1. Carlson, Elizabeth A.

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Errors of Omission: How Missed Nursing Care Imperils Patients by Beatrice J. Kalisch, 2015. Silver Springs, MD: American Nurses Association. 395 pages, $29.95.


Boost your Nursing Leadership Career: 50 Lessons That Drive Success by Kenneth R. White and Dorrie K. Fontaine. Chicago, IL: Health Administration Press. 295 pages, $44.00.


Newsletter: Becker's Hospital Review


The two books and one newsletter discussed are an eclectic grouping. Kalisch's book is research-informed and pertinent to nurses, students, and nursing leaders. White and Fontaine's book is for nurses as they plan a leadership trajectory. And Becker's is a newsletter focused on what is occurring in the world of healthcare.


Previously, I wrote about a book about missed care that was written from the perspective of a nurse who entered the hospital for surgery and encountered complications and poor outcomes (Carlson, 2017). This month one of the books is also about missed care but addresses the issue of missed nursing care first from the research perspective and then presents strategies to decrease missed care.


As the author states in the introduction, "[T]he content of this book address the problem of missed nursing care (standard, required care that is not provided), ramifications of missed nursing care, and strategies to decrease missed nursing care." (p. xv) The Institute of Medicine (1999) report To Err Is Human recommended that reporting errors not result in punishment but be seen as a way to improve care, and the same approach is important when identifying missed care. Kalisch states that early work in safety focused on errors of commission, but this book focuses on errors of omission. The author's list of the audience for this book is extensive and includes anyone giving care in any setting and students. This book highlights why missed nursing care is a "big deal" (p. xviii).


Part 1 addresses "The Problem" and begins with Chapter 1 "Patient Safety: Errors of Omission." This chapter details missed care the author experienced during a hospitalization. The author discusses the patient safety movement and error classification. Of particular interest is Figure 1.1 "The Missed Nursing Care Model" (p. 13) used as the conceptual framework for the book. It is based on Donabedian's (1988) structure, process, and outcome framework. Chapter 2, Missed Nursing Care, and Chapter 3, Reasons for Missed Care, present summarized study findings that demonstrate the extent of missed nursing care and the specific elements of nursing care not completed. The impact of missed care is discussed related to ambulation, turning and positioning, medication administration, hand washing, mouth care, emotional support, promoting sleep, discharge planning patient teaching, and nourishment. Using the MISSCARE Survey designed by Kalisch and Williams, the care that was missed and the reasons for missing the care were gathered and reported. The care that is missed is extensive and widespread. The reasons for missed care include the following: too few staff members, poor use of existing staff resources, time required for the nursing intervention, it's-not-my-job syndrome, ineffective delegation, habit, and denial. Kalisch discusses what research has learned about these and other reasons. Chapter 4 details the differences found in reports of missed care by nurses versus nursing assistants and between staff nurse and nurse leader report.


In Chapter 5, an interesting and revealing comparison is made between Magnet-designated and non-Magnet hospitals and the missed care that occurs. The difference in factors beyond staffing highlights the value of hospitals working toward and achieving Magnet designation. International missed nursing care is reported on in Chapter 6, and Chapter 7 looks at missed nursing care in the operating rooms.


Kalisch also reports on the patient reports of missed nursing care (Chapter 8) and patient outcomes resulting from missed nursing care (Chapter 9). In Chapter 10, the impact on nursing staff of missed nursing care is discussed. This chapter offers insight into staffing issues that may result when nurses are dissatisfied with their job and occupation because complete care is not able to be given. Issues such as moral distress, burnout, and compassion fatigue, as well as other outcomes resulting from the delivery of incomplete nursing care, are discussed related to their influence on the view a nurse holds of their job. Two specific issues resulting in missed care-staffing and teamwork-are discussed in Chapter 11 and Chapter 12, respectively.


Having identified the problems, in Part 1, strategies to decrease missed nursing care are presented in Part 2. The first set of strategies discussed is culture and leadership strategies (Chapter 13). Teamwork under the topics of culture, leadership, size of team, physical space, training, tools, structured protocols, systems redesign, handovers, and staff engagement is addressed in Chapter 14. The role of, and planned engagement of, the patient and family in patient safety and quality of care is discussed. Chapter 15 details how patient engagement can serve as a strategy to decrease missed nursing care. Positive outcomes and barriers to patient engagement are described, as are strategies to overcome these barriers. The last chapter looks at technical strategies that could be used to decrease missed care. The technologies discussed are more frequently found in acute care settings, but innovative use of them into other settings may be able to help reduce missed nursing care.


Each chapter has an extensive reference list that alone makes this book worthwhile, especially if this is a topic of concern for your practice. The book ends in an index. This is a very worthwhile book for students, nurses, and anyone in healthcare leadership, and I highly recommend it.


Boost Your Nursing Leadership Career: 50 Lessons That Drive Success by Kenneth R. White and Dorrie K. Fontaine. Chicago, IL: Health Administration Press. 295 pages, $44.00.


I find books like this interesting. My first thought upon reading the title was does this mean that this book is a sampling of 50 lessons or are these 50 the most important lessons? How can one use these brief lessons to boost his or her career? Given the length of the book, just short of 300 pages, the authors structured the content very effectively. Each lesson offers advice on a single topic and ends with an exercise or two and additional resources to help the reader delve more deeply into the subject matter. The exercises vary from having the reader reflect upon the chapter topic and create a written plan to suggesting someone to interview on the topic to taking a different approach when addressing a future problem. I found the suggested exercises to be pertinent and useful.


So what types of lessons are addressed? The list is fairly comprehensive. The lessons are divided into three sections. Section 1 focuses on managing yourself, Section 2 is on how to manage your job, and the third section looks at boosting your career. In the first section, there are 18 lessons including such topics as establishing a life vision, focusing your time, define and recalibrating expectations, developing a personal brand, and conquering negotiations. The second section, Manage Your Job, has 17 lessons. Selected lessons are as follows: own the job you have, embrace diversity as excellence, identify and support culture, listen to your stakeholders, manage your boss, find and fix problems, and innovate. And the third section offers 13 lessons to boost your career such as orchestrate your career, know and use your strengths, choose your mentor, handle failures and disappointments, discern when it is time to leave, and find your next job. Readers of course will select the lessons of interest to them.


I recommend the book as a good way to have an overview of lessons important to boosting your career. Not all readers need or want all lessons, and each person is at a different point in his or her career development, so this approach can be a useful way of determining what you need to learn to boost your career. It is written in an interesting and engaging manner that drew me in to continue to read lesson after lesson.


Newsletter: Becker's Hospital Review


One easy way I have found to keep abreast of some of the changes occurring in healthcare is through the Becker's Hospital Review e-mailed newsletter. I signed up when someone I work with mentioned a big change at one of the other hospitals in our area and I knew nothing about it. She indicated that she learned about the change via the Becker's Report. I find it to be interesting, easy to read, and informative. This report contains a wide range of topics, interviews, and updates. You can establish the frequency with which it arrives in your e-mail box, and I read it when I can and delete it when I'm too busy (


I recommend each of the books and the newsletter. Kalisch's book reminds us of the need to deliver complete nursing care to those for whom we are responsible. White and Fontaine's book is for nurses as they plan a leadership trajectory. And Becker's is a newsletter focused on what is occurring in the world of healthcare. All three are worth your time to read.




Carlson E. A. (2017). Medical errors, passing along nursing knowledge, and stress and burnout: Three books. Orthopaedic Nursing, 36(4), 308-309. [Context Link]


Donabedian A. (1988). The quality of care. How can it be assessed? JAMA, 260(12), 1743-1748. [Context Link]


Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press. [Context Link]