. The minimal assessment scale states that no injury or no increased level of care or length of stay affects the patient, but does include near misses (HQSCNZ, 2017). It is argued that any level of missed nursing care warrants the event being reported as a near miss under this document.

However, observations of practice suggest that, from my experience this reporting does not happen in practice. To compare this scale to the evidence of the missed care occurrences, research shows that missed nursing care exposes patients to possible adverse effects, such as infection or related injuries that increase the length of stay for the patient and may cause serious harm. With this statement in mind, it is argued that an incident would reflect a much higher level on the SAC such as a moderate to major event outcome. Observations of practice suggest that missed nursing care should be reported more often, especially if the patient has been exposed to harm caused by moderate to high levels of missed care.

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1.6 Missed nursing care effects on moral obligation and Nursing Council of NZ governance

Nurses have a duty of care to provide safe nursing practice through their professional codes of conduct, and a moral obligation to do no harm (expressed as beneficence and non- maleficence). The NZ Code of Conduct for Nurses is based on eight principles that make up the standards required for NZ nurses (Nursing Council of New Zealand (NCNZ), 2012). All nurses are expected to adhere to these standards. Principle four of the Code is to maintain health consumer trust by providing safe and competent care” (p. 3). This is the standard that most relates to the issues concerning missed nursing care. Values that underpin

professional conduct in the Code are respect, partnership, trust and integrity. The definition of integrity in the NZ Code of Conduct for Nurses reads thus:

Being honest, acting consistently and honouring our commitments to deliver safe and competent care is the basis of health consumers’ trust in nurses. Integrity means consistently acting according to values and principles and being accountable and responsible for our actions. As professionals, nurses are personally accountable for actions and omissions in their practice, and must be able to justify their decisions (NCNZ, 2012, p. 4)

Legally, patients have the basic human right to adequate nursing care and care that is not missed. The consequence of not being able to provide the quality of care that nurses believe their patients require has been shown to have a significant impact on nurses’ levels of job satisfaction, intent to stay in their job, burnout, and the quality with which nurses rate their personal lives (Kalisch et al., 2011; Neff, Cimiotti, Heusinger, & Aiken, 2011).

Research by Winters and Neville (2012), revealed that nurses reported having strong concerns about patient care. In this study, nurses commented that they were forced to miss nursing care due to factors beyond their control, such as low staffing numbers. The impact the nurses felt from missing care caused a lack of job dissatisfaction and emotional

exhaustion. Nurses described how trying to minimise that occurrence of missed nursing care was also linked to the moral distress they felt (Winters & Neville, 2012). The pressure for nurses to be accountable for their omissions of missed care in their practice and the overwhelmingly heavy workloads in nursing impacted on the progressively increasing occurrences of missed nursing care (Winters & Neville, 2012.) Winter and Neville’s (2012) research also suggested that missed care in nursing practice had become a ‘norm’ in

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practice, with nurses feeling that they did not know how and when to act to report care that was missed and were unsure about whether their reporting of missed care makes any difference to managing this healthcare issue.

Missed nursing care can cause professionals to feel emotionally distressed and can have professional and legal connotations for the nurse. Nurses become frustrated or

disappointed when unable to provide the quality of care to their patients. Many of these feelings can be categorized as “moral distress”. The concept of moral distress was first identified and defined by researcher Jameton (1984, as cited in Corley, Minick, Elswick, &

Jacobs, 2005), “as painful feelings and/or the psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires but cannot carry out that action because of institutionalised obstacles” (p. 382). Moral distress, inadequate levels of staff, and organisational factors can all play a vital part in how and why missed care happens in nursing practice. In the nursing profession, moral distress is having a huge impact on job retention and satisfaction. Due to these stressors, many nurses are leaving the profession which is impacting on the general workforce environment and having a profoundly negative effect on teamwork and the profession (Corley et al., 2005; Henrich et al., 2017).

1.7 Background history of IC nursing and significance of missed nursing care in IC

IC nurses specialise in the care of patients whose conditions are life-threatening and who require constant monitoring, usually in a dedicated IC ward. IC nurses treat patients who are chronically ill or at risk for deadly illnesses. They apply their specialized knowledge base to care for and maintain the life support of critically ill patients who are often on the verge of death (Minton, 2015). The Critical Care Nursing Section (NZNO, 2014a) defines critical care nursing as “the provision of nursing care for patients and their families within critical care, intensive care, combined intensive/high dependency/coronary care, or high

dependency care units” (p. 2).

Missed nursing care in the IC environment happens due to the same work pressures as other nursing environments. Increased workloads, understaffing, lack of experienced staff, and admission to discharge influences from other medical areas in the hospital to accept and discharge patients from IC to accommodate patients according to their medical needs (Hov, Hedelin, & Athlin, 2007; Minton, 2015; Mpil, Chaboyer, & Mitchell, 2012; Winters &

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Neville, 2012). IC patients are compromised significantly by missed nursing care due to their frailty, life-threatening or chronic illness, and compromised health status. Missed nursing care in this environment may escalate a current illness or introduce new disease pathogens and cause higher rates of morbidity. The most common areas of nursing care that are missed or delayed in IC are oral mouthcare causing VAP, failure to turn patients regularly leading to pressure injuries, and lack of ambulation. Reduced patient mobility as a result of missed ambulation can cause such medical problems as pneumonia, delirium and extreme muscle weakness (Hov et al., 2007; Minton, 2015; Mpil et al., 2012; Winters & Neville, 2012).

The rationale for focusing this study on the IC environment is to highlight the impact of missed nursing care felt by nursing staff working in this intense clinical care environment. To give some background into the IC environment and the effects of missed nursing care in this environment, each of the main potential risks relating to missed care, including pressure injury, VAPs and mobility, will be discussed.

1.8 Missed nursing care triggering pressure injuries in IC

Pressure injuries are preventable, and their occurrence continues to be a problem in all healthcare settings. There are multifactorial reasons why patients may develop a pressure injury while in IC, including severity of illness, mechanical ventilation, bed confinement, and medications such as vasopressors and inotropes that reduce tissue perfusion (Kaitani, Tokunaga, Matsui, & Sanada, 2010; Gillespise et al., 2014). Patients may have decreased haemodynamic stability and fluid overload. There can be delays in patient care or missed nursing care when patients are not turned within the timeframe of every 2 hours as

recommended by the Pan Pacific Clinical Guidelines for the prevention of pressure injury (as cited in Australian Wound Management Association, 2012).

The financial cost to the healthcare organisation caused by pressure injuries is reflected in the increased length of patients’ stay in hospital, possible surgical interventions, wound dressing costs and medication cost due to potential infection risks (Moore, Cowman, &

Posnett, 2013). Patients who are unable to reposition themselves have reduced blood flow to their tissues causing soft tissue damage and ischaemia. When there is no pressure intervention, such as repositioning the patient, pressure to the tissue continues if the patient is not turned for long periods (2 hours or more) and the tissue may become irreversibly damaged (Moore et al., 2013). Currently, pressure injuries occurring in IC units

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remain a concern and are very much a direct consequence of delayed or missed nursing care.

1.9 Missed mouthcare and VAP

Seventy-five percent of patients in IC require ventilator support, and the use of mechanical ventilation makes patients susceptible to VAP (Sedwick et al., 2012). VAP is the second most common healthcare associated infection and is responsible for 25% of the infections that occur in IC. Patients who are exposed to VAP infections have mortality rates of 46% in IC, compared with the 32% mortality rate of IC patients who are not exposed to a VAP

infection. Additionally, patients who develop VAP during their IC admission stay, on average, 4 to 19 days longer in the unit and generally are intubated for much longer periods (Sedwick et al., 2012).

Pathogens linked to VAP in orally intubated patients become colonized in dental plaque and in the oral mucosa. Within 48 hours of admission to an IC unit, patients have changes in the oral flora which predominantly include gram-negative and other virulent organisms. These pathogens colonise in oral mucosa, which becomes a VAP infection (Sedwick et al., 2012).

Maintaining oral hygiene is one of the key components of VAP prevention. Oral hygiene care of patients receiving mechanical ventilation should consist of oral cavity assessment,

swabbing the oral cavity using an oral swab or toothbrush, suctioning, and oral rinses. These practices are commonly known as mouthcare. Mouthcare in IC is provided to patients inconstantly and continues to be an area of nursing care that is often missed (Berry,

Davidson, Masters, & Rolls, 2007). VAP is a potentially serious complication for patients who are already critically ill (Berry et al., 2007). There is much evidence to suggest that when mouth care is neglected VAP occurs. Despite this, mouthcare in IC continues to be one of types of basic nursing care that is frequently and routinely missed (Berry et al., 2007;

Sedwick et al., 2012).

1.10 Significances of missed nursing care involving mobility

Early and regular ambulation of patients in the IC environment helps prevents muscle weakness, delirium, and long-term complications for both ventilated and non- ventilated patients. The long -term complications for patients who have not been ambulated include longer stays in IC, increased need for rehabilitation, and decreased ability to return to work or to their normal life activities prior to IC treatment (Engel, Tutee, Alonzo, Mistitle, &

Rivera, 2013; Ledeitschke et al., 2012). The complications of increased ventilation or time in

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IC also increase patients’ exposure to infections such as VAPs and increase their mortality rate. Failure to ambulate patients can be linked to the onset of delirium, pneumonia, delayed wound healing, pressure ulcers, increased length of stay and delayed discharge.

Other adverse outcomes may include increased pain and discomfort, muscle wasting and fatigue (Engel et al., 2013; Leditschke et al., 2012).

Internationally and within NZ, many hospital IC units have implemented mobilisation guidelines and policies to support early mobilisation of patients, citing the benefits of this for their health outcomes. However, the literature also suggests that in many IC

environments, despite best practice guidelines, patient mobilisation is often an area of nursing care that is missed (Engel et al., 2013; Leditschke et al., 2012). The barriers preventing patients from being ambulated as part of their daily management plans can be reflected in the inability of the nurse to perform these tasks. Nurses who have a high patient workload and patient medical instability are common reasons why patients may not be mobilised in IC. Medical instability factors are unavoidable in IC as patient safety is paramount and any critical changes to a patient’s medical condition may indicate that mobilisation on that day is not appropriate or possible (Engel et al., 2013; Leditschke et al., 2012). However, organisational and management factors contribute to the amount of nursing care that is missed. Kalisch’s (2006, 2012) research findings suggest that these organisational factors include: failure to provide safe staffing levels; understaffed work environments; high patient to nurse ratios; poor teamwork; lack of delegation and poor communication across all healthcare teams.

1.11 Chapter summary

Missed nursing care is complex and there are many concerning factors that impact on the nurses’ ability to perform nursing care. The IC environment is an area of practice that does not escape the incidence of missed nursing care as summarised in this chapter. However, due to the complexity of patients in IC, when nursing care is missed or delayed, it exposes patients to a high risk of added medical complications and harm. The following chapter of this thesis will cover the literature evidence that surrounds the impact felt by nurses when nursing care is missed. It will provide a baseline of evidence of what is already known about missed nursing care and will contribute a complex review of missed nursing care in IC.

Following on from the literature review, the next chapter will focus on the methodology used for this research, providing details about the participants in this study and the research design. The results and findings chapter will follow, highlighting the themes and key factors

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found when investigating the impact of missed nursing care on the participants in IC.

Further discussion about those results will be explained and compared to the literature evidence found previously to form the Discussion chapter. The last chapter of this thesis contains recommendations for nurse education, nursing practice and research relating to the evidence and results of this research. Outlined in the Conclusion chapter are also the limitations and strengths of the research.

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Chapter Two Literature review 2.0 Introduction

This literature review sets out to investigate what is already known about missed nursing care and to explore the impact on nurses working in IC when nursing care is missed. The search methods of the review will be outlined along with an overview of the literature found. Impacts such as factors relating to nurses’ job satisfaction and organisational restraints such as staffing levels will also be included in this review. This literature review will explore the concept of missed nursing care from both a NZ and an international perspective.

2.1 Search methods

Keywords used for this literature search were ‘’missed nursing car”, “nursing care in ICU”,

“nursing missed care”, “missed nursing care in IC” “missed care” “omitted care”, “delayed care”, “rationed care”, “missed basic nursing care” and “missed nursing care in critical care”.

Peer reviewed journal articles were found through searches using the EIT library database. The database resources included CINAHL, ProQuest and Science Direct, and the resource tool was Primo search. The search focused on literature from 2000 to 2017. The search revealed that missed nursing care has been frequently researched, mainly focusing on what, how and why missed nursing care happens, but its impact on nurses has not been specifically researched and there has been little research that related missed nursing care specifically to the IC

environment. Most of the research investigated how missed nursing care happens in clinical practice. Over a hundred articles were found in the search but only those most relevant to the research question were reviewed.

2.2 The issues of missed nursing care

Missed nursing care is defined as any aspect of nursing care that is missed, omitted or delayed, either in part or in whole (Kalisch et al., 2009 p, 1512). Missed nursing care may change and affect patients’ health status, exposing them to risk of further infection or disease processes, increasing their length of stay in hospital, and potentially having life threatening consequences (Kalisch, 2006). The five most cited reasons for missed nursing care that appear in the

literature are as follows: Care is missed when there is an unexpected rise in patient acuity on the ward (Adams, 2016; Kalisch, 2012; Kalisch & Hee Lee, 2011 Kalisch et al., 2009; Ulrich, 2016); when there are inadequate numbers of staff on duty; during urgent patient situations

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(for example, worsening patient conditions); during heavy admission or discharge activity; and when there are inadequate numbers of assistive and clerical personnel (Adams, 2016; Kalisch, 2012; Kalisch et al., 2009; Kalisch & Hee Lee, 2011; Ulrich, 2016). The five most common types of nursing care that are being missed are monitoring of patients’ fluid intake and output, patient education, patient washes and skin monitoring, hand washing of nursing staff, and the administration of medication to patients. The impact on nursing staff involved in missed nursing care can lead to feelings of dissatisfaction in their ability to provide patient care, and to moral and ethical conflict (Adams, 2016; Henrich et al., 2017; Kalisch, 2012; Kalisch & Hee Lee, 2011; Kalisch et al., 2009). Nurses in NZ have a duty of care to provide safe nursing practice through their Nursing Council Code of Conduct standards and to do no harm in relation to beneficence and non-maleficence (NCNZ, 2010; 2012).

According to the NCNZ (2012), patients have the basic human right to adequate nursing care and care that is not missed. Conflict arises from nurses working within the healthcare

infrastructure because organisational influences, such as finances, limited staff resources, time restraints, high patient to nurse ratios, poor teamwork and ineffective delegation, may often affect the nurses’ ability to perform nursing care, resulting in care being missed (Adams, 2016;

Kalisch, 2012; Kalisch & Hee Lee, 2011; Kalisch et al., 2009; Ulrich, 2016). Traditionally, omitted and missed care was blamed on the individual nurse. However, recently in nursing there is a growing awareness and research-based evidence to suggest that omitted or missed nursing care is more likely to originate or stem from environmental, systemic (management) or organisational factors and/or restraints (Iapichino et al., 2005; Kalisch, 2006).

Kalisch (2006) led the research into missed nursing care and has conducted many studies that are investigated in this review. Kalisch’s first major research on missed nursing care involved a qualitative study to find out what nursing care was regularly missed in medical-surgical units in acute hospitals and what reasons nursing staff gave for not completing these aspects of care.

Kalisch (2006) focused on group interviews of a semi structured design of 107 nurses working in medical- surgical wards. The research showed that nurses were more likely to turn patients, rather than ambulate them, due to time restraints. Nurses felt that providing patients with medications and other life saving measures took precedence, even though medications were stated by Kalisch and Hee Lee (2011) as one of the main examples of missed care. Nurses felt that turning patients could often be delayed from the recommended 2 hourly and was more likely to reoccur 4 to 6 hourly. Tasks such as feeding and patient education and hygiene were also delayed or missed due to time restrictions. The documentation of patients’ fluid intake and output was reported as an area regularly missed due to nursing staff not having time to

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monitor patients going to the toilet or other staff members giving fluids to patients without the knowledge of their colleagues. The overall reasons nursing care was missed or omitted, according to the findings of this research, were that nurses felt that their environment was understaffed, there was poor use of existing staff resources, and the time required for the nursing intervention took longer than the planned nursing time. Also, ineffective work delegation and an ‘’It’s not my job’’ attitude was reflected in the nurses’ own beliefs (Kalisch, 2006).

Kalisch furthered her research with colleagues Landstrom and Hinshaw in 2009. Kalisch et al.

(2009) conducted an eight-step method of content analysis to examine the concept of missed nursing care. They found that, in the acute care settings, various themes that contributed to missed care presented through historical factors that impacted on the need for nurses to decide about the priorities of patient care. Elements of the nursing process and internal perceptions and values of the nurse were considered. This research showed that the overall concept of missed nursing care was complex and that the factors contributing to omitted care by nurses included the education level of staff members; years of nursing experience;

workloads; ability to have available the correct resources, such as equipment; teamwork; and organisational factors such as staffing levels (Kalisch et al., 2009).

2.3 Job satisfaction, staffing levels and organisational factors

The most recent research conducted by Kalisch and her research team in 2011 expanded further on the missed care concept and focused on the link between missed nursing care and job satisfaction. The researchers asked the question: “Does missed nursing care predict job satisfaction? This study by Kalisch et al. (2011) is, to date, the only research that looks at missed nursing care from the point of view of how it impacts on nurses directly, particularly focusing on their job satisfaction. Kalisch et al.’s (2011) study incorporated a large survey of 3135 registered nurses from 110 inpatient units in 10 Midwestern hospitals in the United States of America. The results showed that the nurses perceived there were fewer occurrences of missed nursing care in workplaces where nurses were more satisfied with their current positions and occupations. Kalisch et al. (2011) suggested that more focused interventions aimed at decreasing missed care and ensuring adequate staff workloads were needed to improve job satisfaction and patient care. The punitive treatment nurses felt exposed to when they reported missed care could be related to a high turnover of staff, which caused strain on an already taxed system. Nursing staff represents a significant part of personnel resources in a hospital. Kalisch et al. (2011) suggested that there was a need to evaluate the turnover of

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nursing staff when the pressure of missed patient care or delayed treatment might impact on job satisfaction and retention in the nursing workforce (Kalisch et al, 2011). The study also suggested that when staffing levels were higher, with adequate nurse to patient workloads, nurses had more job satisfaction. Safe staffing levels also reduced the incidence of missed nursing care (Kalisch et al., 2011).

Ball, Murrells, Rafferty, Morrow and Griffiths (2014) examined the number of missed care episodes by nursing staff in relation to staffing levels, quality of nursing care, and patient safety. The research method chosen was a cross-sectional survey questionnaire given to 2917 nurses working in general medical and surgical wards in England. The questionnaire consisted of four sections: work environment; job satisfaction; quality of care; and safety. Ball et al.’s (2014) findings suggested that the fewer patients a nurse was assigned to over a shift, the less nursing care was missed or omitted. Nurses in the study also reported that nursing care was missed more on night shifts when staffing levels were lower and fewer management teams were available, meaning fewer senior nurses to consult with or utilise if workloads increased (Ball et al., 2014). Other studies reported similar findings in relation to staffing levels

(Ausserhofer et al., 2014). However, Ball et al.’s study also highlighted other organisational factors, such as management structure and direction to nurses by management staff to reduce non-clinical nursing duties. Ausserhofer et al.’ s (2014) research is the largest multi-country, cross-section study on the topic of missed nursing care, including data collected from 33,659 nurses in 488 European hospitals. The findings of both Ausserhofer et al.’s study and Ball et al.’s study suggest that care was missed less often when staffing levels were higher and the nurse-to-patient ratios were lower. Both studies also suggested that management efforts to improve work environments, by reducing nurses’ non-nursing duties, had the potential to reduce the amount of omitted nursing care. Both Ball et al. and Ausserhofer et al. used large sample groups of participants through survey questionnaires, which added strength to their research results. However, they took a more general approach and did not look at the individual experiences of the nurses.

Jones, Hamilton and Murry (2015) reviewed the research on unfinished nursing care that focused explicitly on rationed care and care that had been left undone, referring to these as missed nursing care. Their review looked at 42 quantitative research reports. The results of this review enquiry found that time scarcity among bedside nurses was the primary driver in unfinished nursing care and that nurse managers had important roles to play in providing their environment with teamwork strategies to reduce missed care. Jones et al. (2015) also found that nurses needed to know how to prioritise care in response to time restraints and that this

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area of inquiry needed to be researched further. A study that did address the concept of low numbers of nursing staff and how it related to missed or omitted nursing care was done by Vryonides, Papastavrou, Charalambous, Andreou, and Merkouris (2015). This study focused on moral and ethical challenges that nurses might have faced due to the low numbers of nursing staff, causing missed care. These challenges included feelings of role conflict, guilt, and distress for the nurses looking after patients and not being able to provide the nursing care needed.

The focus of this study considered the effects on the nurse when care was omitted or missed, which was a different approach from the research done by Kalisch (2006, 2009) that looked at patients’ outcomes when care was missed. The research findings of Vryonides et al. would suggest that more research on the effect of missed care in relation to the nurse providing that care is needed, along with further research behind the moral and ethical outcomes of missed nursing care.

Factors influencing why nursing care is missed and the reasons behind missed care were investigated in a study conducted by Blackman et al. (2015), referred to as the MISSCARE survey. This study used a non-experimental exploratory approach that identified 16 latent variables. These variables were found to have a direct predictor effect on why nursing care was missed and included shift type (day/afternoon/night shifts), nursing resource allocation, health professional communication and workload intensity. Data were obtained by an electronic survey of 289 nurses in NZ. Blackman et al. (2015) confirmed many findings by Kalisch (2006, 2009) and Ball et al. (2012): Nurses often missed care as a result of increased workload, inadequate resources, and poor staffing levels.

Research conducted by Cioffi and Ferguson (2009) explored the skill mix of nursing staff in acute settings and found that team-based nursing practice in nursing environments reduced the incidence of missed care. Their study varied from others and investigated how teamwork and skill mix affected patient safety and the quality of nursing care. This study examined the team experience of nurses working in the acute care setting. Fifteen nurses took part in interviews, and the findings indicated that teamwork improved the quality of patient care and reduced the amount of nursing care that was missed. The findings of Cioffi and Ferguson’s research are similar to Ball et al.’s (2012) findings, and both show the same relationship between missed nursing care and staffing levels and workloads, supporting the research findings of Kalisch and Hee Lee (2011), who also investigated nurse staffing. Kalisch and Hee Lee used a cross-sectional descriptive design of research to find out if nursing staff supported teamwork within the workplace, expanding on Cioffi and Ferguson’s (2009) theory. Kalisch and Hee Lee (2011) found that having adequate levels of staffing, whereby the nurses’ workloads

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were reduced, was desirable to ensure nursing teamwork happened well in clinical practice.

The study also found that staffing mixes that included a mix of nursing skill levels and nursing competence also improved team work, leading to less missed or omitted care and better overall health outcomes for patients (Kalisch & Hee Lee, 2011).

2.4 Missed nursing care in IC

The studies conducted in IC settings mainly looked at direct and indirect nurse patient contact.

Direct patient-nurse contact occurs when the nurse has one-to-one contact with the patient.

Indirect nurse patient care involves tasks related to the patient, specific care planning and documentation. Much of this nursing care is based on task-related nursing care, time frames and workloads (Brack & Sandford, 2011; Gurse & Carayon, 2009; Malekzadeh, Mazluom, Etezadi, & Tasseri, 2013). A limited number of studies have been conducted to investigate the quality of the care given or indeed whether basic nursing care has been missed or omitted, and what the impact of missed care has on the nurse. The most current research sourced

concerning IC was a study by Henrich et al. (2017). Henrich et al. interviewed 19 nurses working in IC, not in NZ, and focused on the consequences of the moral distress of nurses working in IC. Moral distress in nursing practice was seen to have a significant effect on nurses and, when nurses were carrying this feeling of moral distress, it could affect patient care and the quality of interdisciplinary team relationships. The results showed that the most commonly reported emotion associated with moral stress was frustration from not being able to perform nursing tasks or to provide nursing care when needed. The nurses felt a sense of

powerlessness, frustration and guilt when nursing care was missed and this, in turn, caused anger and frustration when they were unable, as health professionals, to practise within their ethical standards and codes of conduct. This study by Henrich et al. looked at the environment of IC and investigated the impact of missed care on nurses from an international perspective. It suggested that missed nursing care is cyclical: Missed nursing care causes moral distress, which in turn causes further missed care.

Other research on missed care in IC was conducted by Malekzadeh et al. (2013). This research focused on a nursing shift handover protocol tool used to improve patient safety and reduce missed nursing care and errors in nursing practice. The aim of the research was to investigate the handover communication of information about patients in IC. According to Malekzadeh et al., ineffective staff handover accounted for delays in treatment and missed or omitted care.

This study recruited 56 nurses over a period of 6 months to use a shift handover evaluation checklist (Malekzadeh et al., 2013). On the checklist, certain nursing tasks were ticked as

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performed, not-performed or not indicated. Nursing care on the list included mouthcare, fluid balance measures, eye care, position changes, feeding, and routine washes along with other interventions. The results considered interventions performed before the introduction of the checklist and compared the findings of the data after the introduction of the checklist. The findings indicated that the overall communication at handover was better with the use of the checklist, which improved nursing practice, reducing errors and missed nursing care. This study showed that basic nursing care in IC, such as patient position changes, mouthcare, skin care and patient washes, is often missed by up to 75 % of IC nurses. It also found that implementing the shift handover protocol increased knowledge about patients’ needs, improved the quality of nursing care and reduced missed care meaningfully (Malekzadeh et al., 2013).

The purpose of Brack and Sandford’s (2011) study was to explore an alternative nursing model in the IC workforce to improve patients’ care and manage nursing workforce challenges. This study was an exploratory descriptive research design with two parts to the work force model, introducing enrolled nurses into IC and focusing on developing a partnership between enrolled nurses and RNs. Enrolled nurses were introduced to work in IC alongside registered nurses.

With the increasing workload of registered nurses in IC, this study looked at the inclusion of enrolled nurses in patient care to reduce the workload of RNs, therefore reducing incidences of missed or omitted nursing care. The findings of this study showed that patient hygiene and basic nursing care were less likely to be missed when enrolled nurses were employed to do these tasks, and there was a reduction in the number of patients suffering from pressure areas, along with overall improved nursing care of patients.

Similar research to that of Brack and Sandford (2011) was conducted by Binnekade, Vroom, de Mol and Haan (2003) and looked at including other staff members, such as enrolled nurses, in the daily care of patients to reduce the workloads of IC nurses. Binnekade et al. explored the use of non-experienced IC nurses to provide basic nursing care in order to reduce missed care.

It was an observational study to measure changes in the quality of care, looking at the number of errors or missed care per patient. In this study, 16 extra enrolled nurses were employed to assist the IC nurses with their basic nursing care over a 6-month period. Observations of 256 patients were completed. The results reported on the care given pre-employment of the extra nurses compared with post-employment when the extra nurses were involved. The results showed a significantly lower rate of missed nursing care (with the extra staff) and better patient safety. The use of extra nurses generated 6 minutes per hour extra time for IC in clinical practice, which accounts for 1 hour in an 8-hour nursing shift. As a result, missed nursing care was significantly reduced (Binnekade et al., 2003).

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Mphil et al. (2012) took Binnekade et al.’s (2003) research findings and expanded on them, by conducting a time and motion study of nursing care spent on direct and indirect nursing care in IC. The study by Mphil et al. sought to consider and analyse the work activities of IC nurses over a day shift. It was a time and motion observation design study, using 10 nurses who were monitored over their shift, with their activities recorded and timed. The activities were then coded according to whether they were direct or indirect patient care. Direct patient care was described as direct contact with the patient and indirect patient care was time away from patient contact, including documentation or nurse planning. The results found that 60 % of the care was direct contact, and 40 % was indirect patient care. Basic nursing care, such as patient washes, mouthcare and personal grooming, was often not done in this study and it suggested that basic nursing care was missed or omitted at some point (Mphil et al., 2012). This study provided valuable insights and showed how time restrictions may have led to missed nursing care, suggesting similar findings to Kalisch (2006). The literature suggests that high nursing workloads contributed to poor patient care and poor health outcomes for patients.

Gurses and Carayon’s (2009) research also supports the concept that nursing care could be missed due to increased nursing workloads. Gurse and Carayon looked at high nursing workloads and the links that reduced patient safety in IC. Their purpose was to

comprehensively identify and describe performance obstacles as perceived by IC nurses.

Qualitative interviews of 15 nurses were undertaken, and it was found that the obstacles that nurses encountered during a nursing shift were lack of equipment to perform care, inadequate number of staff around to help with patient cares, and poor performance by other nurses such as time management skills. These obstacles led to missed or delayed nursing care and job dissatisfaction for nursing staff. This study revealed that often care was delayed because of nurses’ inability to perform tasks with patients, due to patient assessment by doctors, visiting hours, or lack of support from other team members. The research also suggested that care was often delayed or missed due to poor communication between medical teams and nurses, with no structured mechanism to inform nurses about new orders written in patient medical notes (Gurse & Carayon, 2009).

Research conducted by Olausson, Ekebergh and Osterberg (2014) took a different view from other researchers of missed nursing care in IC. Their study explored how the environment affected the way nurses cared for critically ill patients. The qualitative study included 14 nurses and focussed on bed space design in the ward and on the lack of space and resources that affect how care is delivered, possibly leading to missed or omitted nursing care. The findings of this study suggested that nurses, and also unit managers, should aspire to making

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the bedside environment safer so that nurses can provide safer, nursing care (Olausson et al., 2014) This study does not place emphasis on missed care as such, but considers how having a safe workplace design can improve care, therefore reducing the incidence of missed nursing care. Another study that does not look at missed nursing care directly but was still relevant is one conducted by Hov et al. (2007). Their research considered IC nurses’ experiences, with the aim of gaining a better understanding of what was good nursing care for patients. Fourteen nurses were interviewed, and the results found that good nursing care depended on several basic conditions: continuity of care; knowledge and competence of the nurse; and cooperation between health professionals. Hov et al. (2007) looked at what aspects were needed to provide good nursing care but did not look at missed care directly. However, their study does suggest that, without continuity of care and with nursing staff who do not have adequate competency or experience, patients will be exposed to the risk of delayed nursing care or care that is missed altogether.

2.5 NZ research

The NZ research on missed nursing care provides a more local reflection on what is happening currently in practice and supports the evidence found internationally. The research mentioned before is literature from an international perspective. NZ research on the topic of missed nursing care is current and very inspiring, adding to the core knowledge of missed nursing care on a local and international level. Winters and Neville’s (2012) study is a qualitative research design study that explored missed nursing care, using a similar framework to that used by Kalisch (2006). Interviews were held with five nurses from acute medical and surgical wards in NZ. The themes that emerged were the types of care that were regularly missed, the reasons for that missed care, and the moral distress caused for nursing staff by missed nursing care (Winters & Neville, 2012). Hygiene cares was indicated as being one of those commonly missed, such as shaving, bathing and personal grooming. Turning of patients was also delayed or missed, along with patient ambulation. When patients were in hospital, many factors made it difficult for them to perform these tasks themselves, making nurse assistance necessary (Winters & Neville, 2012).

The consequences for the patients of not being turned or not being mobile were that their ability to get better might be compromised or other conditions, such as pressure injuries or infection, might develop. Other nursing care that was reported as being missed was delays to patients’ observations, such as recorded vital signs of temperature, blood pressure, heart rate, and respiratory rate (Winters & Neville, 2012). The nurse participants in Winter and Neville’s

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(2012) study expressed feelings of frustration and inadequacy when not being able to complete their tasks, and their feelings were accompanied by moral distress. Several participants expressed feelings of being unsupported by their managers and felt that the managers were not sympathetic to the nurses’ workload concerns. Nurses in this study also believed that staffing shortages impacted on and led to missed nursing care in practice (Winters & Neville, 2012).

Harvey et al. (2015) conducted research to explore the prevalence of missed nursing care in NZ. The study represents some replication of the MISSCARE survey tool created by Kalisch et al. (2009), which was used internationally to measure missed nursing care. The focus of this study was to replicate the research from other countries such as Australia and America, with the view of examining missed nursing care in order to make comparisons. The researchers used a mixed methodology, developing an electronic survey (Harvey et al., 2015). The survey was sent out to all NZNO members in NZ. A total of 199 nurses completed the survey, making a response rate of 23.6%, with 94% of them female. 33% of the respondents practised in medical and surgical wards, 15% in critical or IC, 13% in aged care, and 12% in primary health care. One of the findings from this survey found that the 88% of the participants worked over their rostered hours, even when sick, fatigued or stressed; with the reasons given being feelings of obligation to work because of their workplaces being short staffed (Harvey et al., 2015). When asked about adequacy of staffing, 61% of the participants thought that their workplace had adequate staff only 75% of the time. However, 17% felt that their nursing staff levels were inadequate all of the time. The missed care survey inquired about care reportedly missed during different nursing shifts over 24 hours. It found that weekends and night shifts reported higher incidences of missed nursing care, along with times when nurses worked longer hours than an 8 hour shift (Harvey et al., 2015). Three factors perceived by over half the participants in this survey indicated that missed nursing care was impacted upon by increased acuity or workload, urgent clinical situations, and inadequate staffing numbers (Harvey et al., 2015).

This study also suggested that nurses rationalise nursing cares. Some care is delayed and then it becomes missed when the nurse runs out of time to perform these tasks. The types of nursing care reported in the survey as missed or delayed included blood glucose monitoring, feeding patients, ambulating patients, personal grooming, and turning patients to avoid pressure areas (Harvey et al., 2015).

The most current research related to missed nursing care, from both a local and international perspective, was conducted by Willis, Harvey, Thompson, Pearson and Meyer (2017). It is NZ based study that followed up on the MISSCARE survey and focused on why nurses avoided and

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delayed nursing care, particularly considering work intensification and quality assurance factors. An overwhelming response from the research suggested that nurses blamed hospital management for missed nursing care. The nurses felt that management had the fundamental responsibility for poor staffing levels and, in fact, many participants perceived that the nurse managers were out of touch with the pace and workloads in the clinical area (Willis et al., 2017). This study considered missed care as rationalised care, a term used when nurses prioritise nursing care. Results showed that 14.5 % of the nurses who responded saw staff rosters as contributing to poor patient safety and nurse exhaustion (Willis et al., 2017). The inadequate skill mix of nurses on duty was also reported to compromise patient safety and contributed to nurses missing care. The participants commented that ward coordinators had patient loads and could not manage the nursing staff in the workplace, leading to missed care and a compromise in patient safety (Willis et al., 2017). Another finding of this study showed that nurses felt that when their concerns about skill mix and work intensification surfaces were voiced, management did not act on complaints and were unsympathetic (Willis et al., 2017).

Willis et al. (2017) also investigated the use of the CCDM tool designed to provide a safer work environment for staff. There were 363 participants in this research: 12% indicated that the CCDM tool was used in their workplace, but 28.65% of these participants commented that the manager assigned nurses’ patient loads (Willis et al., 2017). The participants also reported that even when the CCDM tool indicated the need for more staff, the hospital budget did not allow for extra staff and none would be located to the area of need. Overall, Willis et al. (2017) suggested that many nurses considered the CCDM tool to be a positive staffing tool.

2.6 Summary of the review

In summary, a review of the literature indicated that there is an abundance of research examining why nursing care is missed, but little about how this impacts on the individual nurse, which is the focus of this thesis. Nurses are also required to ensure patient safety in accordance with the NCNZ guidelines and codes of conduct. It is expected, therefore, that missing vital

Missed nursing care: Its impact on nurses working in intensive care