Practicing nurses, especially those at the bedside, would likely agree that there are elements of care that should be delivered that are simply missed. Patients may not be turned or ambulated as frequently as we would like, may not eat as much if no time is available for feeding, may not have linens changed or baths given frequently enough, or be taught enough information for us to feel safe about sending them home. Patients receive enough care to get through the shift, or get through the hospitalization, but not complete care. In fact, a serious gap exists between the care that we learn about and propose to deliver and what is actually given. According to a 2006 study by Beatrice Kalisch, nursing care has eroded over time, and omission of elements of care has become a routine. The reasons cited for omissions in care include decreased staffing, increased paperwork, and too little time.
Why should we be concerned about this? Nurses feel guilty about not providing care patients deserve and are frustrated; this can lead to decreased job satisfaction and increased turnover rates. Perhaps you know some nurses who have left our specialty, stating, "I just can't do it all." Routine omissions of care also place nurses at legal risk. Accountability for care is also an issue. Elements of care are increasingly being delegated to non-nursing personnel, with little to no accountability to nursing. The care then becomes, "not my job,"or something for someone else to worry about. Patients suffer from routine omissions of care. Omissions may increase the complication rate, increase length of stay as well as cost, and decrease satisfaction for both patients and families. This is a serious concern since neuroscience patients are often more dependent on nursing assistance than many other patient populations. In addition, the interventions that are missed are often the time-consuming ones.
How can we approach this problem? As with any problem, the solution begins with recognizing the problem exists. When nurses are involved in identifying a problem, they also become part of the solution. Staff nurses in particular must be afforded the opportunity to examine care delivered to identify areas that may be missed. Strategies to address those omissions can then be developed. Omissions in care cannot be allowed to become a habit.
An example of a successful approach to an omission in care was addressed by intensive care unit nurses related to mouth care. The need was discussed at a staff meeting, and nurses in attendance agreed upon the method and frequency for mouth care. With everyone committed, care was delivered. Not surprisingly, the pneumonia rate decreased and family satisfaction increased.
Nurse rounding programs have also been suggested as ways to prevent care omissions. Sharing care through care teams, such as nurse-coordinated mobility teams to turn, lift, and ambulate patients, is another approach.
It is also about time that we identify just how much time is needed to provide care, and use this data to enhance staffing. There is no doubt that nursing research into this area, as Kalisch has embarked upon, is sorely needed. Nurses also need to build confidence in support staff actions by becoming involved in training and delegation of responsibilities. Last, we must celebrate our commissions of care.
If you would like to share your ideas to prevent routine omissions in care, please write!! By incorporating such approaches, we can say that we have provided the best care that we can to our patients.