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Missed care in children's nursing—An emergent concern

2019; Wiley; Volume: 75; Issue: 5 Linguagem: Inglês

10.1111/jan.13965

1365-2648

Annamaria Bagnasco, Nicoletta Dasso, Silvia Rossi, Fiona Timmins, Giuseppe Aleo, Gianluca Catania, Milko Zanini, Loredana Sasso,

Healthcare Decision-Making and Restraints

Journal of Advanced NursingVolume 75, Issue 5 p. 921-923 EDITORIALFree Access Missed care in children's nursing—An emergent concern 儿童护理方面看护的缺失——一个亟待解决的问题 Annamaria Bagnasco, Corresponding Author Annamaria Bagnasco annamaria.bagnasco@unige.it orcid.org/0000-0002-9079-8460 Department of Health Sciences, University of Genoa, Genova, Italy Correspondence Annamaria Bagnesco, Department of Health Sciences, University of Genoa, Genoa, Italy. Email: annamaria.bagnasco@unige.itSearch for more papers by this authorNicoletta Dasso, Nicoletta Dasso Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorSilvia Rossi, Silvia Rossi Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorFiona Timmins, Fiona Timmins orcid.org/0000-0002-7233-9412 School of Nursing and Midwifery Studies, Dublin, IrelandSearch for more papers by this authorGiuseppe Aleo, Giuseppe Aleo orcid.org/0000-0002-1306-3364 Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorGianluca Catania, Gianluca Catania Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorMilko Zanini, Milko Zanini orcid.org/0000-0002-1081-6279 Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorLoredana Sasso, Loredana Sasso Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this author Annamaria Bagnasco, Corresponding Author Annamaria Bagnasco annamaria.bagnasco@unige.it orcid.org/0000-0002-9079-8460 Department of Health Sciences, University of Genoa, Genova, Italy Correspondence Annamaria Bagnesco, Department of Health Sciences, University of Genoa, Genoa, Italy. Email: annamaria.bagnasco@unige.itSearch for more papers by this authorNicoletta Dasso, Nicoletta Dasso Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorSilvia Rossi, Silvia Rossi Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorFiona Timmins, Fiona Timmins orcid.org/0000-0002-7233-9412 School of Nursing and Midwifery Studies, Dublin, IrelandSearch for more papers by this authorGiuseppe Aleo, Giuseppe Aleo orcid.org/0000-0002-1306-3364 Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorGianluca Catania, Gianluca Catania Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorMilko Zanini, Milko Zanini orcid.org/0000-0002-1081-6279 Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this authorLoredana Sasso, Loredana Sasso Department of Health Sciences, University of Genoa, Genova, ItalySearch for more papers by this author First published: 13 March 2019 https://doi.org/10.1111/jan.13965Citations: 7AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat “Missed care”, coined initially by Kalisch (2006); and also defined as “unfinished care” or “implicitly rationalized care” (Jones, Hamilton, & Murry, 2015), is becoming of increasing concern to nurses internationally. Missed care is an error of omission in the care process that has three primary influencing factors: labour resources; material resources; and communication (Jones et al., 2015). The way by which these three latter factors influence the nurses’ “internal processes” (team norms, priority decision making, internal values, and beliefs and habits) determines whether or not care is missed (Kalisch & Xie, 2014). Missed care is a result of “implicit rationing as a form of clinical priority setting” rather than arising from deliberate action or inaction (Jones et al., 2015:1134). To measure the impact of missed care Kalisch went on to develop the MISSCARE Survey (Kalisch & Williams, 2009) used subsequently to examine this phenomenon internationally. Patterns and trends began to emerge suggesting that while essential nursing tasks receive priority, oral care, mobility/turning, preventative activities, education of patients and information giving are often overlooked. Subsequent follow-up in Italy revealed similar findings (Sasso, Bagnasco, Zanini, et al., 2017; Sasso, Bagnasco, Petralia, et al., 2017). There are potentially negative clinical consequences from this inaction, such as adverse events, falls, nosocomial infection, pressure ulcer formation, and increased mortality rates, although these have not been conclusively determined, nor are they consistent (Jones et al., 2015). Work in this field is ongoing with increasing efforts internationally to more closely identify tasks are left undone, what influences these decisions and how this impacts on patient outcomes (Aiken et al., 2012; Sermeus et al., 2011; Srulovici & Drach-Zahavy, 2017; VanFosson, Yoder, & Jones, 2017; Zúñiga et al., 2015). To address some of these issues, this topic is also the subject of an ongoing COST Action (Rancare, 2018a,b). This Action aims to develop expertise and knowledge for both research and clinical practice at European and international level, and also develop policy and practical approaches to the phenomenon. Action is also ongoing in Italy, where missed care is under close scrutiny. Importantly, Italy has a high nurse–patient ratio, 9.5 patients per nurse compared with other European with an average of 8 (Ausserhofer et al., 2014). Of concern in the context of this international research is that missed care is clearly influenced by staffing levels (Ball et al., 2018; Phelan, McCarthy, & Adams, 2018). Each additional patient per nurse has been found to have serious implications in terms of patient safety, such as a 7% increase in the risk of dying (Aiken et al., 2012). Missed care reduces by 50% when a nurse cares for six patients compared to when a nurse cares for patients (Ball et al., 2018). In the Italian RN4CAST study, a mean 41% of the key nursing activities were left undone, such as oral hygiene, changing patient's position, patient and family education, appropriate patient surveillance, and planning care (Sasso, Bagnasco, Zanini, et al., 2017; Sasso, Bagnasco, Petralia, et al., 2017). These results also demonstrated that, in keeping with RN4CAST findings internationally, nurses in Italy mainly tend to omit relational, communication, educational, and planning activities (Sasso, Bagnasco, Zanini, et al., 2017; Sasso, Bagnasco, Petralia, et al., 2017). However, while we have the same concerns as our international colleagues in terms of needing to understand and address missed care, we have an additional concern that the low staffing levels may adversely influence care so that missed care is possibly more widespread and pervasive. We have also identified are area where missed care that has received little attention internationally children's nursing. Children's nursing is a particular context that requires consistent high quality care due to the high number of children hospitalized each year (1.8 million) and their particular vulnerability to risk and harm standards should fall below expected (Owens, Thompson, Elixhauser, & Ryan, 2003). Care of the child is also more comprehensive and far reaching than nursing adults, as it involves care of individuals across a wide range of developmental phases but also care of the family (Glasper, 2017; Niemeier, Hektner, & Enger, 2012). Of particular concern from RN4CAST findings is that families may not be receiving the necessary education and support that they need. Indeed missed care would most likely have a more profound effect in this cohort, given the complexity of this field, the wide range of developmental phases of patients, increased prevalence of chronic illness and disability but also the requirement to care for the family (Glasper, 2017; Niemeier et al., 2012). Not educating the family and lack of preparation for discharge, for example, could have negative consequences on the child's recovery. Yet there has been only limited exploration of this topic. Recently Lake et al. (2017) did reveal that most nurses reported missing out on children's care, in the areas of documentation, health education, discharge preparation, oral hygiene, providing medications on time. Although essential issues like pain management were attended to, there were also small number who missed out on this too. These findings are of concern, particularly among this vulnerable population. However, one particular challenge with childrens’ care is that it is difficult exactly what elements of care were completely omitted, as parents often take over much of the child's care in the hospital setting. Other than missing out on completing documentation (Lake et al., 2017), which is usually a specific nurse role, whether or not parents then carry out tasks supposed to be done by nurses is not clear. Nonetheless missed care for children is something that is of concern and warrants more attention internationally. To address deficits in our understanding we recently adapted the MISSCARE Survey (Kalisch & Williams, 2009) under the guidance of Kalisch for use with children. The subsequent development of the MISSCARE Tool for Childrens’ Nursing (Bagnasco et al., 2018) has been so far piloted (N = 48) with nurses in Italy and has thus far confirmed the predicting factors for missed care as resources, material resources, and communication (Bagnasco et al., 2018). Further work using this MISSCARE survey paediatric version is essential for nurses internationally as there are consequences for missed care in this filed. Importantly from this pilot study we observed that even with using a reliable data collection instrument, determining a true picture of missed care is more challenging to identify in children's healthcare settings as much of the tasks related to caring for the child can be delegated to the family (Mackie, Marshall, & Mitchell, 2017; Jones & Lynn, 2018). This family presence is a support for their child and participation in the care, planning and decision-making empowers parents and make them feel part of their child's care (Wieczorek, Nowak, Frampton, & Pelikan, 2018). Indeed there is now a tripartite expectation, from child, nurse, and family that basic care needs are provided by the family (Curtis & Northcott, 2017). In fact, families will arrange ‘cover’ for one another when taking breaks, rather expecting the child's surveillance and care to be done by nursing staff (Curtis & Northcott, 2017). Overall the effect of missed care on either the family caregiver's role in terms of actual activities or lack of information/support is not clear, nor is it clear whether or not children's nurses truly miss care, as they may implicitly delegate it to parents. However in the context of missed care, parental support is possibly being overused and they could be of service to the organization (Wieczorek et al., 2018) and thus substituting for missed nursing care. If this is occurring then there are potential consequences, as the partnership between professionals and the family must not be permitted to fall into the mere ‘delegation’ of activities. Moreover, in this process, the family must always be supported, informed, and educated by nursing staff. However, if care is already being missed and thus falling to parents, it is likely too that information and support are also not occurring as these less tangible nursing actions are most frequently missed. Family caregivers need to be autonomous, but also supported and informed (Melo, Ferreira, Lima, & Mello, 2014). Studies exploring in more detail the extent of missed care among childrens’ nurses internationally are urgently required to determine the extent and true effect of missed care in childrens’ outcomes and on parental empowerment and support. ACKNOWLEDGEMENTS The Associazione Ospedali Pediatrici Italiani (AOPI) (Italian association of paediatric hospitals) funded and supported the study. REFERENCES Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., … Tishelman, C. (2012). Patient safety, satisfaction, and quality of hospital care: Cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ, 344, e1717. Ausserhofer, D., Zander, B., Busse, R., Schubert, M., De Geest, S., Rafferty, A. M., … Sjetne, I. S. (2014). Prevalence, patterns and predictors of nursing care left undone in European hospitals: Results from the multicountry cross-sectional RN4CAST study. BMJ Quality & Safety, 23(2), 126– 135. 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