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Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units
YJPDN-01512; No of Pages 5 Journal of Pediatric Nursing xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units Heather L. Tubbs-Cooley a,⁎, Rita H. Pickler b, Constance A. Mara c, Mohammad Othman d, Allison Kovacs a, Barbara A. Mark e a
Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 11016, Cincinnati, OH 45229, USA The Ohio State University College of Nursing, Cincinnati Children's Hospital Medical Center, 324 Newton Hall, 1585 Neil Ave, Columbus, OH 43210, USA Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 7014, Cincinnati, OH 45229, USA d University of Cincinnati College of Nursing, 3110 Vine St., 310 A, Cincinnati, OH 45221, USA e The University of North Carolina at Chapel Hill School of Nursing, 1301 Carrington Hall, CB# 7460, Chapel Hill, NC 27599, USA b c
a r t i c l e
i n f o
Article history: Received 16 August 2016 Revised 21 October 2016 Accepted 3 December 2016 Available online xxxx Keywords: Nursing Missed care NICU Magnet® hospital Quality
a b s t r a c t Missed nursing care is an emerging measure of front-line nursing care effectiveness in neonatal intensive care units (NICUs). Given Magnet® hospitals' reputations for nursing care quality, missed care comparisons with non-Magnet® hospitals may yield insights about how Magnet® designation influences patient outcomes. The purpose of this secondary analysis was to evaluate the relationship between hospital Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals. A random sample of certified neonatal intensive care unit nurses was invited to participate in a cross-sectional survey in 2012; data were analyzed from nurses who provided direct patient care (n = 230). Logistic regression was used to model relationships between Magnet® designation and reports of the occurrence of and reasons for missed care while controlling for nurse and shift characteristics. There was no relationship between Magnet® designation and missed care occurrence for 34 of 35 types of care. Nurses in Magnet® hospitals were significantly less likely to report tensions and communication breakdowns with other staff, lack of familiarity with policies/procedures, and lack of back-up support from team members as reasons for missed care. Missed nursing care in NICUs occurs regardless of hospital Magnet® recognition. However, nurses' reasons for missed care systematically differ in Magnet® and nonMagnet® hospitals and these differences merit further exploration. © 2016 Elsevier Inc. All rights reserved.
Purpose Differentiation of hospitals based on specific leadership and organizational structures that support high quality nursing care is foundational to the American Nurse Credentialing Center's Magnet® Recognition Program. Formally initiated in 1993, the program recognizes health care organizations that demonstrate excellence in nursing care, an environment that supports professional nursing practice, and an organizational structure that promotes the leadership capabilities and professional development of nurses (American Nurses Credentialing Center, 2013). Although it's unclear whether participation in Magnet® Recognition Program acts as an organizational intervention to produce positive patient outcomes or merely identifies already high-performing hospitals,
⁎ Corresponding author. E-mail addresses: [email protected] (H.L. Tubbs-Cooley), [email protected] (R.H. Pickler), [email protected] (C.A. Mara), [email protected] (M. Othman), [email protected] (A. Kovacs), [email protected] (B.A. Mark).
Magnet® designation is a publically accessible indicator of a hospital's investment in nursing that is factored into high-profile quality rating schemes such as the annual U.S. News and World Report Best Hospitals and Best Children's Hospitals rankings (Olmsted et al., 2016). Multiple studies demonstrate relationships between hospital Magnet® designation and better outcomes for adult patients including lower central line-associated bloodstream infection rates (Barnes, Rearden, & McHugh, 2016), lower odds of in-hospital and 30-day mortality (Evans et al., 2014; Friese, Xia, Ghaferi, Birkmeyer, & Banerjee, 2015; Kutney-Lee et al., 2015), and decreased odds of failure-torescue (Friese et al., 2015; Kutney-Lee et al., 2015). In pediatrics, Lake et al. (2012) examined the effect of hospital Magnet® status on outcomes of 70,000 very low-birth-weight infants in 558 neonatal intensive care units (NICUs) in the U.S.; rates of three outcomes (7-day mortality, intraventricular hemorrhage, and infection) were significantly lower in NICUs in Magnet®-recognized hospitals. While the available evidence supports a positive association between Magnet® designation and improved patient outcomes, there remains a lack of clarity in how the organizational structures and characteristics underpinning the
http://dx.doi.org/10.1016/j.pedn.2016.12.004 0882-5963/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
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designation affect front-line nursing care delivery such that better outcomes can be confidently attributed to better nursing care. Missed nursing care, or nursing care that is deemed necessary but not delivered (Kalisch, Landstrom, & Hinshaw, 2009), is an emerging process measure of front-line nursing care quality with theoretical and empirical linkages to hospital characteristics such as staffing resources (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014; Kalisch & Lee, 2012) and increasingly, to patient outcomes (Brooks-Carthon, Lasater, Reardan, Holland, & Sloane, 2016; Kalisch, Tschannen, Lee, & Friese, 2011; Kalisch, Tschannen, & Lee, 2012). Missed nursing care may be an especially useful measure of nursing care quality in NICUs given the intensity of critically ill infants' nursing care needs and their prolonged hospitalizations. We previously described the frequency of missed nursing care in NICUs; nurses most frequently missed oral care for ventilated infants, attendance at daily rounds, involving parents in care, and oral feeding opportunities (Tubbs-Cooley, Pickler, Younger, & Mark, 2015). Separately, we found that nurse-driven missed oral feeding opportunities lead to significant delays in preterm infants' achievement of full oral feeding and NICU discharge (Tubbs-Cooley, Pickler, & Meinzen-Derr, 2015). If missed care is a direct measure of the quality and effectiveness of front-line nursing care in hospitals, then it theoretically plausible that a relationship exists between missed care and hospital Magnet® designation. Kalisch and Lee (2012) published the sole paper examining this relationship in adult general medical and surgical units; nurses in Magnet® hospitals reported significantly less missed care than nurses in non-Magnet® hospitals. This finding supports the position that nursing care quality is enhanced in Magnet®-designated hospitals but further examination in different populations, especially pediatric populations, is needed. The purpose of this analysis was to evaluate the relationship between hospital Magnet® designation and missed nursing care in the NICU setting. We aimed to examine associations between Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals.
designation) on clinical and safety outcomes of patients. In this study we do not test the full model but explore a co-varying relationship between hospital Magnet® designation and missed nursing care. If Magnet® hospitals provide better organizational supports for nurses that result in elevated quality of nursing care, then it is expected that NICU nurses in Magnet® hospitals will report less missed care than their peers working in non-Magnet® hospitals. Measures An adapted version of the MISSCARE Survey (Kalisch & Williams, 2009) was developed to quantify missed nursing care in neonatal intensive care settings. We describe the item revisions and survey adaptation in a separate publication (Tubbs-Cooley et al., 2015b). We did not assess item reliability due to the cross-sectional nature of the data as well as our belief that self-report of missed care is a direct, albeit subjective, measure of nurse behavior. Face and content validity were evaluated through qualitative review by expert NICU nurses in two separate hospitals. The final version used in the study included one screening question to determine eligibility (currently working as a registered nurse in a NICU-yes/no), 13 questions related to nurse characteristics (demographics, unit tenure, years of experience, highest degree in nursing), five questions about conditions in the NICU during the last shift worked (e.g. maximum number of infants assigned to the nurse at a given time), eight questions about the structure and organization of the NICU where the nurse is employed (e.g. NICU within a Magnet® hospital), 35 questions related to the frequency of specific missed nursing care activities (see Table 3) and 24 questions about the reasons why care was missed (see Table 4). Response categories for missed care frequency items were: frequently missed, occasionally missed, rarely missed, never missed, not applicable. Response categories for reasons for missed care items were: major reason, moderate reason, minor reason, not a reason. For ease of analysis, we generated dichotomous variables for each of the items: 1) care missed (rarely/occasionally/frequently) versus not missed (never) and 2) factor was a reason for missed care (minor/moderate/major) versus not a reason.
Design and Methods Data Collection Procedures Design, Participants, Setting This was a secondary analysis of data resulting from a larger observational study of missed nursing care in NICUs (Tubbs-Cooley, Pickler, Younger, & Mark, 2015). The data were collected through a crosssectional web-based survey in April 2012. We purchased a list from the Nurse Credentialing Center of all certified neonatal intensive care nurse names and addresses in seven states (California, Illinois, Iowa, Florida, New York, Washington, and Texas). Certified neonatal intensive care nurses were selected as the target sample in order to maximize the likelihood of reaching our intended target population of NICU nurses who provide direct patient care; we selected the seven states to maximize regional diversity and also because they had the greatest number of certified nurses of all states in the respective regions. A 40% random sample per state was taken due to study budget constraints; 1850 nurses were invited to participate. We received responses from 402 nurses resulting in an overall response rate of 22%. Conceptual Framework We conceptualize missed nursing care as a process-oriented measure of healthcare quality similar to Lucero, Lake, and Aiken (2009) and Kalisch et al. (2009). Both models are based on Donabedian's (1966) structure-process-outcomes model; Magnet® designation is a structural feature of hospitals that is likely to influence how nursing care is delivered in the organization while missed care is a process measure of nursing care effectiveness. Missed care may mediate, at least partly, the direct effect of hospital characteristics (e.g., Magnet®
Data were electronically collected through a web-based survey that was developed and hosted by the primary author's home institution. We used tailored survey research methods outlined by Dillman, Smyth, and Christian (2009) to solicit nurse participation. An initial mailed paper invitation included a small monetary incentive ($1). Three follow-up post-card reminders were sent at days 5, 10, and 15 after the initial mailing. The paper solicitations included the secure survey link, a passcode, and a deadline for participation. The survey was closed 30 days after the initial mailing. All respondents submitted data anonymously; there were no fields in the survey that could link a respondent with his/her data. The local institutional review board reviewed the study and classified it as exempt from human subject research oversight. Analysis Descriptive statistics were used to examine frequency distributions of sample characteristics between two groups: nurses working in NICUs within Magnet® hospitals and nurses working in NICUs in nonMagnet® hospitals. The analytic sample was restricted to nurses who reported providing direct patient care. Logistic regression models were developed to estimate the effect of working in a Magnet® hospital on a) the occurrence of missed care during the last shift work and b) reasons for missed care on the last shift worked while controlling for nurse and shift characteristics such as highest degree in nursing (Associate/Diploma vs. Bachelor's or higher), years of NICU nursing experience, and maximum number of infants cared for at a given time during
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
H.L. Tubbs-Cooley et al. / Journal of Pediatric Nursing xxx (2016) xxx–xxx
the shift. List-wise deletion occurred in analyses of observations with missing values. Analyses were conducted using Stata version 11.0 (StataCorp, College Station, TX, USA) and alpha was set a priori at 0.05.
Table 2 Nurse-reported NICU characteristics. NICU characteristic
No. RNs (%) Magnet NICU
Results The final analytic sample (n = 230) was nearly evenly distributed on the key predictor variable (employment in a NICU within a Magnet hospital, 47% yes to 53% no). Characteristics of nurses are shown in Table 1. There were minimal differences between groups with respect to education or years of nursing experience with the exception of number of years nurses held professional certification; on average, NICU nurses in non-Magnet® hospitals held their neonatal intensive care nursing certification for two years more than NICU nurses in Magnet® institutions. Nurses also reported on NICU characteristics of their employing hospital (Table 2). NICU nurses in Magnet® hospitals were significantly more likely to document using electronic health records or a hybrid electronic and paper-based documentation system. Nurses in nonMagnet® hospitals were significantly more likely to report working in a NICU with an open-ward design. Occurrence of Missed Care between Groups Odds ratios demonstrating differences in the occurrence of missed care between NICU nurses working in Magnet® and non-Magnet® hospitals are shown in Table 3. After controlling for nurse education, years of NICU experience, and shift staffing ratio, there were no significant differences in the odds of nurses' reports of the occurrence of missed care during their last shift worked for 34 of the 35 surveyed missed care items. However, nurses in Magnet® hospitals were 75% less likely to miss preparing parents and caregivers for discharge (OR: 0.25, 95% CI: 0.09–0.71). Reasons for Missed Care between Groups Compared to NICU nurses in non-Magnet® hospitals, nurses in Magnet® hospitals were significantly less likely to report certain factors as reasons for missing care (Table 4). Notably, nurses in Magnet® hospitals were 68% less likely to report communication breakdown with other nurses (OR: 0.32, 95% CI: 0.18–0.59), 64% less likely to report lack of familiarity with equipment/procedure/policy (OR: 0.36, 95% CI: 0.17–0.75), 51% less likely to report a lack of back-up support from team members (OR: 0.49, 95% CI: 0.28–0.86), 49% less likely to report tension or communication breakdown with the medical staff (OR: 0.51, 95% CI: 0.03–0.91), and 47% less likely to report an inadequate number of assistive and/or clerical personal (OR: 0.53, 95% CI: 0.31– 0.92) as reasons for missing care on their last shift worked. Discussion Contrary to our expectation that NICU nurses in Magnet® hospitals would report significantly less missed care than their peers in nonMagnet® hospitals, we found virtually no relationship between
Table 1 Sample characteristics (n = 230). RN characteristic
Magnet NICU
Non-Magnet NICU
Age (mean, SD) Years RN experience (mean, SD) Years NICU experience (mean, SD) Years tenure in current NICU (mean, SD) Years certified (mean, SD)⁎ Weekly hours worked (mean, SD) BSN degree or higher (No, %)
44.46 (10.63) 19.40 (10.58) 17.19 (10.04) 13.78 (10.18) 6.68 (7.09) 35.38 (7.72) 77 (69.37)
46.23 (10.17) 20.76 (11.06) 18.0 (9.65) 12.26 (8.95) 8.5 (8.27) 34.52 (8.48) 82 (68.91)
⁎ p b 0.05.
3
Maximum no. of infants cared for at a given time on last shift 1 2 3 4 or more NICU level of care⁎⁎ Level II Level III or higher Documentation (charting) format⁎⁎⁎ Paper Electronic Combination paper/electronic NICU room design⁎ Open ward Single (private) room Pod Combination open/single/pod
12 (10.81) 55 (49.55) 39 (35.14) 5 (4.50)
Non-Magnet NICU
7 (5.88) 61 (51.26) 42 (35.29) 8 (6.72)
3 (2.70) 17 (14.41) 107 (96.40) 101 (85.59) 4 (3.64) 90 (81.82) 16 (14.55)
23 (19.49) 64 (54.24) 31 (26.27)
31 (27.93) 24 (21.62) 27 (24.32) 29 (26.13)
46 (38.66) 10 (8.40) 34 (28.57) 29 (24.37)
⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.
Magnet® designation and the occurrence of missed care with the exception of preparing patients and families for discharge. In other words, missed care happened in NICUs in both Magnet® and nonMagnet® hospitals with near equal occurrence. However, we found evidence of a strong relationship between Magnet® designation and NICU nurses' reasons for missing care: nurses in Magnet® hospitals were significantly less likely to cite communication breakdowns, lack of familiarity with policies and/or procedures, lack of support from team members, and inadequate assistive personnel as reasons for missing care on their last shift worked. Our finding of essentially no relationship between hospital Magnet® status and reported occurrence of missed nursing care contradicts the results of Kalisch and Lee (2012) who found substantially more reported missed care among nurses employed in non-Magnet® hospitals. Unlike the dichotomous measures of missed care used in this analysis, Kalisch and Lee computed an average missed care score per unit based on a numeric conversion of the original scale, then compared means via independent t-tests. A two-group comparison using a continuous score that did not account for possible co-varying factors could explain the differing results. It is also possible that nursing care is missed less overall in NICUs compared to adult medical surgical units, the primary unit type from which nurses were sampled in the Kalisch and Lee study. This may happen because NICUs, as a pediatric subspecialty embedded within a larger healthcare organization, often have dedicated staff and equipment and thus may be largely buffered from resource fluctuations. A core component of the Magnet® model is support for exemplary professional practice which is actualized in a number of ways including front-line nurses' involvement in ensuring the adequacy of staffing resources for patient care, promotion of positive interdisciplinary relationships and collaboration, and facilitation of autonomous nursing practice (American Nurses Credentialing Center, 2013). NICU nurses in Magnet® hospitals were significantly less likely to report issues with team communication and dynamics, resource adequacy, and lack of awareness of policies and procedures as reasons for missed care, suggesting that these environmental and structural characteristics resulted in tangible differences in nursing care delivery. Unlike the prior model, Kalisch and Lee (2012) similarly found that nurses in Magnetdesignated hospitals were less likely to report issues related to communication or labor resources as reasons for missing care.
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
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Table 3 Association between magnet status and nurse reports of missed care (non-Magnet NICU as reference).
Parents prepared for discharge Oral feed offered at each feeding opportunity (when infant cleared to PO) Parents included in baby's care Focused reassessments according to the baby's condition Hand hygiene per protocol Peripheral IV site care and assessments per protocol Baby received developmentally supportive care (skin-to-skin care, nesting) High-risk medications verified per protocol Alarms responded to in a timely manner Baby repositioned at least once Q2 hours Intake and output monitored hourly or per protocol Critical labs/vital sign values communicated to team per protocol Feedings offered when baby exhibits cues of hunger Code readiness data assessed once per shift or per protocol “6 rights” of medication administration adhered to each time a medication is given Medications administered within 30 min of scheduled time Emotional support provided to parents/family Pain managed using pharmacological or supportive care approaches Central line site care and assessments per protocol Documentation completed as care is provided Medication effectiveness assessed within 30–60 min of administration or per protocol Labs/specimens obtained as ordered Skin and wound care provided routinely and/or as needed Attendance at daily rounds Vital signs assessed per protocol Comprehensive physical assessments per protocol All vital information communicated to other staff during hand-offs Safety checks of bedside equipment completed once per shift or per protocol Oral care for ventilated babies provided per protocol Oxygen titrated per protocol/order Baby bathed routinely and/or as needed PRN meds given per order Parents educated about home management of illness including devices, medications, and general care of preterm infant Pain assessed according to protocol
OR (95% CI)
p-Value
0.25 (0.09–0.71) 2.20 (0.91–5.76)
0.01 0.08
0.53 (0.24–1.18) 0.51 (0.19–1.33)
0.12 0.17
0.54 (0.22–1.31) 0.59 (0.24–1.46) 0.62 (0.27–1.41)
0.18 0.26 0.26
2.48 (0.50–12.30) 0.61 (0.25–1.53) 0.61 (0.23–1.58) 0.66 (0.28–1.56) 0.62 (0.23–1.64)
0.27 0.30 0.31 0.34 0.34
1.55 (0.63–3.84) 0.63 (0.23–1.78)
0.34 0.39
1.44 (0.57–3.67)
0.44
0.71 (0.26–1.89)
0.49
0.77 (0.36–1.67) 0.75 (0.32–1.75)
0.51 0.51
0.72 (0.27–1.97) 1.23 (0.55–2.72) 0.80 (0.33–1.95)
0.52 0.61 0.63
1.21 (0.46–3.22) 0.84 (0.33–2.14)
0.70 0.71
0.85 (0.36–2.04) 0.85 (0.34–2.12) 1.22 (0.37–4.00) 0.88 (0.40–1.91)
0.72 0.72 0.74 0.74
0.86 (0.35–2.10)
0.74
1.14 (0.46–2.80)
0.78
1.12 (0.47–2.65) 0.91 (0.38–2.16) 1.10 (0.41–2.98) 0.99 (0.43–2.28)
0.80 0.83 0.85 0.98
1.00 (0.40–2.47)
0.99
At least two alternative explanations for our results bear consideration. First, the proverbial jury is still out on the validity of missed nursing care as a process measure of nursing care quality and effectiveness. It's possible that missed nursing care may not reflect quality of care but instead is a measure of nurses' decision-making process when working under time and resource constraints, similar to the concept of task ‘stacking’ (Patterson, Ebright, & Saleen, 2011). Missed care may, in some situations, reflect clinically appropriate decision-making within a complex or poorly designed system. Additionally, many Magnet® hospitals are reputationally known as financially well-resourced organizations. This detail has implications for our findings regarding differing reasons for missed nursing care between Magnet® and non-Magnet® hospitals: better resourced hospitals may invest in other non-nursing supports, technologies, personnel, and programs that improve the delivery system overall and enable front-line nurses to focus on direct patient care. We were unable to account for hospital financial resources in our analyses and thus cannot speak to the effect of hospital resources on missed care except to acknowledge possible confounding.
Table 4 Differences in reasons for missed care (non-Magnet NICU nurses as reference group).
Tension or communication breakdowns within the nursing team Other participants not available (i.e. parents not present for teaching) Lack of familiarity with equipment/procedure/policy Lack of back-up support from team members Parent or familial caregiver not present at the bedside Medications were not available when needed Electronic health records difficult to use Inadequate number of assistive and/or clerical personnel (e.g. nursing assistants, techs, unit secretaries etc.) Tension or communication breakdowns with the medical staff Tension or communication breakdowns with other ancillary/support departments Inadequate number of nurses Supplies/equipment not available when needed Heavy admission and/or discharge activity Other departments did not provide the care needed (e.g. respiratory therapy did not titrate oxygen) Lack of protected time to complete lengthy care Frequent interruptions Supplies/equipment not functioning properly when needed Nursing assistant did not communicate that care was not provided Unbalanced patient assignments Inadequate hand-off from previous shift or sending unit Did not think care was necessary Unexpected rise in patient volume and/or acuity on the unit Urgent patient situations (e.g. a patient's condition worsening) Inability to “see” what care needs to be completed in the electronic health record
OR (95% CI)
p-Value
0.32 (0.18–0.59)
0.000
0.42 (0.24–0.74)
0.002
0.36 (0.17–0.75)
0.006
0.49 (0.28–0.86) 0.50 (0.29–0.86)
0.013 0.013
0.50 (0.29–0.87) 1.04 (1.01–1.06) 0.53 (0.31–0.92)
0.014 0.02 0.02
0.51 (0.029–0.91)
0.023
0.58 (0.32–1.03)
0.06
0.61 (0.36–1.05) 0.63 (0.37–1.07) 0.63 (0.37–1.07) 0.62 (0.35–1.10)
0.08 0.088 0.09 0.10
0.64 (0.37–1.11) 0.62 (0.34–1.13) 0.65 (0.37–1.13)
0.11 0.12 0.13
0.44 (0.15–1.30)
0.14
0.71 (0.41–1.21) 0.82 (0.47–1.43)
0.21 0.48
0.78 (0.37–1.62) 1.17 (0.68–2.02)
0.50 0.57
1.11 (0.64–1.95)
0.71
0.97 (0.53–1.74)
0.91
Limitations Generalizability of the results may be limited for several reasons. The NICU is often characterized as a highly specialized and unique environment and conditions in NICUs may not generalize to other unit types. Additionally, our sample was comprised of nurses who held a voluntary specialty certification and may not reflect the broader population of NICU nurses, the majority of whom are not certified. The response rate (22%), while within a typical range for mailed surveys (VanGeest & Johnson, 2011), raises concerns about generalizability and possible non-response bias. Because of the anonymous nature of the survey and lack of benchmarking data for comparison we were unable to conduct recommended post-hoc analyses to assess non-response bias (Halbesleben & Whitman, 2013). Assessments of missed nursing care at one point in time may not generalize to typical practice. Lastly, social desirability bias may have influenced nurses' responses given the sensitivity of the subject matter. We believe that the estimates of selfreported missed care in this study are likely to under-represent its true occurrence.
Practice Implications The differences we observed in reasons for missed care may have implications for identification and selection of interventions to reduce missed care in NICUs in each type of organization. In particular, NICU nurse leaders in non-Magnet® facilities are encouraged to assess communication, teamwork, assistive personnel resources, and nurse
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
H.L. Tubbs-Cooley et al. / Journal of Pediatric Nursing xxx (2016) xxx–xxx
familiarity with policies and procedures to improve the quality of care delivered to babies and their families. Conclusions Hospital Magnet® designation does not influence missed nursing care in neonatal intensive care environments; NICU nurses report missing care nearly equally in Magnet® and non-Magnet® hospitals. However, nurses' reasons for missed care differ substantially between the two types of organizations, differences that may be partly explained by increased support for an exemplary nurse practice environment in Magnet® hospitals. Further research is needed to understand whether (and how) hospital Magnet® designation influences front-line nursing care effectiveness and quality. Conflicts None to declare. Funding Funding for this work was provided by Cincinnati Children's Hospital Medical Center. References American Nurses Credentialing Center (2013). The magnet model components and sources of evidence magnet recognition program. Silver Spring, MD: American Nurses Credentialing Center. Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2014). ‘Care left undone’ during nursing shifts: Association with workload and perceived quality of care. BMJ Quality and Safety, 23(2), 116–125. http://dx.doi.org/10.1136/bmjqs-2012-001767. Barnes, H., Rearden, J., & McHugh, M. D. (2016). Magnet® hospital recognition linked to lower central line-associated bloodstream infection rates. Research in Nursing and Health, 39(2), 96–104. http://dx.doi.org/10.1002/nur.21709. Brooks-Carthon, J. M., Lasater, K. B., Reardan, J., Holland, S., & Sloane, D. (2016). Unmet nursing care linked to re-hospitalizations among older black AMI patients. Medical Care, 54(5), 457–465. http://dx.doi.org/10.1097/MLR.0000000000000519. Dillman, D. A., Smyth, J. D., & Christian, L. M. (2009). Internet, mail and mixed-mode surveys: The tailored design method (3rd ed.). Hoboken, NJ: Wiley. Donabedian, A. (1966). Evaluating the quality of medical care. The Milbank Memorial Fund Quarterly, 44(3,2), 166–203. Evans, T., Rittenhouse, K., Horst, M., Osler, T., Rogers, A., Miller, J. A., ... Rogers, F. B. (2014). Magnet® hospitals are a Magnet® for higher survival rates at adult trauma centers.
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Journal of Trauma and Acute Care Surgery, 77(1), 89–94. http://dx.doi.org/10.1097/ TA.0000000000000262. Friese, C. R., Xia, R., Ghaferi, A., Birkmeyer, J. D., & Banerjee, M. (2015). Hospitals in ‘Magnet®’ program show better patient outcomes on mortality measures compared to non-‘Magnet®’hospitals. Health Affairs, 34(6), 986. http://dx.doi.org/10.1377/ hlthaff.2014.0793. Halbesleben, J. R., & Whitman, M. V. (2013). Evaluating survey quality in health services research: A decision framework for assessing nonresponse bias. Health Services Research, 48(3), 913–930. http://dx.doi.org/10.1111/1475–6773.12002. Kalisch, B. J., & Lee, K. H. (2012). Missed nursing care: Magnet® versus non-Magnet® hospitals. Nursing Outlook, 60(5), e32–e39. http://dx.doi.org/10.1016/j.outlook.2012.04. 006. Kalisch, B. J., & Williams, R. A. (2009). Development and psychometric testing of a tool to measure missed nursing care. Journal of Nursing Administration, 39, 211–215. http:// dx.doi.org/10.1097/NNA.0b013e3181a23cf5. Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509. http://dx.doi.org/10.1111/j.13652648.2009.05027.x. Kalisch, B. J., Tschannen, D., Lee, H., & Friese, C. R. (2011). Hospital variation in missed nursing care. American Journal of Medical Quality, 26(4), 291–299. http://dx.doi.org/ 10.1177/1062860610395929. Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012). Missed nursing care, staffing, and patient falls. Journal of Nursing Care Quality, 27(1), 6–12. http://dx.doi.org/10.1097/NCQ. 0b013e318225aa23. Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with Magnet® hospital recognition. Medical Care, 53(6), 550–557. http://dx.doi.org/10.1097/MLR. 0000000000000355. Lake, E. T., Staiger, D., Horbar, J., Cheung, R., Kenny, M., Patrick, T., & Rogowski, J. A. (2012). Association between hospital recognition for nursing excellence and outcomes of very low birth weight infants. JAMA: The Journal of the American Medical Association, 307(16), 1709–1716. http://dx.doi.org/10.1001/jama.2012.504. Lucero, R. J., Lake, E. T., & Aiken, L. H. (2009). Variations in nursing care quality across hospitals. Journal of Advanced Nursing, 65(11), 2299–2310. http://dx.doi.org/10.1111/j. 1365–2648.2009.05090.x. Olmsted, M. G., Geisen, E., Murphy, J., Bell, D., Moreley, M., Stanley, M., & Powell, R. (2016). Methodology: U.S. News & World Report 2016–17 best hospitals: Specialty rankings (Report No. BH 2016–17). Research Triangle Park, NC: RTI International. Patterson, E. S., Ebright, P. R., & Saleen, J. J. (2011). Investigating stacking: How do registered nurses prioritize their activities in real-time? International Journal of Industrial Ergonomics, 41(4), 389–393. http://dx.doi.org/10.1016/j.ergon.2011.01.012. Tubbs-Cooley, H. L., Pickler, R. H., & Meinzen-Derr, J. K. (2015a). Missed oral feeding opportunities and preterm infants' time to achieve full oral feedings and neonatal intensive care unit discharge. American Journal of Perinatology, 32(1), 1–8. http://dx.doi. org/10.1055/s-0034-1372426. Tubbs-Cooley, H. L., Pickler, R. H., Younger, J., & Mark, B. A. (2015b). A descriptive study of nurse-reported missed care in neonatal intensive care units. Journal of Advanced Nursing, 71(4), 813–824. http://dx.doi.org/10.1111/jan.12578. VanGeest, J., & Johnson, T. P. (2011). Surveying nurses: Identifying strategies to improve participation. Evaluation & the Health Professions, 34(4), 487–511. http://dx.doi.org/ 10.1177/0163278711399572.
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units Heather L. Tubbs-Cooley a,⁎, Rita H. Pickler b, Constance A. Mara c, Mohammad Othman d, Allison Kovacs a, Barbara A. Mark e a
Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 11016, Cincinnati, OH 45229, USA The Ohio State University College of Nursing, Cincinnati Children's Hospital Medical Center, 324 Newton Hall, 1585 Neil Ave, Columbus, OH 43210, USA Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 7014, Cincinnati, OH 45229, USA d University of Cincinnati College of Nursing, 3110 Vine St., 310 A, Cincinnati, OH 45221, USA e The University of North Carolina at Chapel Hill School of Nursing, 1301 Carrington Hall, CB# 7460, Chapel Hill, NC 27599, USA b c
a r t i c l e
i n f o
Article history: Received 16 August 2016 Revised 21 October 2016 Accepted 3 December 2016 Available online xxxx Keywords: Nursing Missed care NICU Magnet® hospital Quality
a b s t r a c t Missed nursing care is an emerging measure of front-line nursing care effectiveness in neonatal intensive care units (NICUs). Given Magnet® hospitals' reputations for nursing care quality, missed care comparisons with non-Magnet® hospitals may yield insights about how Magnet® designation influences patient outcomes. The purpose of this secondary analysis was to evaluate the relationship between hospital Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals. A random sample of certified neonatal intensive care unit nurses was invited to participate in a cross-sectional survey in 2012; data were analyzed from nurses who provided direct patient care (n = 230). Logistic regression was used to model relationships between Magnet® designation and reports of the occurrence of and reasons for missed care while controlling for nurse and shift characteristics. There was no relationship between Magnet® designation and missed care occurrence for 34 of 35 types of care. Nurses in Magnet® hospitals were significantly less likely to report tensions and communication breakdowns with other staff, lack of familiarity with policies/procedures, and lack of back-up support from team members as reasons for missed care. Missed nursing care in NICUs occurs regardless of hospital Magnet® recognition. However, nurses' reasons for missed care systematically differ in Magnet® and nonMagnet® hospitals and these differences merit further exploration. © 2016 Elsevier Inc. All rights reserved.
Purpose Differentiation of hospitals based on specific leadership and organizational structures that support high quality nursing care is foundational to the American Nurse Credentialing Center's Magnet® Recognition Program. Formally initiated in 1993, the program recognizes health care organizations that demonstrate excellence in nursing care, an environment that supports professional nursing practice, and an organizational structure that promotes the leadership capabilities and professional development of nurses (American Nurses Credentialing Center, 2013). Although it's unclear whether participation in Magnet® Recognition Program acts as an organizational intervention to produce positive patient outcomes or merely identifies already high-performing hospitals,
⁎ Corresponding author. E-mail addresses: [email protected] (H.L. Tubbs-Cooley), [email protected] (R.H. Pickler), [email protected] (C.A. Mara), [email protected] (M. Othman), [email protected] (A. Kovacs), [email protected] (B.A. Mark).
Magnet® designation is a publically accessible indicator of a hospital's investment in nursing that is factored into high-profile quality rating schemes such as the annual U.S. News and World Report Best Hospitals and Best Children's Hospitals rankings (Olmsted et al., 2016). Multiple studies demonstrate relationships between hospital Magnet® designation and better outcomes for adult patients including lower central line-associated bloodstream infection rates (Barnes, Rearden, & McHugh, 2016), lower odds of in-hospital and 30-day mortality (Evans et al., 2014; Friese, Xia, Ghaferi, Birkmeyer, & Banerjee, 2015; Kutney-Lee et al., 2015), and decreased odds of failure-torescue (Friese et al., 2015; Kutney-Lee et al., 2015). In pediatrics, Lake et al. (2012) examined the effect of hospital Magnet® status on outcomes of 70,000 very low-birth-weight infants in 558 neonatal intensive care units (NICUs) in the U.S.; rates of three outcomes (7-day mortality, intraventricular hemorrhage, and infection) were significantly lower in NICUs in Magnet®-recognized hospitals. While the available evidence supports a positive association between Magnet® designation and improved patient outcomes, there remains a lack of clarity in how the organizational structures and characteristics underpinning the
http://dx.doi.org/10.1016/j.pedn.2016.12.004 0882-5963/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
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designation affect front-line nursing care delivery such that better outcomes can be confidently attributed to better nursing care. Missed nursing care, or nursing care that is deemed necessary but not delivered (Kalisch, Landstrom, & Hinshaw, 2009), is an emerging process measure of front-line nursing care quality with theoretical and empirical linkages to hospital characteristics such as staffing resources (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014; Kalisch & Lee, 2012) and increasingly, to patient outcomes (Brooks-Carthon, Lasater, Reardan, Holland, & Sloane, 2016; Kalisch, Tschannen, Lee, & Friese, 2011; Kalisch, Tschannen, & Lee, 2012). Missed nursing care may be an especially useful measure of nursing care quality in NICUs given the intensity of critically ill infants' nursing care needs and their prolonged hospitalizations. We previously described the frequency of missed nursing care in NICUs; nurses most frequently missed oral care for ventilated infants, attendance at daily rounds, involving parents in care, and oral feeding opportunities (Tubbs-Cooley, Pickler, Younger, & Mark, 2015). Separately, we found that nurse-driven missed oral feeding opportunities lead to significant delays in preterm infants' achievement of full oral feeding and NICU discharge (Tubbs-Cooley, Pickler, & Meinzen-Derr, 2015). If missed care is a direct measure of the quality and effectiveness of front-line nursing care in hospitals, then it theoretically plausible that a relationship exists between missed care and hospital Magnet® designation. Kalisch and Lee (2012) published the sole paper examining this relationship in adult general medical and surgical units; nurses in Magnet® hospitals reported significantly less missed care than nurses in non-Magnet® hospitals. This finding supports the position that nursing care quality is enhanced in Magnet®-designated hospitals but further examination in different populations, especially pediatric populations, is needed. The purpose of this analysis was to evaluate the relationship between hospital Magnet® designation and missed nursing care in the NICU setting. We aimed to examine associations between Magnet® designation and 1) the occurrence of nurse-reported missed care and 2) reasons for missed nursing care between NICU nurses employed in Magnet® and non-Magnet® hospitals.
designation) on clinical and safety outcomes of patients. In this study we do not test the full model but explore a co-varying relationship between hospital Magnet® designation and missed nursing care. If Magnet® hospitals provide better organizational supports for nurses that result in elevated quality of nursing care, then it is expected that NICU nurses in Magnet® hospitals will report less missed care than their peers working in non-Magnet® hospitals. Measures An adapted version of the MISSCARE Survey (Kalisch & Williams, 2009) was developed to quantify missed nursing care in neonatal intensive care settings. We describe the item revisions and survey adaptation in a separate publication (Tubbs-Cooley et al., 2015b). We did not assess item reliability due to the cross-sectional nature of the data as well as our belief that self-report of missed care is a direct, albeit subjective, measure of nurse behavior. Face and content validity were evaluated through qualitative review by expert NICU nurses in two separate hospitals. The final version used in the study included one screening question to determine eligibility (currently working as a registered nurse in a NICU-yes/no), 13 questions related to nurse characteristics (demographics, unit tenure, years of experience, highest degree in nursing), five questions about conditions in the NICU during the last shift worked (e.g. maximum number of infants assigned to the nurse at a given time), eight questions about the structure and organization of the NICU where the nurse is employed (e.g. NICU within a Magnet® hospital), 35 questions related to the frequency of specific missed nursing care activities (see Table 3) and 24 questions about the reasons why care was missed (see Table 4). Response categories for missed care frequency items were: frequently missed, occasionally missed, rarely missed, never missed, not applicable. Response categories for reasons for missed care items were: major reason, moderate reason, minor reason, not a reason. For ease of analysis, we generated dichotomous variables for each of the items: 1) care missed (rarely/occasionally/frequently) versus not missed (never) and 2) factor was a reason for missed care (minor/moderate/major) versus not a reason.
Design and Methods Data Collection Procedures Design, Participants, Setting This was a secondary analysis of data resulting from a larger observational study of missed nursing care in NICUs (Tubbs-Cooley, Pickler, Younger, & Mark, 2015). The data were collected through a crosssectional web-based survey in April 2012. We purchased a list from the Nurse Credentialing Center of all certified neonatal intensive care nurse names and addresses in seven states (California, Illinois, Iowa, Florida, New York, Washington, and Texas). Certified neonatal intensive care nurses were selected as the target sample in order to maximize the likelihood of reaching our intended target population of NICU nurses who provide direct patient care; we selected the seven states to maximize regional diversity and also because they had the greatest number of certified nurses of all states in the respective regions. A 40% random sample per state was taken due to study budget constraints; 1850 nurses were invited to participate. We received responses from 402 nurses resulting in an overall response rate of 22%. Conceptual Framework We conceptualize missed nursing care as a process-oriented measure of healthcare quality similar to Lucero, Lake, and Aiken (2009) and Kalisch et al. (2009). Both models are based on Donabedian's (1966) structure-process-outcomes model; Magnet® designation is a structural feature of hospitals that is likely to influence how nursing care is delivered in the organization while missed care is a process measure of nursing care effectiveness. Missed care may mediate, at least partly, the direct effect of hospital characteristics (e.g., Magnet®
Data were electronically collected through a web-based survey that was developed and hosted by the primary author's home institution. We used tailored survey research methods outlined by Dillman, Smyth, and Christian (2009) to solicit nurse participation. An initial mailed paper invitation included a small monetary incentive ($1). Three follow-up post-card reminders were sent at days 5, 10, and 15 after the initial mailing. The paper solicitations included the secure survey link, a passcode, and a deadline for participation. The survey was closed 30 days after the initial mailing. All respondents submitted data anonymously; there were no fields in the survey that could link a respondent with his/her data. The local institutional review board reviewed the study and classified it as exempt from human subject research oversight. Analysis Descriptive statistics were used to examine frequency distributions of sample characteristics between two groups: nurses working in NICUs within Magnet® hospitals and nurses working in NICUs in nonMagnet® hospitals. The analytic sample was restricted to nurses who reported providing direct patient care. Logistic regression models were developed to estimate the effect of working in a Magnet® hospital on a) the occurrence of missed care during the last shift work and b) reasons for missed care on the last shift worked while controlling for nurse and shift characteristics such as highest degree in nursing (Associate/Diploma vs. Bachelor's or higher), years of NICU nursing experience, and maximum number of infants cared for at a given time during
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
H.L. Tubbs-Cooley et al. / Journal of Pediatric Nursing xxx (2016) xxx–xxx
the shift. List-wise deletion occurred in analyses of observations with missing values. Analyses were conducted using Stata version 11.0 (StataCorp, College Station, TX, USA) and alpha was set a priori at 0.05.
Table 2 Nurse-reported NICU characteristics. NICU characteristic
No. RNs (%) Magnet NICU
Results The final analytic sample (n = 230) was nearly evenly distributed on the key predictor variable (employment in a NICU within a Magnet hospital, 47% yes to 53% no). Characteristics of nurses are shown in Table 1. There were minimal differences between groups with respect to education or years of nursing experience with the exception of number of years nurses held professional certification; on average, NICU nurses in non-Magnet® hospitals held their neonatal intensive care nursing certification for two years more than NICU nurses in Magnet® institutions. Nurses also reported on NICU characteristics of their employing hospital (Table 2). NICU nurses in Magnet® hospitals were significantly more likely to document using electronic health records or a hybrid electronic and paper-based documentation system. Nurses in nonMagnet® hospitals were significantly more likely to report working in a NICU with an open-ward design. Occurrence of Missed Care between Groups Odds ratios demonstrating differences in the occurrence of missed care between NICU nurses working in Magnet® and non-Magnet® hospitals are shown in Table 3. After controlling for nurse education, years of NICU experience, and shift staffing ratio, there were no significant differences in the odds of nurses' reports of the occurrence of missed care during their last shift worked for 34 of the 35 surveyed missed care items. However, nurses in Magnet® hospitals were 75% less likely to miss preparing parents and caregivers for discharge (OR: 0.25, 95% CI: 0.09–0.71). Reasons for Missed Care between Groups Compared to NICU nurses in non-Magnet® hospitals, nurses in Magnet® hospitals were significantly less likely to report certain factors as reasons for missing care (Table 4). Notably, nurses in Magnet® hospitals were 68% less likely to report communication breakdown with other nurses (OR: 0.32, 95% CI: 0.18–0.59), 64% less likely to report lack of familiarity with equipment/procedure/policy (OR: 0.36, 95% CI: 0.17–0.75), 51% less likely to report a lack of back-up support from team members (OR: 0.49, 95% CI: 0.28–0.86), 49% less likely to report tension or communication breakdown with the medical staff (OR: 0.51, 95% CI: 0.03–0.91), and 47% less likely to report an inadequate number of assistive and/or clerical personal (OR: 0.53, 95% CI: 0.31– 0.92) as reasons for missing care on their last shift worked. Discussion Contrary to our expectation that NICU nurses in Magnet® hospitals would report significantly less missed care than their peers in nonMagnet® hospitals, we found virtually no relationship between
Table 1 Sample characteristics (n = 230). RN characteristic
Magnet NICU
Non-Magnet NICU
Age (mean, SD) Years RN experience (mean, SD) Years NICU experience (mean, SD) Years tenure in current NICU (mean, SD) Years certified (mean, SD)⁎ Weekly hours worked (mean, SD) BSN degree or higher (No, %)
44.46 (10.63) 19.40 (10.58) 17.19 (10.04) 13.78 (10.18) 6.68 (7.09) 35.38 (7.72) 77 (69.37)
46.23 (10.17) 20.76 (11.06) 18.0 (9.65) 12.26 (8.95) 8.5 (8.27) 34.52 (8.48) 82 (68.91)
⁎ p b 0.05.
3
Maximum no. of infants cared for at a given time on last shift 1 2 3 4 or more NICU level of care⁎⁎ Level II Level III or higher Documentation (charting) format⁎⁎⁎ Paper Electronic Combination paper/electronic NICU room design⁎ Open ward Single (private) room Pod Combination open/single/pod
12 (10.81) 55 (49.55) 39 (35.14) 5 (4.50)
Non-Magnet NICU
7 (5.88) 61 (51.26) 42 (35.29) 8 (6.72)
3 (2.70) 17 (14.41) 107 (96.40) 101 (85.59) 4 (3.64) 90 (81.82) 16 (14.55)
23 (19.49) 64 (54.24) 31 (26.27)
31 (27.93) 24 (21.62) 27 (24.32) 29 (26.13)
46 (38.66) 10 (8.40) 34 (28.57) 29 (24.37)
⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.
Magnet® designation and the occurrence of missed care with the exception of preparing patients and families for discharge. In other words, missed care happened in NICUs in both Magnet® and nonMagnet® hospitals with near equal occurrence. However, we found evidence of a strong relationship between Magnet® designation and NICU nurses' reasons for missing care: nurses in Magnet® hospitals were significantly less likely to cite communication breakdowns, lack of familiarity with policies and/or procedures, lack of support from team members, and inadequate assistive personnel as reasons for missing care on their last shift worked. Our finding of essentially no relationship between hospital Magnet® status and reported occurrence of missed nursing care contradicts the results of Kalisch and Lee (2012) who found substantially more reported missed care among nurses employed in non-Magnet® hospitals. Unlike the dichotomous measures of missed care used in this analysis, Kalisch and Lee computed an average missed care score per unit based on a numeric conversion of the original scale, then compared means via independent t-tests. A two-group comparison using a continuous score that did not account for possible co-varying factors could explain the differing results. It is also possible that nursing care is missed less overall in NICUs compared to adult medical surgical units, the primary unit type from which nurses were sampled in the Kalisch and Lee study. This may happen because NICUs, as a pediatric subspecialty embedded within a larger healthcare organization, often have dedicated staff and equipment and thus may be largely buffered from resource fluctuations. A core component of the Magnet® model is support for exemplary professional practice which is actualized in a number of ways including front-line nurses' involvement in ensuring the adequacy of staffing resources for patient care, promotion of positive interdisciplinary relationships and collaboration, and facilitation of autonomous nursing practice (American Nurses Credentialing Center, 2013). NICU nurses in Magnet® hospitals were significantly less likely to report issues with team communication and dynamics, resource adequacy, and lack of awareness of policies and procedures as reasons for missed care, suggesting that these environmental and structural characteristics resulted in tangible differences in nursing care delivery. Unlike the prior model, Kalisch and Lee (2012) similarly found that nurses in Magnetdesignated hospitals were less likely to report issues related to communication or labor resources as reasons for missing care.
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
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Table 3 Association between magnet status and nurse reports of missed care (non-Magnet NICU as reference).
Parents prepared for discharge Oral feed offered at each feeding opportunity (when infant cleared to PO) Parents included in baby's care Focused reassessments according to the baby's condition Hand hygiene per protocol Peripheral IV site care and assessments per protocol Baby received developmentally supportive care (skin-to-skin care, nesting) High-risk medications verified per protocol Alarms responded to in a timely manner Baby repositioned at least once Q2 hours Intake and output monitored hourly or per protocol Critical labs/vital sign values communicated to team per protocol Feedings offered when baby exhibits cues of hunger Code readiness data assessed once per shift or per protocol “6 rights” of medication administration adhered to each time a medication is given Medications administered within 30 min of scheduled time Emotional support provided to parents/family Pain managed using pharmacological or supportive care approaches Central line site care and assessments per protocol Documentation completed as care is provided Medication effectiveness assessed within 30–60 min of administration or per protocol Labs/specimens obtained as ordered Skin and wound care provided routinely and/or as needed Attendance at daily rounds Vital signs assessed per protocol Comprehensive physical assessments per protocol All vital information communicated to other staff during hand-offs Safety checks of bedside equipment completed once per shift or per protocol Oral care for ventilated babies provided per protocol Oxygen titrated per protocol/order Baby bathed routinely and/or as needed PRN meds given per order Parents educated about home management of illness including devices, medications, and general care of preterm infant Pain assessed according to protocol
OR (95% CI)
p-Value
0.25 (0.09–0.71) 2.20 (0.91–5.76)
0.01 0.08
0.53 (0.24–1.18) 0.51 (0.19–1.33)
0.12 0.17
0.54 (0.22–1.31) 0.59 (0.24–1.46) 0.62 (0.27–1.41)
0.18 0.26 0.26
2.48 (0.50–12.30) 0.61 (0.25–1.53) 0.61 (0.23–1.58) 0.66 (0.28–1.56) 0.62 (0.23–1.64)
0.27 0.30 0.31 0.34 0.34
1.55 (0.63–3.84) 0.63 (0.23–1.78)
0.34 0.39
1.44 (0.57–3.67)
0.44
0.71 (0.26–1.89)
0.49
0.77 (0.36–1.67) 0.75 (0.32–1.75)
0.51 0.51
0.72 (0.27–1.97) 1.23 (0.55–2.72) 0.80 (0.33–1.95)
0.52 0.61 0.63
1.21 (0.46–3.22) 0.84 (0.33–2.14)
0.70 0.71
0.85 (0.36–2.04) 0.85 (0.34–2.12) 1.22 (0.37–4.00) 0.88 (0.40–1.91)
0.72 0.72 0.74 0.74
0.86 (0.35–2.10)
0.74
1.14 (0.46–2.80)
0.78
1.12 (0.47–2.65) 0.91 (0.38–2.16) 1.10 (0.41–2.98) 0.99 (0.43–2.28)
0.80 0.83 0.85 0.98
1.00 (0.40–2.47)
0.99
At least two alternative explanations for our results bear consideration. First, the proverbial jury is still out on the validity of missed nursing care as a process measure of nursing care quality and effectiveness. It's possible that missed nursing care may not reflect quality of care but instead is a measure of nurses' decision-making process when working under time and resource constraints, similar to the concept of task ‘stacking’ (Patterson, Ebright, & Saleen, 2011). Missed care may, in some situations, reflect clinically appropriate decision-making within a complex or poorly designed system. Additionally, many Magnet® hospitals are reputationally known as financially well-resourced organizations. This detail has implications for our findings regarding differing reasons for missed nursing care between Magnet® and non-Magnet® hospitals: better resourced hospitals may invest in other non-nursing supports, technologies, personnel, and programs that improve the delivery system overall and enable front-line nurses to focus on direct patient care. We were unable to account for hospital financial resources in our analyses and thus cannot speak to the effect of hospital resources on missed care except to acknowledge possible confounding.
Table 4 Differences in reasons for missed care (non-Magnet NICU nurses as reference group).
Tension or communication breakdowns within the nursing team Other participants not available (i.e. parents not present for teaching) Lack of familiarity with equipment/procedure/policy Lack of back-up support from team members Parent or familial caregiver not present at the bedside Medications were not available when needed Electronic health records difficult to use Inadequate number of assistive and/or clerical personnel (e.g. nursing assistants, techs, unit secretaries etc.) Tension or communication breakdowns with the medical staff Tension or communication breakdowns with other ancillary/support departments Inadequate number of nurses Supplies/equipment not available when needed Heavy admission and/or discharge activity Other departments did not provide the care needed (e.g. respiratory therapy did not titrate oxygen) Lack of protected time to complete lengthy care Frequent interruptions Supplies/equipment not functioning properly when needed Nursing assistant did not communicate that care was not provided Unbalanced patient assignments Inadequate hand-off from previous shift or sending unit Did not think care was necessary Unexpected rise in patient volume and/or acuity on the unit Urgent patient situations (e.g. a patient's condition worsening) Inability to “see” what care needs to be completed in the electronic health record
OR (95% CI)
p-Value
0.32 (0.18–0.59)
0.000
0.42 (0.24–0.74)
0.002
0.36 (0.17–0.75)
0.006
0.49 (0.28–0.86) 0.50 (0.29–0.86)
0.013 0.013
0.50 (0.29–0.87) 1.04 (1.01–1.06) 0.53 (0.31–0.92)
0.014 0.02 0.02
0.51 (0.029–0.91)
0.023
0.58 (0.32–1.03)
0.06
0.61 (0.36–1.05) 0.63 (0.37–1.07) 0.63 (0.37–1.07) 0.62 (0.35–1.10)
0.08 0.088 0.09 0.10
0.64 (0.37–1.11) 0.62 (0.34–1.13) 0.65 (0.37–1.13)
0.11 0.12 0.13
0.44 (0.15–1.30)
0.14
0.71 (0.41–1.21) 0.82 (0.47–1.43)
0.21 0.48
0.78 (0.37–1.62) 1.17 (0.68–2.02)
0.50 0.57
1.11 (0.64–1.95)
0.71
0.97 (0.53–1.74)
0.91
Limitations Generalizability of the results may be limited for several reasons. The NICU is often characterized as a highly specialized and unique environment and conditions in NICUs may not generalize to other unit types. Additionally, our sample was comprised of nurses who held a voluntary specialty certification and may not reflect the broader population of NICU nurses, the majority of whom are not certified. The response rate (22%), while within a typical range for mailed surveys (VanGeest & Johnson, 2011), raises concerns about generalizability and possible non-response bias. Because of the anonymous nature of the survey and lack of benchmarking data for comparison we were unable to conduct recommended post-hoc analyses to assess non-response bias (Halbesleben & Whitman, 2013). Assessments of missed nursing care at one point in time may not generalize to typical practice. Lastly, social desirability bias may have influenced nurses' responses given the sensitivity of the subject matter. We believe that the estimates of selfreported missed care in this study are likely to under-represent its true occurrence.
Practice Implications The differences we observed in reasons for missed care may have implications for identification and selection of interventions to reduce missed care in NICUs in each type of organization. In particular, NICU nurse leaders in non-Magnet® facilities are encouraged to assess communication, teamwork, assistive personnel resources, and nurse
Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004
H.L. Tubbs-Cooley et al. / Journal of Pediatric Nursing xxx (2016) xxx–xxx
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Please cite this article as: Tubbs-Cooley, H.L., et al., Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units, Journal of Pediatric Nursing (2016), http://dx.doi.org/10.1016/j.pedn.2016.12.004