COMMENTARY

The Missed List: Revelations of Busy NICU Nurses

Laura A. Stokowski, RN, MS

Disclosures

January 12, 2015

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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