The Missed List: Revelations of Busy NICU Nurses

Findings: Missed Most, and Why

Slightly more than half (52%) of the respondents reported missing at least one (and a median of five) of the 35 common nursing care activities during their last shift worked. The care activities most often missed were attendance at rounds, oral hygiene for intubated infants on mechanical ventilation, routine infant care activities (eg, bathing), parent education, involving parents in care, and oral feeding. Other nursing care activities reported as "frequently missed" by the highest percentage of nurses included assessing the effectiveness of a medication within 30-60 minutes of administration and administering feedings when infants exhibited hunger cues. Nursing care reported to have been missed least frequently included medication administration, patient assessment (either comprehensive patient assessments or focused reassessments), and hand hygiene (Table 1).

Table 1. Percentage of Nurses Who Reported Missing Nursing Care Activities During Their Last Shift Worked

Nursing Care Activity	Nurses (%)*	Nursing Care Activity	Nurses (%)*
Attended daily rounds	44.0	Peripheral IV site care	25.0
Oral care (ventilated baby)	41.3	Communicated labs/vital signs	24.8
Routine bath	40.4	Hourly intake and output	24.6
Parents included in care	39.1	Infection control precautions	24.5
Parent education	37.6	Timely alarm response	21.4
Med effectiveness assessed	37.0	Skin and wound care	21.3
Oral feeding given	33.0	Pain assessment	20.4
Vital data communicated	32.9	Lab specimens obtained	20.2
Fed when hunger cues seen	32.4	Hand hygiene	20.0
Prepared parents for discharge	32.4	Equipment safety check	18.9
Routine repositioning	31.8	Meds given within 30 minutes	18.3
Emotional support of parents	31.4	Vital signs assessed	18.2
PRN meds given	29.5	Focused reassessments	17.3
Oxygen titrated	29.3	Code data updated	16.9
Pain management	29.0	6 "rights" of meds followed	16.7
Developmental care	28.9	Comprehensive physical exam	10.6
Central line site assessment	27.9	High-risk meds verified	9.5
Document-as-you-go	26.1

*Percentages are a combination of rarely/occasionally and frequently

IV = intravenous; med = medication, PRN = as needed

Most nurses reported missing these care activities only "rarely" or "occasionally." For example, although about 41% of nurses reported missing oral care on ventilated infants, only 1% of nurses reported frequently missing this care activity, 40% occasionally missed it, and 59% never missed it.

With a view toward finding solutions to the problem of missed nursing care, the survey queried nurses about the reasons they were unable to complete all necessary nursing interventions during their last shift worked. Very few nurses reported missing care activities because they believed them to be unimportant or unnecessary; rather, the most commonly reported reasons for missing nursing care were interruptions, urgent patient situations, changing patient conditions, and unexpected increases in patient volume or acuity on the unit. Half of the nurses reported insufficient numbers of staff and missing equipment or supplies as reasons for missing care (Table 2).

Table 2. Reasons for Missed Nursing Care Activities on the Last Shift Worked

Reason for Missed Care	Nurses (%)
Frequent interruptions	73.6
Urgent patient situation (condition worsening)	66.0
Unexpected increase in patient volume or acuity	61.4
Others unavailable (eg, parents)	60.2
Medications not available when needed	54.3
Supplies/equipment not available	50.8
Unbalanced patient assignments	50.2
Inadequate number of nurses	48.6
Heavy admission/discharge activity	46.2
Lack of protected time	45.5
Lack of assistive/clerical personnel	42.5
Equipment not functional	35.4
Inadequate hand-off report	35.2
Tension/communication breakdown (medical staff)	34.8
Other departments did not provide care	32.8
Tension/communication breakdown (nursing)	32.1
Tension/communication (other department)	30.8
Lack of familiarity (equipment, procedure, policy)	18.7
Did not think necessary	16.3

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