By Rose O. Sherman, EdD, RN, NEA-BC, FAAN
In a recent webinar, I discussed with leaders how important it is to give young nurses direction about what they can stop doing when short-staffed. One nurse leader jokingly told me that she clearly remembers as a new graduate, seasoned nurses told her to skip the baths that day and just do “pits and pubs.” She said they were very specific with me about what not to do.
Somehow we have lost that reality, and the expectation is that “everything is done for patients – no exceptions.” Young nurses with limited critical thinking skills are left to make their own decisions about what care to skip and may not make the right choices.
Dr. Beatrice Kalisch is well known for her research and assessment instrument on missed nursing care. Pre-pandemic, the nine key areas where nurses missed care included the following:
- Ambulation
- Turning
- Delayed or missed feedings
- Patient Education
- Discharge planning
- Emotional support
- Hygiene
- Intake and output documentation
- Surveillance
In her extensive research, Dr. Kalisch found that a significant percentage of nursing care was missed (pre- COVID), as demonstrated in one large study.
Ambulation three times per day or as ordered – missed 76% of the time
Mouth care – missed 64% of the time.
Medications administered on time – missed 60% of the time.
Feeding patient when the food is still warm – missed 57% of the time.
Patient teaching – missed 55% of the time.
Response to call light within 5 minutes – missed 50% of the time.
Patient bathing/skincare – missed 45% of the time.
Emotional support to the patient and family – is missed 42 % of the time.
Dr. Kalisch found that when missed care increases – nurses become less satisfied, and patient outcomes such as infections and pressure ulcers are directly impacted. She linked teamwork, lack of a healthy work environment, and staffing to missed care. A lack of teamwork alone accounted for 11% of the variance in missed care. We are seeing all this play out in real-time in our healthcare environments today.
Most acute care units today are staffed by fewer nurses with significantly less tenure than when Dr. Kalisch did her research. Making decisions about what care to miss without a significant impact on patients is complex and requires a high level of critical thinking.
Yet we are leaving our nurses to make their own decisions. I would urge leaders to talk with staff about how they make decisions about what care to omit and how frequently they do not do the following:
- Ambulate patients as ordered.
- Turn patients every 2 hours.
- Feed patients when the food is warm.
- Medicate patients within a one-hour window 30 minutes before or after the scheduled time.
- Assess vital signs as ordered.
- Monitor patient intake and output.
- Fully document all necessary data.
- Teach patients about their illness and the tests they will undergo.
- Provide emotional support to patients and families.
- Give baths and skin care.
- Do oral care.
- Do discharge teaching.
- Perform bedside glucose monitoring as ordered.
- Assess patients on each shift.
- Provide IV and Central line care per hospital policy.
- Respond to call lights within 5 minutes.
- Give PRN medications within 15 minutes after a request.
- Assess medication effectiveness.
- Attend interdisciplinary care planning conferences.
- Do skin and wound care as ordered.
These young nurses need our help in critically thinking through the decisions they are already making about what care can be missed.
© emergingrnleader.com 2022
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