缺失护理、低价值活动和忙碌文化| J Adv Nurs

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Nurses hold an important role in society and an essential role in healthcare delivery. Nurses are a trusted workforce-it is nurses who people rely on when they are sick, injured, incapacitated and when seeking various forms of health care. As nurses, we know the value and vital importance of skilled, empathic nursing and of strong nurse advocacy for patients, families and communities. In most settings, nursing services are funded by the public purse (sometimes with the additional contribution of those in receipt of services). Members of the public often fund these services through the taxation system and want to believe that quality and skilled nursing care will be available to them, if they or a family member become ill, incapacitated or injured, or find themselves in any situation in which health care is needed.

However, there is increasing and compelling evidence that many patients experience missed nursing care. Since Kalischs's (2006) seminal work, missed care has become a growing area of interest to researchers, and research findings show that missed care is widespread in many settings, including hospitals (Ball et al., 2016) and community settings (Phelan et al., 2018) and affects patients across the lifespan, including neonates and children (Bagnasco et al., 2019; Tubbs-Cooley et al., 2015). In a concept analysis, Kalisch et al. (2009, p. 1509) defined missed nursing care as ‘any aspect of required patient care that is omitted (either in part or in whole) or delayed’. These authors linked missed care to patient safety and positioned missed care as an error of omission.

Missed care occurs much more frequently than we might think. A systematic review reported that ‘care left undone on the last shift ranged from 75% in England, to 93% in Germany, with an overall estimate of 88% across 12 European countries’ (Griffiths et al., 2018, p. 1475). This review also provides important and detailed information on the nature of missed nursing care and shows that all manner of care is liable to being missed, including personal hygiene, skin care, oral care, discharge preparation, assistance with food and hydration, medications and infusions and hand hygiene. Blackman et al. (2022) focused on issues around infection control and found that 13 variables exerted influence on missed infection control care, including methods used to prevent hospital-acquired infections, surveillance and hand hygiene practices.

Clearly, omission of care to this extent and across this range of areas can affect patient outcomes, experience and satisfaction. In a review of literature on the impact of missed care on patient outcomes, Recio-Saucedo et al. (2018) identified nine studies that reported associations between missed care and outcomes such as pressure injury, medication errors, hospital-acquired infection, falls, unplanned 30-day readmission, critical incidents and mortality. For these reasons alone, it is imperative that nursing responds to findings of this nature and seeks to interrogate and resolve the antecedents to and consequences of missed care.

Kalisch et al. (2009) suggest that the decision to either attend, delay or omit patient care activities is affected by factors internal to the nurse. These factors are named as team norms; decision-making processes; internal values and beliefs and habits. However, there are also many factors external to the nurse that play a role in missed care. Findings by Dutra and Guirardello (2021) suggest a link between the nursing work environment, quality of leadership and missed care. Missed care has also been associated with other factors including austerity, interruptions, pressures associated with patient acuity and numbers, high staff turnover, labour and resource limitations and sub-optimal staffing (Dutra & Guirardello, 2021; Griffiths et al., 2018; Tubbs-Cooley et al., 2015; Willis et al., 2017). These factors also contribute to cultures of busyness, in which nurses may be too busy or pressured to complete all patient care activities, meaning that nurses must respond to what they consider the most pressing patient needs to be.

The area of missed care has many complexities and clearly is multi-factorial. In their daily work, nurses are continually prioritizing and reprioritizing activities in response to changing patient need, meaning that intended or planned care activities may be relegated to a lower priority. However, missed care is an issue of critical concern and is increasingly being viewed as a care quality indicator (Recio-Saucedo et al., 2018). If nurses are unable to provide nursing care, for whatever reason, there is an imperative to carefully consider what this means and to identify and implement strategies to mitigate (or at least reduce the frequency of) missed care.

Busyness is frequently referred to in relation to nursing and missed care—to the point it has become a mantra that is almost uncritically accepted as truth, and oft-times spoken of as a truth that is not amenable to change. Busyness has become the ‘go-to’ response to queries about care quality and in discussions about changing practices in any way, it is often not long before the issue of nurse busyness is raised as a barrier to change. However, we cannot continue to cite busyness (and its antecedents) as a reason for missed care without interrogating the context and nature of this busyness and bringing a solution-focused stance to the issue. This means a critical evaluation of processes, practices and contextual factors that shape the nursing workplace.

For a start there is a need to really listen and respond to nurses when they say they are too busy to provide optimal patient care and have to omit or delay care activities. There may be a need to critically re-evaluate models of care—if nurses are trapped in relentless cycles of busyness and care activities are not being delivered to patients, then surely there is a need to reconsider the models and frameworks for care that are in use. Because these models may be ineffective, and not work well for patients or for nurses.

There is also a need to reconsider skill mix in the nursing workforce. The review by Griffiths et al. (2018) suggests that the presence of support workers did ‘not generally reduce the level of missed nursing care and may even increase it where skill mix is diluted’ (p. 1485). In the face of widespread missed nursing care, there is a need to better understand why strategies such as adding support workers are not effective and how (or if) these workers can be better integrated to reduce missed care. It may be that increased advocacy for prescribed staff-to-patient ratios would be a more successful and appropriate way forward.

There is also a need to rigorously interrogate low value activities that may be taking up nursing time, often at the expense of care that will be of benefit to patients. Low value care refers to activities that do not benefit patients, can even harm patients, and use up resources. Low value care takes the time and energy of healthcare professionals and is potentially a contributing factor to cultures of busyness and missed care. Reducing low value care could have a significant and positive impact on cultures of busyness in health care and could transform health care through cost savings and reducing missed care (Rietbergen et al., 2020). In several countries, ‘Choosing Wisely’ lists of low value nursing care have been created and it is important we promote these to our colleagues and students (Rietbergen et al., 2020). It is also useful to scrutinize policies and practices in our own organizations with a view to identifying and reducing low value activities (Osorio et al., 2019).

Much of the published work on missed nursing care is survey-data based on retrospective self-report by nurses, and while this is very useful work and certainly provides important insights into missed care, it is also important that we engage with patients and carers to better understand their views on missed care and the implications of missed care to them and their health trajectory. Qualitative research with all key stakeholders could also provide crucial additional insights, including why it is that additional support workers do not reduce (and may even increase) the frequency of missed care. It is also important to have access to patient views on low value activities and their support for de-implementation processes (Osorio et al., 2019).

The culture of busyness does not serve us well. It can mean that we may not be able take the time to step back, reflect on practice, and consider how things could be done differently to improve care for patients, enhance the nursing work environment and reduce the frequency of missed care. Collectively, we must come to terms with damaging cultures of busyness that contribute to the unacceptably high levels of missed care that are reported in the literature. This is not only an essential issue for patient care and patient safety but is linked to job satisfaction for nurses—a factor in nurse retention. In coming to terms with missed care and its antecedent factors, we could potentially not only better meet our social mandate, through improved patient experiences of care and patient outcomes but contribute to a more robust and sustainable workforce through improvements to nurse job satisfaction and potentially, enhanced nurse retention.

全文翻译（仅供参考）

护士在社会中扮演着重要的角色，在医疗服务中扮演着重要的角色。护士是一个值得信赖的劳动力-这是护士的人依靠当他们生病，受伤，丧失能力，并寻求各种形式的医疗保健。作为护士，我们知道的价值和熟练的，同情的护理和强大的护士倡导患者，家庭和社区的至关重要性。在大多数情况下，护理服务是由公共资金资助的（有时还有接受服务的人的额外捐款）。公众往往通过税收制度为这些服务提供资金，并希望相信，如果他们或家庭成员生病、丧失能力或受伤，或发现自己处于需要保健的任何情况下，他们将获得优质和熟练的护理。

然而，有越来越多的令人信服的证据表明，许多患者的经验错过了护理。自从Kalischs（2006）的开创性工作以来，错过的护理已经成为研究人员越来越感兴趣的领域，并且研究发现表明错过的护理在许多环境中普遍存在，包括医院（Ball等人，& nbsp; 2016）和社区环境（Phelan et al.，& nbsp; 2018），并影响患者的整个生命周期，包括新生儿和儿童（Bagnasco et al.，& nbsp; 2019; Tubbs-Cooley et al.，& nbsp; 2015年）。在概念分析中，Kalisch等人& nbsp;（2009年，第1509页）将遗漏的护理定义为“遗漏（部分或全部）或延迟的所需患者护理的任何方面”。这些作者将漏诊与患者安全性联系起来，并将漏诊定位为遗漏错误。

错过的护理发生的频率比我们想象的要高得多。一项系统回顾报告称，“上一次轮班未完成的护理比例从英国的75%到德国的93%不等，12个欧洲国家的总体估计为88%”（Griffiths et al.，& nbsp; 2018，第1475页）。该综述还提供了关于错过护理的性质的重要和详细信息，并表明所有方式的护理都可能被错过，包括个人卫生，皮肤护理，口腔护理，出院准备，食物和水合作用的帮助，药物和输液以及手部卫生。Blackman等人&（2022）关注感染控制问题，发现13个变量对错过感染控制护理产生影响，包括用于预防医院获得性感染的方法，监测和手部卫生习惯。

显然，在这种程度和范围内忽略护理可能会影响患者的结局、体验和满意度。在一篇关于错过护理对患者结局影响的文献综述中，Recio-Saucedo et al. nbsp;（2018年）确定了9项研究，报告了错过护理与结果之间的关联，如压力损伤，用药错误，医院获得性感染，福尔斯，计划外30天再入院，危急事件和死亡率。仅仅因为这些原因，护理人员必须对这种性质的调查结果做出反应，并寻求询问和解决错过护理的前因和后果。

Kalisch等人& nbsp;（2009）建议，参加、延迟或省略患者护理活动的决定受护士内部因素的影响。这些因素被称为团队规范;决策过程;内在价值观、信仰和习惯。然而，也有许多外部因素的护士，在错过护理的作用。Dutra和Guirardello（2021）的研究结果 表明，护理工作环境，领导质量和错过护理之间存在联系。错过的护理也与其他因素有关，包括紧缩，中断，与患者病情和数量相关的压力，高员工流动率，劳动力和资源限制以及次优人员配备（Dutra& Guirardello， 2021; Griffiths等人，& nbsp; 2018; Tubbs-Cooley et al.，& nbsp; 2015; Willis et al.，& nbsp; 2017年）。这些因素也有助于忙碌的文化，其中护士可能太忙或压力太大，无法完成所有的病人护理活动，这意味着护士必须对他们认为最紧迫的病人需求做出反应。

错过护理的领域有许多复杂性，显然是多因素的。在他们的日常工作中，护士响应于变化的患者需求而不断地对活动进行优先级排序和重新优先级排序，这意味着预期的或计划的护理活动可能被降级到较低的优先级。然而，错过的护理是关键关注的问题，并且越来越多地被视为护理质量指标（Recio-Saucedo等人，& nbsp; 2018年）。如果护士无法提供护理，无论出于何种原因，有必要仔细考虑这意味着什么，并确定和实施战略，以减轻（或至少减少频率）错过的护理。

忙碌经常被提到与护理和错过护理的关系，以至于它已经成为一个几乎不加批判地被接受为真理的咒语，并且经常被认为是一个不适合改变的真理。忙碌已成为“去”的回应有关护理质量的查询，并在讨论以任何方式改变做法，它往往是不久前护士忙碌的问题提出了一个障碍，以改变。然而，我们不能继续引用忙碌（及其前因）作为错过护理的原因，而不询问这种忙碌的背景和性质，并为这个问题带来一个以解决方案为中心的立场。这意味着对塑造护理工作场所的流程，实践和背景因素进行批判性评估。

首先，当护士说他们忙碌而不能提供最佳的病人护理，不得不省略或推迟护理活动时，有必要真正倾听和回应护士的意见。可能有必要批判性地重新评估护理模式，如果护士被困在无情的繁忙周期和护理活动没有被交付给病人，那么肯定有必要重新考虑的模式和框架，在使用中的护理。因为这些模型可能是无效的，并且对患者或护士不起作用。

此外，还需要重新考虑护理人员的技能组合。Griffiths et al.&（2018）表明，支持工作者的存在“通常不会降低错过护理的水平，甚至可能在技能组合被稀释的情况下增加”（第1485页）。面对普遍错过护理，有必要更好地了解为什么战略，如增加支持工作者是无效的，以及如何（或如果）这些工作者可以更好地整合，以减少错过的护理。加强对规定的工作人员与病人比例的宣传可能是一种更成功和更适当的前进方式。

还需要严格询问可能占用护理时间的低价值活动，通常以牺牲对患者有益的护理为代价。低价值护理指的是对患者没有好处，甚至可能伤害患者，并消耗资源的活动。低价值护理需要医疗保健专业人员的时间和精力，并且可能是忙碌和错过护理文化的一个促成因素。减少低价值护理可以对卫生保健中的忙碌文化具有显著和积极的影响，并且可以通过节省成本和减少错过的护理来改变卫生保健（Rietbergen等人，& nbsp; 2020年）。在一些国家，已经创建了低价值护理的“明智选择”列表，重要的是我们向我们的同事和学生推广这些列表（Rietbergen等人，& nbsp; 2020年）。为了识别和减少低价值活动，仔细检查我们自己组织中的政策和实践也是有用的（Osorio等人，& nbsp; 2019年）。

大部分已发表的关于错过护理的工作是基于护士回顾性自我报告的调查数据，虽然这是非常有用的工作，肯定为错过护理提供了重要的见解，但我们与患者和护理人员接触也很重要，以更好地了解他们对错过护理的看法以及错过护理对他们及其健康轨迹的影响。与所有关键利益相关者的定性研究也可以提供关键的额外见解，包括为什么额外的支持工作者不会减少（甚至可能增加）错过护理的频率。获得患者对低价值活动的意见以及他们对去实现过程的支持也很重要（Osorio等人，& nbsp; 2019年）。

忙碌的文化对我们没有好处。这可能意味着我们可能无法花时间退后一步，反思实践，并考虑如何以不同的方式来改善对患者的护理，改善护理工作环境并减少错过护理的频率。总的来说，我们必须接受破坏性的忙碌文化，这种文化导致了文献中报道的不可接受的高水平的错过护理。这不仅是病人护理和病人安全的一个重要问题，而且与护士的工作满意度有关，这是护士保留的一个因素。在与错过的护理及其前因因素的条款，我们可能不仅可以更好地满足我们的社会任务，通过改善患者的护理和患者的结果的经验，但有助于更强大和可持续的劳动力，通过提高护士的工作满意度和潜在的，增强护士保留。

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