Pediatric nurses with poor work environments, higher patient loads more likely to miss care

In a new study, researchers at the University of Pennsylvania School of Nursing's Center for Health Outcome and Policy Research and the Children's Hospital of Philadelphia examined the factors influencing the likelihood of missed nursing care in a pediatric setting. Their findings indicate that pediatric nurses with poor work environments and higher patient loads are more likely to miss required care.

"It's a complex and provocative subject when we talk about a health-care professional to be unable to give the care that's needed," said Eileen T. Lake, the Jessie M. Scott Endowed Term Associate Professor of Nursing and Health Policy at Penn Nursing. "There has been a lot of research on this topic but very little in pediatrics. Given that children are a particularly vulnerable population, our question was, To what extent do nurses in pediatrics miss care and how does it relate to levels of staffing and their work environment?"

Lake was first author on the paper, published this week in the journal Hospital Pediatrics, an official journal of the American Academy of Pediatrics. She collaborated with Penn Nursing's Linda H. Aiken, the Claire M. Fagin Leadership Professor in Nursing and the senior author on the paper, and Chief Nurse Paula D. Agosto and researchers Kathryn E. Roberts and Beth Ely at CHOP, as well as several colleagues now at other institutions.

To address their questions, the researchers relied on a survey data collected from 2,187 pediatric registered nurses in 223 hospitals between 2006 and 2008. Among other questions, nurses were asked whether they had omitted any required or necessary care activities due to a lack of time. They were also asked which activities were missed.

More than half of the nurses, which included staff from neonatal intensive care, pediatric intensive care and general pediatrics units, reported having missed at least one care activity. As has been found in other settings, care such as planning, comforting, teaching and counseling were missed most frequently, while pain management, treatments and procedures were missed rarely.

Notably, the fraction of nurses who said they failed to complete at least one activity varied considerably from hospital to hospital.

"Seeing that, we say, Okay then, there are some places where nurses can complete required care and others where they don't; that's a fundamental finding," said Lake, "The next question is, How does this relate to the nurses' work environment?"

The quality of the environment was determined from survey responses regarding nurses' relationships with physicians, whether they had a capable and supportive nurse manager, whether a nursing philosophy formed the basis of their care, whether their resources and staffing were adequate and the extent to which nurses participated in decision making at the hospital.

Categorizing hospitals into poor, mixed and better work environments, Lake and colleagues found that, while 61 percent of nurses in poor environments missed care, only 46 percent of those in better environments reported a missed care activity. Nurses in better environments also missed fewer care activities: 1.2 compared to 1.9 in poor environments.

Work load made a difference as well. For every additional patient, nurses were 70 percent more likely to miss care.

"The implications are that quality of care differs pretty significantly across institutions and that if we can either provide better staffing or better work environments or both that nurses can get their care completed," Lake said.

She noted that not only would ensuring that nurses have supportive work environments and manageable workloads improve care quality, but it could also improve care efficiency for hospitals.

"Completing tasks like providing education and discharge instructions helps parents have what they need to leave the hospital and feel comfortable doing so," Lake said.

Such attention to quality care is particularly significant in pediatric nursing, where patients have specific vulnerabilities.

"They're vulnerable developmentally, cognitively and in terms of their ability to express their symptoms and advocate for themselves," Lake said. "One of nursing's roles is an advocacy role, so offering quality care is especially key in this population."

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