The Missed List: Revelations of Busy NICU Nurses

Laura A. Stokowski, RN, MS


January 12, 2015


Does any nurse ever close his or her locker at the end of a shift and think that nothing was left undone? It's not likely. Maybe all of the nurse's meds and feedings were given on time, and all of the intravenous lines and bags were changed. Maybe even all of the charting was completed. But was all of the teaching that should have been done, really done? Was the nurse able to respond to, evaluate, and document all of the alarms that sounded during the shift? Was the nurse able to review and update the care plans? If the answers to these questions are "yes," and no nagging thoughts about unfinished tasks disturb the nurse's consciousness on the drive home, then that nurse was very lucky to have had a reasonable patient load for an entire shift. Or we just met Wonder Nurse.

Missed nursing care is essential or necessary nursing care that doesn't get done. We could argue about the definition of "essential," but if it isn't essential, should we really be doing it at all? It always comes down to relativity and judgment. Some things are just "more essential" than others—and the consequences of omitting them are more serious. Missed care, commented the study authors, "may not necessarily be an indicator of poor-quality nursing, but rather a by-product of rational nurse decision-making in the midst of competing priorities."

Overburdened nurses have no choice but to set priorities. Given often unrealistic time pressures, they must determine what tasks to do and what tasks can safely be omitted or deferred. They have to decide when to ask for help so that critical tasks are not neglected. It is a constant juggling act, especially when a baby's condition is unstable, all of the parents show up at the same time, or, without any warning, the nurse must fit a new patient into his or her assignment.

How much weight can we put into the findings of this study by Tubbs-Cooley and colleagues? Does missing care now and then really influence outcomes? Evidence to date is limited, but at least one other study by this research team suggests that the answer is "yes."

Here is an example that nearly every NICU nurse can relate to. A common time-saving strategy in the NICU is to occasionally administer a preterm infant's enteral feeding by gavage tube rather than orally, by bottle. Nurses don't skip oral feedings because they are lazy; instead, this choice is made when time and workload reach a crisis level, and the feeding is likely to be administered extremely late if it is not given by feeding tube. When feedings are late, feeding and oral medication schedules must be revised, and this can result in the infant receiving fewer calories per 24-hour period, not to mention the prolonged episode of hunger-induced crying that continues until the baby is fed. When time is short, nurses believe that it is better to give the feeding by gavage rather than risk delaying or rushing the oral feeding.

However, a recent study[3] demonstrates that these lost oral feeding opportunities are detrimental to the infant in other ways. When infants whose conditions permit oral feeding are fed by gavage instead, the time that it takes to reach full oral feedings and the duration of hospitalization are both prolonged dramatically. Each 1% increase in the proportion of missed oral feeding opportunities extends the time to achieve full oral feeding by 1.45 days (P = .007) and time to discharge by 1.36 days (P = .047).

This missed care study is a vital first step in finding ways to provide patients and families in the NICU with the full range of nursing care that will achieve the best possible outcomes. "We now have data to show that nurses are not always able to complete core nursing care activities during the course of their shifts," says Tubbs-Cooley, "but we don't have a good understanding of why, or whether missed care is always negative. There could be good reasons for missing care. We need a better understanding of the effects of missed care, as well as how nurses prioritize tasks for individual patients." More research is needed on the link between missed care and patient outcomes to aid nurses in setting nursing care priorities. To this end, Tubbs-Cooley and colleagues are conducting a longitudinal study of missed nursing care linked to shift-level infant outcomes in the NICU.[4]

The solutions to missed care will be as varied and multifaceted as the causes. Improved teamwork, for example, has been shown to be an effective strategy for preventing missed care,[5] but nurses have to be willing to ask for help or to offer help when their colleagues are "drowning." Still, many of the reported reasons for missed care are not under the direct control of bedside nurses. It is clear from the list of reasons in Table 2 that administrators have a lot of work to do. Insufficient staffing, missing or nonfunctioning supplies or equipment, and lack of clerical or assistive personnel fall under the purview of administrators, as does the problem of missing medications. If nurses are experiencing frequent interruptions, managers should be investigating the reasons for them and attempting to mitigate this problem because interruptions are also a common reason for errors.

Tubbs-Cooley has a clear message for administrators. "We can't keep adding to the nurse's workload and expect that everything will get done. Nurses are going to make decisions about what they can and can't accomplish, and this will often depend on what hospitals are holding them accountable for." In other words, the prioritization of tasks won't necessarily be driven by patient condition, or what is best for the patient and family, but by performance measures that are being audited in the electronic record. Do we want checks in all the right boxes, or do we want nurses to provide the care that patients need?


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