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STRATEGIES TO DECREASE MISSED NURSING CARE: STAFFING, TEAMWORK AND BEYOND
Beatrice Kalisch, PhD, RN, FAANTitus Professor of Nursing University of Michigan
School of NursingAnn Arbor, Michigan, USA
Oregon Nurses’ AssociationApril, 2016
Errors of Commission versus Omission
Commission “Doing something wrong”
– Wrong site surgery– Giving a patient a
medication they are allergic to
– Giving a patient the wrong dosage of medication
Omission “Failing to do the right
thing”– Missed Care– Failure to respond to an
urgent situation– Delay in treatment
…Any aspect of required patient care omitted or delayed
ERRORS OF OMISSION
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What we DON’T know
Presentation Outline
1. Missed nursing care and reasons2. Consequences/ outcomes 3. Solutions
1. Staffing2. Leader ship and culture3. Teamwork4. Patient engagement5. Technology6. Systems approach7. Measurement8. Unit design
CONCEPTUAL FRAMEWORK
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THE MISSED NURSING CARE MODEL
UNIT CHARACTERISTICSCase mix index
Nurse staffing (HPPD, RN HPPD, skill mix)Type of nurse staffing (education, experience)AbsenteeismWork schedules
HOSPITAL CHARACTERISTICS
•Size•Teaching intensity•Magnet
PATIENT OUTCOMES
e.g. Falls, infections, pressure ulcers, readmissions etc.
MISSED NURSING
CARE
STAFF OUTCOMES
e.g. Satisfaction,Turnover,intent to leave
TEAMWORK
How much nursing care is being missed?
Kalisch B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21:4; 306-313.
9 areas of missed care– Ambulation– Turning– Delayed or missed feedings– Patient education– Discharge planning– Emotional support– Hygiene– Intake and output documentation– Surveillance
Missed Care: A Qualitative Study
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Kalisch B & Williams R. (2009) The development and psychometric testing of a tool to measure missed nursing care (MISSCARE Survey). Journal of Nursing Administration. 39 (5). 211-219.
Acceptability Validity
– Content validity– Construct validity (EFA and
CFA) Reliability
- Consistency: Cronbach’s alphas 0.88 to 0.64 - Test-retest: 0.87
The Development & Psychometric Testing of theMISSCARE Survey
Kalisch B, G. Landstrom & R. Williams, (2009) . Missed Nursing Care: Errors of Omission, Nursing Outlook, 57(1), 3-9.
Research questions– What nursing care is missed?– What are the reasons for missing
care?
Methods– 3 hospitals in same system (459 RNs),
35 patient units– MISSCARE Survey-- response rate
57%
Findings– Large amount of missed care– Reasons – labor, material and
communication
Missed Care and Reasons: 3 Hospital Study
Kalisch, B., Tschannen, D., Lee, H., & Friese, C. (2011). Hospital variation in missed nursing care. American Journal of Medical Quality.
Research Questions
• To what extent is nursing care missed?
• How does missed nursing care vary across hospitals?
• What are the reasons for missed nursing care?
• Do reasons for missed care vary across hospitals?
• Does missed nursing care vary by staff characteristics?
Variations of Missed Care and Reasons across 11 Hospitals
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Study Sample
– Nursing staff on 124 adult patient care units in 11 hospitals.
– 4,412 nursing staff(3,349 RNs, 83 LPNs and 980 NAs)
– Return rate 57.3%– Hospitals ranged
from 60 to 913 beds
Age (over 35 yrs) 55% Gender (female): 90% Nursing education
(BSN or higher): 49% Experience (greater
than 5yrs): 54% Occupation (RN): 73% Employment status
(more than 30 hrs/wk): 82%
Shift worked (day or rotating shift): 58%
Measures
The MISSCARE Survey
Nursing Teamwork Survey (NTS)
– Kalisch, B., Lee, H., & Salas, E. (2010). The development and testing of the nursing teamwork survey. Nursing Research, 59(1): 42-50.
MISSCARE Survey-Patients
From hospital administrative data (unit level variables)
– Actual turnover– HPPD, RN HPPD,
skill mix– Unit Case Mix Index
(CMI)– Average daily
census– Fall rates
To what extent is nursingcare missed?
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Missed Nursing Care
Elements of Nursing Care % missed
Ambulation three times per day or as order 76%Interdisciplinary rounds 66%Mouth care 64%Medications administered on time 60%Feeding patient when the food is still warm 57%Patient teaching 55%Response to call light within 5 minutes 50%Patient bathing/skin care 45%Emotional support to patient and/or family 42%
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5 Most Often Missed Nursing Care
76%
66% 64%60% 59%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ambulation
Interdisciplinary careconference attendance
Mouth care
Timely medicationadministration
Turning
5 Most Least Missed Nursing Care
9%14%
24% 25% 26%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patient assessment
Glucose monitoring
Discharge plan
Vital sign
Focused reassessment
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Kalisch, B., McLaughlin, P. and Dabney, B. (2012). Patients perceptions of missed nursing care. Joint Commission Journal on Patient Safety, 38(4), 161-167.
Sample: 38 patients Method: In depth, semi-
structured interviews Fully reportable (e.g. bathing,
mouth care, pain medication)
Partially reportable (e.g. hand washing, vital signs, patient education)
Not reportable (e.g. nursing
assessment, skin assessment, intravenous site care)
What canpatients report about nursing care that is missed?
\
Kalisch, B., Xie, B., & Dabney, B. (in press). Patient reported missed nursing care correlated with adverse events. American Journal of Medical Quality.
What nursing care do patients report as missed?2 hospitals, 729 patients
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MOST AND LEAST MISSED
MOST MISSED
(1) Mouth care (50.3%)(2) Ambulation (41.3%)(3) Getting out of bed into a
chair (38.8%)(4) Providing information
about tests/procedures (27%)
(5) Bathing (26.4%)
LEAST MISSED
(1) Not listening to patients’ questions and concerns (7.8%)
(2) Not answering call lights (8.6%)
(3) Not responding to beeping monitor (8.8%)
(4) Requests not fulfilled (10.3%)
(5) Not being helped to the bathroom (10.9%).
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Comparison of Identified Missed Nursing Care : Nursing Staff vs. Patients
Note:1=Rarely or never missed, 2=Occasionally missed, 3=Frequently missed, 4=Always missed
2.17
2.17
2.09
1.91
1.35
1.88
2.53
1.55
1.44
1.82
1.54
2.19
1.8
1.91
1.8
1.68
1.61
2.06
1.52
1.81
1.57
1.71
0 0.5 1 1.5 2 2.5 3
Ambulation
Reposition Assitance
Patient Feeding
Patient Education
Patient EmotionalSupport
Patient Bathing/SkinCare
Patient Mouth Care
IV Check
Call Light Response
PRN MedicationResponse
Patient ToiletingAssistance
Nurse Perception Patient Perception
Does missed care varyacross hospitals?
5 MOST OFTEN MISSED
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5 LEAST MISSED CARE
Variation
0 10 20 30 40 50 60 70 80 90
Ambulation three times per day or as ordered
Mouth care
Attended interdisciplinary care conferences whenever held
Medications administered within 30 minutes before or af ter scheduled time
Turning patient every 2 hours
Patient discharge planning and teaching
Vital signs assessed as ordered
Focused reassessments according to patient condition
Bedside glucose monitoring as ordered
Patient assessments performed each shif t
Mean ± SD Percent Reported as Missed Always, Frequently, or Occasionally
• The solid bars represent the means across all hospitals, and the range-lines indicate the standard deviations
What are the reasons formissed nursing care?
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Overall Reasons for Missed Care
Reasons For Missed Care
LABOR RESOURCES ‐ OVERALL 92.8
(Level of staffing) Inadequate number of staff 91
Urgent patient situations (e.g. a patient's condition worsening) 92
Unexpected rise in patient volume and/or acuity on the unit 95
Inadequate number of assistive personnel (e.g. nursing assistants, techs, unit secretaries etc.)
94
Heavy admission and discharge activity 93
Reasons for Missed Care(continued)
MATERIAL RESOURCES – OVERALL 89.6
Medications were not available when needed 95
Supplies/equipment not available when needed 90
Supplies/equipment not functioning properly when needed 84
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Reasons For Missed Care(continued)
COMMUNICATION/TEAMWORK – OVERALL 81.8Unbalanced patient assignments 91
Inadequate hand‐off from previous shift or sending unit 88Other departments did not provide the care needed (e.g. physical therapy did not ambulate)
85
Lack of back up support from team members 80Tension or communication breakdowns with other ancillary/support departments
80
Tension or communication breakdowns within the nursing team 76
Tension or communication breakdowns with the medical staff 82
Nursing assistant did not communicate that care was not done 85
Caregiver off unit or unavailable 70
Other Reasons
FATIGUE– Long work hours– Mandated overtime– Rotating shifts – Lack of breaks– Multiple jobs– Moral distress– Burnout– Compassion fatigue
Other Reasons (continued)
Interruptions, multitasking and task switching
Cognitive biases
– Omission bias, bandwagon effect, status-quo bias
Complacency and habit: mind not on task
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How do reasons for missedcare vary across hospitals?
Reasons for Missed Care across 11 Hospitals
1 2 3 4 5 6 7 8 9 10 11
Labor Resources(Total: 93%)
92% 96% 87% 92% 92% 94% 96% 94% 96% 94% 95%
Material Resources(Total: 90%)
84% 91% 88% 86% 88% 90% 91% 94% 93% 89% 92%
Communication(Total: 82%)
79% 75% 80% 79% 80% 83% 84% 78% 84% 83% 82%
Gender and education: No difference
Age: Under 35 reported less missed care than those over 36
Experience: less than 6 months reported the least
Work schedules:– Night shifts less– Less than 12 hour shift less
missed care Absenteeism: Staff missing
more shifts, more missed care
How are staff character-isticsassociated with missed nursing care?
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Kalisch, B. (2009). Nurse and nurse assistant perceptions of missed nursing care: What does it tell us about teamwork? Journal of Nursing Administration, 39(11):485-493
RNs reported significantly more missed care than NAs
RNs reported more missed care on elements of care typically completed by NAs
Do RNs and NAs (nursing assistants) have the same assessment of missed nursing care?
Kalisch, B. and Lee, K. (2012). Missed nursing care: Magnet versus non-Magnet Hospitals. Nursing Outlook, 60 (5):32-39.
Magnet hospitals had significantly less missed care.
Magnet hospital staff reported less staffing and communication problems.
There is no difference in staffinglevels and type
Is there a difference in missed nursing care in Magnet vs. non-Magnet hospitals?
Kalisch, B., Tschannen, D., and Lee, H. (2011). Does missed nursing care predict job satisfaction? Journal of Healthcare Management. 56(2): 117-134.
The more missed nursing care, the higher the dissatisfaction with their current position (p < 0.001) and with their occupation (OR = 0.57, 95% CI = 0.41 – 0.80).
Males less satisfied (OR = 0.69, 95% CI = 0.53 -0.90)
NAs less satisfied than RNs (OR = 0.28, 95% CI = 0.20 - 0.40).
ADN nurses more satisfied than BSN nurses (OR=1.12, 95% CI = 0.12 – 0.90).
Does missednursing carepredict jobsatisfaction &/oroccupationsatisfaction?
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Tschannen, D., Kalisch, B., & Lee, K. (2010). Missed nursing care and nurse turnover and intent to leave Canadian Journal of Nursing Research, 42(4): 22-39.
Units with higher missed care (β =
.302, p< .0001) and greater absenteeism (β = .247, p= .034) had more plans to leave.
However, units with nursing staff who worked overtime (β =-.283, p= .001)
and were older than 35 years (β
=-.270, p= .050) less likely to leave. Model accounted for 58.4% of
the variation in intent to leave Turnover not related to missed
nursing care.
Does missed nursing care predict intent to leave and/or turnover?
Relational Job Theory (Grant )
People more motivated when they witness a positive impact of their actions on their beneficiariesNurses have direct knowledgeDescribe their work as protecting the welfare of others
“Benevolent employees” motivated to give more to others than they get back
When nurses cannot or do not provide acceptable care, they are more dissatisfied with their jobs than would be true for employees who do not have these values and service orientation.
Does missed nursing care impact patient outcomes?
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Kalisch, B. J., Tschannen, D., & Lee, K. H. (2011). Missed Nursing Care, Staffing, and Patient Falls. Journal of Nursing Care Quality,
Does missed nursing care mediate the relationship between staffing and patient falls?
Equation 1 R2=9.6%β=-.31 (p<.001)
Equation 2R2=13.0%β=-.36 (p<.001)
PATIENT OUTCOME
S- Fall rate
MISSED NURSING CARE
STAFFING- HPPD
Equation 3R2=8.7%β=-.20 (p=.030)
Equation 3R2=7.8%β=-.29 (p=.001)
Patient reported missed nursing care and adverse events
The higher the patient reported missed nursing care, the more adverse events
– Skin breakdown/pressure ulcers– Medication errors– New infections– Falls– IVs running dry– IVs leaking
What difference does it make?• Failure to
ambulate – New onset delirium – Pneumonia – Delayed wound healing – Pressure ulcers
– 2006, more than 500,000 hospital stays with pressure ulcer
– 1993: 280,000 (80% increase) – Increased LOS – Increased pain and
discomfort – Muscle wasting and
fatigue – Physical disability
• Failure to do mouth care – Reluctance to eat– Pressure ulcer
development– Pneumonia, particularly in
ventilated patients
• Failure to turn– Pressure ulcers– Pneumonia– Venous statis– Thrombosis– Embolism– Stone formation– UTI– Muscle wasting– Bone demineralization– Atelectasis
• Failure to administer medications– Example: Clostridium
difficile missing the first two doses of vancomycin—increased LOS
• Failure to teach– Adverse events– Readmission
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What difference does it make?
• Failure to sleep– Mental impairment– Susceptible to infections– Slows recovery, longer LOS
• Failure to wash hands
– HAIs (CAUTIs, CLABSIs, etc.)
• Failure to answer call lights
– Death, adverse events– Falls– Increased LOS– Increased pain & discomfort
• Failure to eat– Greater mortality– Higher nursing home use– Infections – Increased LOS– Readmission– Higher costs
• Failure to provide emotional support
– Feelings of not being safe– Lack of hope– Distressed, agitated – Inability to cope
• Failure to do interdisciplinary rounds
– Adverse events– Readmissions– Catheters in too long– Higher mortality
Post Hospital Syndrome
During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity. Each of these trepidations can adversely affect health and contribute to substantial impairments during the early recovery period, an inability to fend off disease, and susceptibility to mental error (Krumholtz, NEJM, 2013).
Post Hospital Syndrome (continued)
Hospitalization sentinel event often precipitates disability– Inability to live independently--basic ADLs
Hospitalization-associated disability -- one-third of patients 70 years of age and over
20% readmitted; $26 billion annually– More than $17 billion of it pays for unnecessary
readmissions
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How does missed nursing care vary across countries?
More missed care in Italy and USA; least Iceland and Lebanon
More reasons for missing care in Turkey and Lebanon
Family members in hospital Other countries
Kalisch,B, Doumit, M, Lee, K.H., Zei, J. (2013). Missed nursing care, level of staffing, and job satisfaction: Lebanon Versus the United States. Journal of Nursing Adminstration; Kalisch B, Terzioglu, Duygulu (2012). The MISSCARE Survey-Turkish. Nursing Economics, 30(1) 29-37.Bragadóttir, H., Kalisch, B., Jónsdóttir, H.,H., Smáradóttir, S. (in press). Translation and psychometric testing of the Icelandic version of the MISSCARE Survey. Scandinavian Journal of Caring Sciences. Available on line ahead of press.
How does missed nursing care in the USA compare with other countries?
Mean number of patients cared for, admissions, and discharges during last shift: A comparison across countries (Mean ± SD) (N=6212)
USA Iceland Australia Lebanon Korea Italy
Patients cared for
4.10±1.74a
5.81±3.01b
5.31±3.
01b
4.12±2.6
0a
9.87±7.
30c
13.25±4
.07d
Admissions1.09±1
.13a
1.00±1
.86a
2.03±2.
71bc
1.57±2.2
8ab
2.38±3.
39c
3.49±2.8
4d
Discharges
0.83±1
.16a
0.95±1
.89a
1.67±2.
48b
1.34±2.1
2ab
2.10±3.
34c
3.03±2.
48d
SD, standard deviation.Note: Means that do not share subscripts differ at p<.05 using the Bonferronicorrection @all rights protected. Do not reproduce without
permission.
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STRATEGIES TO REDUCE MISSED NURSING CARE
STRATEGIES
• Staffing• Culture and leadership• Teamwork• Patient engagement• Technology• Systems approach• Measurement• Unit design
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Kalisch, B., Tschannen, D. (2011). Do staffing levels predict missed nursing care? International Journal for Quality in Health Care, 23(3): 1-7. Bivariate analyses
– Higher Hours Per Patient Day (HPPD)
associated with less missed care (r=-0.32,
p<0.01)
Higher RN Hours Per Patient Dayassociated with less missed care (r=-
0.27, p<0.01)
Skill mix no significant relationship
Multivariate analysis – The higher the HPPD, the lower the
level of missed nursing care (β = -.45, p=.002).
– Other variables not significant predictors of missed nursing care.
– Overall model accounted for 29.4% of the variation in missed nursing care (p<.001).
Do nurse staffing levelspredict missed care?
Kalisch, B. and Lee, K. (2011). Nurse staffing levels and teamwork: A cross sectional study of patient care units in acute care hospitals. Journal of Nursing Scholarship, 43(1): 82-88.
Nurses taking care of fewer patients rated teamwork higher
The more staff perceived their staffing as adequate, the higher teamwork
HPPD and skill mix significantly associated with teamwork
After controlling for CMI and bed size, the higher the HPPD, the higher the teamwork (β=.417, p= .033)
The higher the skill mix, the higher the teamwork (β=.436, p= .009)
Overall model accounted for 33.1% of the variation in teamwork (p=.003).
Do nurse staffing levels pre-dict nurs-ing team-work?
Staffing (continued)
Essential but not everything Making the case for adequate staffing:
tie into patient and nursing staff outcomes and cost
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Culture and leadership solutions
"Culture is everything“ Focus on prevention, not punishment
– Build a culture of safety and move beyond the culture of blame
– Acknowledge that missed care occur
Focus on team culture Need open dialogue supported by management Support of safe practices such as structured
protocols (do not interrupt med administration; standardized
communication processes, etc.)
Culture and leadership solutions (continued)
Conduct strategic planning to create a safe, quality culture
Transformational leadership (vs. transactional)
TEAMWORK
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Kalisch, B. & Lee, K. (2010). The impact of the level of nursing teamwork on the amount of missed nursing care. Nursing Outlook.58(5), 233-241.
Controlling for occupation of staff members (e.g., RN/LPN, NA) and staff characteristics (e.g., education, shift
worked, experience, etc), teamwork alone accounted for about 11% of missed nursing care.
Does teamworkpredict missed nursing care?
Teamwork …..
increase in patient safety higher level of job staff satisfaction higher quality of care greater patient satisfaction with their care more productivity decreased stress level
Kalisch, B., Weaver S., & Salas, E. (2009). What does nursing teamwork look like? A qualitative study. Journal of Nursing Care Quality, 24(4), 298-307.
34 focus groups Substantiated that the
Salas model of teamwork applies to inpatient nursing teams
What does nursing teamwork look like?
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Salas Model: 8 behaviors
1. Team leadership
2. Team orientation
3. Mutual performance monitoring
4. Back up
5. Adaptability
6. Closed loop communication
7. Shared mental model
8. Mutual trust
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Mutual Trust
Shared Mental Models
Closed LoopCommunication
Team Leadership
Team Orientation
Mutual Performance Monitoring
Back-UpBehavior
Adaptability
THE CORE
Team Leadership
Team leadership refers to the structure, direction and support provided by both the formal leader and/or on the part of team members.
Everyone should act as a leader at some point.
Team Orientation
Team’s awareness of itself as a team
Team’s success takes precedence over individual performance
– Do not view themselves as isolated individuals
– Team members first
Team members see that part of their job is to ensure that everyone on the team can and do get their work done in a quality way.
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Team Orientation (continued)
Example comments when not PRESENT:
Counting the number of patients assigned
“Days left baths for me.” RN looking for a nursing assistant to put patient on
a bedpan.
Mutual Performance Monitoring
The observation and awareness of team members of one another.
Effective team members keep track of fellow team members’ work while completing their own work.
Mutual Performance Monitoring (continued)
Could be interpreted in negative terms (e.g. spying, trying to find problems etc.)
But it is accepted as part of a “psychological contract/ agreement” among the team members.
– They agree that is appropriate to watch one another in order to maximize the overall performance of the team.
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Mutual Performance Monitoring (continued)
EXAMPLES:
– A nurse watching another nurse to ensure they are following procedures Hand washing, medication administration
– The nursing assistant observing the behavior of the nurse Example: a nurse leaves a medication at the patient’s
bedside
Back-Up
Team members help one another with their tasks and responsibilities.
Unable to perform tasks or carry out responsibilities and another team member steps in.
Can be a physical act or feedback.
Back-Up (continued)
Back-up is critical for teamwork for it means that the team is more than the sum of its parts.
Requires willingness to provide and seek assistance.
– Willingness to jump in and help and accept help without fear of being perceived as weak.
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Back-Up (continued)
Example comments when NOT present:
RN: Sometimes I feel bad asking for help. It looks like I am just not able to handle my job, that I am not a good nurse. And there are times when you have asked for help and you don’t get help.
CNA: I just don’t like it when a nurse walks by my blinking light, and I am in the room with a patient doing something and she walks by twice and doesn’t bother to stop by and say “May I help you.”
Adaptability Ability to adjust strategies and resource
allocation on the basis of the information gathered from the environment.
Example when present– Nursing Assistant: Some units really watch out for their
NAs and make sure they are not being given too much work.
Example when NOT present– RN: We have staff on both 8- and 12-hour shifts and
instead of reassigning patients so the nurse coming on doesn‘t have patients on all three wings, we let her run.
Closed Loop Communication The active exchange of information between two
or more team members where both parties have the same understanding of what was communicated (closed loop).
Essential: – Individually team members may have an
understanding of a situation, work they need to do . . .
– But for a team to act in concert to achieve common goals, the team must have shared information.
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Closed Loop Communication (continued)
Important issues are brought before the team and not ignored.
Constructive conflict is inevitable.
– Without it, no way to sense the need to change
or draw attention to problems.
– Need to be able to deal with it in a positive manner.
Closed Loop Communication (continued)
Example when NOT present:
Not giving nursing assistants report until 2 hours into the shift.
Nursing assistant goes on break and does not tell other staff.
Shared Mental Models
What people use to organize information about the environment, the team purpose and team interdependencies.
Example when NOT present:– RN: A nurse floated to our unit and did things the way they do on
her floor. This created a safety problem because she thought the other staff members would give her patients their medications when she took a break. She found out several hours later this was not the case.
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Mutual Trust Shared perception that members will perform
actions necessary to reach interdependent goals and act in the interest of the team.
Trust occurs when the individual has the expectation that their teammates will take actions that will most benefit the team.
Example when NOT present:– RN: If I work with certain people, I know a good
job is being done.– RN: I would like to believe the aide when she
tells me she ambulated the patient, but I am not sure.
Kalisch, B. and Lee, K. (2013). Variations of nursing teamwork by hospital, patient unit, and staff characteristics. Applied Nursing Research 26(1). 2-9.
Type of unit– Highest: psychiatric, perioperative – Next: ICU, pediatric, maternity units
next; – Lowest: Medical-surgical,
intermediate, rehab, ED
Shifts– Full time less teamwork than part
time.– Nights more teamwork than days,
evenings
How does nursing teamwork vary by hospital, patient unit and staff?
Teamwork Solutions
Training (e.g. simulation, Crew Resource Management (CRM), TeamSTEPPS, nursing teamwork, other training, etc.),
Tools to enhance teamwork (e.g. checklists, goal sheets, case analysis, etc.)
Systems interventions (e.g. workflow assessment and redesign, reconstruction of care teams, resizing teams etc.)
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Kalisch, B., Lee, H., and Rochman, M. (2010). Nursing staff teamwork and job satisfaction. Journal of Nursing Management, 18, 938-947.
Satisfaction with position– The more satisfied with
current position, the higher the teamwork score (F [4, 212.727] = 113.256, p < 0.001)
Satisfaction with occupation– The more satisfied with being
nurse (or attendant), the higher the teamwork score (F [4, 3699] = 30.709, p < 0.001)
Planning to leave position– The more likely to leave, the
lower the teamwork score (F [2, 541.891] = 25.475, p < 0.001)
Does nursingteamwork predict job satisfaction & occupationsatisfaction?
Kalisch, B., Gosselin, A. and Choi, S. (2012). A comparison of patient care units with high versus low levels of missed nursing care. Health Care Management Review.37(4), 320-328.
Qualitative study– 5 units with the most missed
care– 5 units with the least missed
care
Key primary difference was teamwork
How do patient care units with high vs. low levels of missed nursing care differ?
Kalisch, B., Curley, B. and Stefanov, S. (2007). An intervention to enhance nursing teamwork and engagement. Journal of Nursing Administration, 37(2): 77-84.
41 bed medical unit, 55 staff Measures
– rate of patient falls – the staff’s assessment of level
of teamwork on their unit – vacancy and turnover rates
Is an intervention to increase nursing teamwork & engagement effective? 7.73
2.99
0
1
2
3
4
5
6
7
8
9
mean before mean after
Fa
ll R
ate
/10
00 P
atie
nt D
ays 13.14%
5.23%
8.05%6.14%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
Before After
Perc
ent T
urno
ver o
r V
acan
cy
Turnover
Vacancy
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Kalisch, B., Abersold, M, Tschannen, D., McLauflin, M. and Lane, S. (in press). An intervention to increase nursing teamwork using virtual media. Western Journal of Nursing Research
Medical unit 1 hour Second life Significant increase in
nursing teamwork Missed care did not decrease
significantly
Can virtual simulation be used to increase nursing teamwork and decrease missed nursing care?
Kalisch, B., Xie, B. & Ronis, D. (2013) A train the trainer intervention to increase teamwork and decrease missed nursing care in acute care patient units. Nursing Research. 62(6), 405-413. Train the trainer (staff nurses 3 from
each unit serve as trainers)– Each staff member received 3 one
hour sessions during work hours on their units
Role play scenarios typical of teamwork problems– Patient needs bedpan, asks RN,
searches for nursing assistant – Day shift does not do the patient’s
bath and night shift staff resents it Debriefing
– 8 elements of teamwork– What care is missed because of
teamwork problems
A train-the-trainer intervention to increase teamwork and decrease missed nursing care
Teamwork solutions (continued)
Does a train-the-trainer intervention increase nursing teamwork and decrease missed nursing care?
30
Patient and family engagement solutions There has been significant interest internationally in
involving patients in efforts to improve patient safety
Example: Nurse administering drugs in hospitals could enable patients to be involved in the final check that takes place at the point of care– Communicates respect – Educates patients; reinforces patients’ understanding of
what drugs being given and why – Opportunity for questions and to express concerns– Chance for patient to check that appropriate steps being
taken
Patient and family engagement solutions Liberal visitation Interdisciplinary rounds at the bedside Including family members in rounds Permitting patients’ to read and write on their own
healthcare record Change of shift report at the patients’ bedside Putting patient advocate on the care team Patient councils and committee memberships
Technology solutions
Electronic Health Record– work lists or queues, dashboards
Electronic reminders Phones, pagers, nurse call systems and other
communication devices Barcoding Tracking devices (e.g. hand washing)
Mobile technology
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Systems solutions
Humans are viewed as fallible and errors can occur, even in good organizations (Reason, 2000) Ask: “Why did it happen”
Systems solutions (continued)
Use Human Factors Principles Avoid reliance on memory Simplify Standardize Use constraints and forcing functions Use protocols and checklists
Systems solutions (continued)
Target and eliminate systems vulnerabilities – We'll never eliminate all individual errors
The goal is to design systems that are "fault tolerant," so that when an individual error occurs, it does not result in harm to a patient.
Look for ways to break that link in the chain of events that can create a recurring problem
Learn from close calls ("near misses“) Focus everyone's efforts on continually identifying
potential problems and fixing them.
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Measurement
You get what you measure!
You cannot use information you do not have.
Measure attitudes
The Safety Organizing Scale Hospital Survey on Patient Safety
Culture The Safety Attitudes QuestionnaireEtc.
Measure processes
Hand washing Time to resuscitate Documentation Missed nursing care Etc.
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Measure outcomes Falls Pressure ulcers Infection rates
– Urinary catheter-associated urinary tract infections– Central line catheter-associated blood stream infection rates– VAP
Hospital length of stay Readmission rates Mortality Restraint prevalence Etc.
Unit Design
Smaller units
Decrease the size of nursing teams
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
0
50
100
150
200
250
300
TEAM SIZE
FREQUENCY (Number of occurances)
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The bigger the team the more transactions
610
15
21
28
36
45
55
66
0
10
20
30
40
50
60
70
1 2 3 4 5 6 7 8 9 10 11 12
Group Size
Tra
nsa
cti
on
Ch
an
nel
s
Group ComplexitySize of Number of Group Sub-groups
4 118 24716 65,51924 16,777,191
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SHIFT REPORTS
January April
Kalisch, B., Russell, K. and Lee, K. (2013). Nursing teamwork and unit size. Western Journal of Nursing Research. 35 (1).
n=2,265; 53 units 4 hospitals
The larger the unit, the less the nursing teamwork
How does nursing teamwork vary with the size of patient units?
In summary…
An extensive amount of nursing care is missed
The reasons for missed care are inadequate labor and material resources and communication/teamwork plus cognitive processes
Both amount and type of missed nursing care and reasons are similar across hospitals
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In summary…
Higher teamwork results in less missed nursing care
The higher the staffing levels, the less the missed nursing care and the higher the teamwork
More missed care and lower teamwork leads to less satisfaction and more intent to leave
In summary…
Missed nursing care leads to negative patient outcomes
Patient can report on whether or not specific aspects of their nursing care have been completed and has the potential of adding an important measure of the quality of nursing care
The EndQuestions?Comments?