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Missed nursing care: View from the hospital bed (Part One)
 

While traveling, a respected nurse educator—a fellow in the American Academy of Nursing—finds herself in a U.S. hospital, alone and far from home, for seven horrific days and nights, and lives to tell about it. A side benefit of the unplanned experience? It corroborated her research on missed nursing care.

By Beatrice J. Kalisch
Missed nursing care: View from the hospital bed (Part One)Health care providers often assume they know what inpatients are experiencing. How different the view is from the hospital bed. Suddenly, the paradigm is flipped. Insights gained about hospital care from that vantage point can be quite astounding and must be examined if inpatient care is to improve. It is toward this end that I share my experience as an inpatient for seven days in an acute-care U.S. hospital. I was out of town and a longtime friend took me to the emergency department (ED).

First impressions
I didn’t know what was wrong with me, just that I was in intense pain. Immediately after arriving at the ED, I suggested an EKG to the triage nurse. (I didn’t want to take any chances that the staff was unaware of research showing that women present differently.) For the EKG, I was placed on a stretcher in the hall—no room was available—where I remained for more than 2 1/2 hours. My only contact with the staff during that time was when my friend asked for an emesis basin, which was handed to her. The staff member didn’t even look my way. I assume a nurse was assigned to me, but I never saw one, despite my obvious and intense pain. My friend noted that, while I waited, staff members were laughing and talking at the desk.

Finally, I was moved into a room. I told a nurse, “You must be really busy.” She replied tersely, “You’re lucky; yesterday, it was a six-hour wait.” Once in the ED room, my care was good. They started a morphine IV, sent me for a CT scan, diagnosed my problem as pancreatitis and informed me that I was going to be transferred to an inpatient unit.

The morphine began wearing off, and my pain was coming back. Knowing that, once on the unit, an assessment would need to be made by the nurse and physician orders obtained before I could receive pain medication, I asked the ED nurse if I could have pain medication before being transferred. She said, “Honey, you will get it when you get to the unit.”

Thirty minutes later, my pain was worse and the transporter had not arrived. I asked again for pain medication and, again, the nurse responded that I would receive medication on the unit. Another half hour passed. I asked for pain medication again and received the same response. When I finally asked, “When am I going to be transferred?” they apparently realized I had been waiting a very long time—I wonder when it would have dawned on them if I had not asked—and decided to send one of the ED techs with me to the unit. The transfer finally occurred 45 minutes later. During my two-plus-hour wait, staff members gathered at the nurses’ station, laughing and talking.  So much for first impressions!

On the unit
In my room on the unit, I waited for what seemed an interminable time. I was in very intense pain. Finally, a nursing assistant came in, I asked for pain medication, and a nurse came to do my assessment. Her first comment was, “No one let us know you were here!” Again, I asked for pain medication and she, predictably, said she couldn’t give me anything until she finished her assessment. I said, “Well, can we hurry?” She was pleasant and moved through the process quickly. Eventually, another nurse came in with the pain medication and said, “I have overridden the Pyxis to get this, and I can only do it one time.” I don’t know why she said that but my internal response was, “Shame on me. I am getting special favors, which is a great inconvenience to the staff. And don’t ask again! I hope this kills my pain!”

The hospitalists
Since I was from out of town, the hospitalists were my sole physicians, except for one referral to a gastroenterologist. Over the course of my hospital stay, I estimate that I had five hospitalists. The first one came into my room shortly after I was admitted to the unit and said, “Your pain is not exactly in the right place.” Miserable and not in the problem-solving mode, I wondered what he wanted to do. He said I would be on IVs and that I could have a catheter if I wanted so I wouldn’t have to get up to go to the bathroom. I practically rose out of the bed and said, “NO!” That would have been all I needed—a urinary tract infection and more immobility! That was my last glimpse of a hospitalist for another three days. I asked a nurse why no doctor had come in to see me, and she said, “Oh, he was here. Maybe you were sleeping.”

Several days into my hospitalization, I was referred to a gastroenterologist, who ordered an upper GI for the next morning. When I arrived in the diagnostic area, the nurse questioned me several times about my pain location and finally told me it could be a pulmonary embolism (PE). She also informed me that I didn’t have to have the procedure if I didn’t want to. Not fully capable of decision making, to say the least, I found that alarming and wasn’t sure what to do. Clearly, she was trying to tell me something, coaching me. My oxygen saturation rate was low, just .85. When the physician came, I asked about the implications of having a PE in light of the procedure he was about to do. He replied, “I shouldn’t put you under anesthesia for two hours, if that is the case.” Instead, he ordered a CT scan and they found pneumonia. He said it was probably hospital-acquired. I never did have that upper GI.

Nursing care
To describe the nursing care I received on the medical unit during those seven days, I have divided it into the following categories: basic care, psychosocial care and discharge planning. Since I was too sick to evaluate medication doses or the accuracy of IVs, I assumed everything was being dispensed correctly and on time but, given the other nursing care I was receiving, I was anxious about the possibility of errors.

Basic care
I received practically no hygiene care. Since I was on nothing-by-mouth (NPO) status, my mouth was extremely dry and my lips crusted, worse than I had ever experienced. I asked for ice chips but was told I couldn’t have them. I asked for mineral oil and received one small tube to apply myself. When I asked for more, they gave me a disposable mouth-care packet, complete with two swabs to stick into a cup of water that sat there for 36 hours until I asked for fresh water. I knew I shouldn’t reuse the swabs but, since no one offered additional ones and I was too sick to ask, it seemed low on the priority list at that point.

In seven days, I had two baths (showers). I would have had only one, but I insisted upon the second and had it the day I was discharged. When I rang to go to the bathroom, staff members responded within a reasonable time but repeatedly scolded me for making a mess of my tubes, which took time for them to straighten out. After about the fifth time, I said, “I am not doing it on purpose.” Shortly after, a nurse used a Velcro cord borrowed from a computer to tie the tubes together. At that point, I felt heard.

Ambulation was totally absent throughout my hospitalization. I turned myself and, whenever I could, maneuvered into a chair on my own but, throughout my entire hospital stay, no one came to get me out of bed, much less ambulate me. After several days, I felt good enough to think about my need to walk and started down the hall, but a staff member said, “No, you have to have your oxygen.” Thinking they would come and help me with ambulation, I went back to my room but they never did help me, and I felt too sick to do anything about it. No physical therapy was ordered, either. Consequently, it took seven weeks of costly physical therapy after discharge for me to become conditioned again.

The hand-washing situation was revelatory. I searched the room for Purell and finally found it by my roommate’s bed, which was closer to the window. Staff members would have had to walk in front of me to use it, and I saw only one of them do that. I wondered if there was a sink outside my room and hoped there was, because the thought of my caretakers not washing their hands was too frightening to contemplate. Later, I discovered there was no sink and wondered what infections I might have acquired.

My first roommate kept the television and lights on all night, and I couldn’t sleep. The nurses said there was nothing they could do about it, so I finally asked to move to another room, a request they granted. A private room was unavailable, but they said they would put me on the list. I finally got moved to a private room two days before discharge.

Intake and output documentation was scant at best. I often told the staff that I had used the toilet, but I didn’t see anyone measure output. I was concerned because my output was extremely low but, when I told them, they didn’t seem concerned.

Emotional support
On repeated occasions, staff members did not listen to me although, in the midst of all of this missed nursing care, I did have one excellent nurse intervention. I was hallucinating and asked the nurse if I could talk with her. She sat down by my bed, and I told her I was seeing things. She said: “You are exhausted. Your roommate is going to be out of the room for two hours. We will put a sign on the door to not disturb you, and you can get two hours of sleep.” After that, I had no more hallucinations.

Discharge planning/teaching
No one mentioned anything about post-discharge arrangements until the day before I left the hospital. At 10:30 a.m. on Day 6, a hospitalist I had never seen before came into the room and stood by the door, as far away from me as she could get, and said, “You are being discharged today.” I asked when, and she said by noon. I panicked. I was feeling an extreme bloating sensation in my chest and stomach, and I had gained 15 pounds during my stay without eating or drinking much of anything. I had been on oxygen 24 hours a day, but my oxygen saturation rate, without oxygen, was still 85 percent, and I had pitting edema on my ankles.

Out of town and feeling absolutely horrible, I very much wanted to go home, but couldn’t imagine how I would make it. I expressed my concern to the nurse, who said: “Well, you can’t stay here just because you don’t feel good. Most people want to go home for Christmas.” I thought, “Not me. I want to spend Christmas right here in this wonderful environment!”

I received a phone call from a social worker. (She lived an hour away and didn’t want to come in.) “You need to leave the hospital today,” she said and proceeded to make me feel I had been labeled a deadbeat. “Where did you come from?” she asked. “A hotel,” I responded, “but I need to get a plane reservation.” Frankly, I was confused and anxious about what to do.

“Can you go back to the hotel?” she asked. I said it didn’t have a restaurant. Without giving any indication she had heard me, she fired several more questions: “Can you go to your mother’s home?” “Can you go to assisted living?” “Maybe you can go to the assisted living your mother is going to go to. You have to leave the hospital. We have several places you can go, but you can’t stay in the hospital.” Now my anxiety was skyrocketing! I was also angry and frustrated that this social worker wasn’t listening or giving me a chance to say anything.

Thirty minutes later, the nurse said, “The doctor wants me to tell you that you can’t stay in the hospital just because you don’t feel well. You haven’t been getting out of bed and walking.” Now, it was my fault I was deconditioned and not because ambulation had been entirely omitted from my care.

The respiratory therapist rescued me. Recognizing my frustration, she walked me down the hall and stayed with me for more than an hour. I told her I had a friend I could stay with for a short time, but her husband was very sick. I was afraid that, if I went there feeling the way I did, she would need to bring me back to the ED. The therapist was helpless to keep me in the hospital, but she arranged for oxygen to be delivered to my friend’s house and for oxygen to take on the airplane.

When my friend came to the hospital, she was clearly worried about taking me home in the condition I was in. She asked the staff why I had gained 15 pounds. She knew something was wrong with me. By that time, I was at my wit’s end and asked to see the administrator in charge. Instead, they sent the house supervisor, who came in and said, “You don’t have to leave until midnight,” as if that was going to solve my problem.

When my friend asked the supervisor about my weight gain, the supervisor seemed puzzled and offered no explanation. Assuming I was retaining fluid, I asked the nurse if I should have Lasix, but she told me they were afraid of the side effects. “Is there anything else you can do?” I asked. She responded, “You’re a nurse; you know the answer to that.”

Finally, at 7 p.m., the same nurse informed me that they were keeping me another day and, in the meantime, I would receive Lasix intravenously. She was going off duty, so the night nurse would administer it, which she did—three hours later. Afraid I would have to get up to go to the bathroom all night and not be able to sleep, I wished she had given it to me sooner. I voided 1500-plus cc in the next several hours, felt like a new person and finally felt ready for discharge.

Ironically, I was involved in conducting a series of studies on missed nursing care at the time, and we were discovering that a significant amount of nursing care is being missed in hospitals everywhere (Kalisch, 2006; Kalisch, Landstrom, & Williams, 2009; Kalisch, Landstrom, & Hinshaw, 2009; Kalisch & Williams, 2009). I now had personal experience to corroborate my research findings! RNL

Missed nursing care: View from the hospital bed (Part Two)

 

 Beatrice Kalisch
Beatrice Kalisch
Beatrice J. Kalisch, PhD, RN, FAAN, is Titus Distinguished Professor, Chair of Division III, at the University of Michigan School of Nursing in Ann Arbor, Michigan, USA.

 

References:
Kalisch, B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.

Kalisch, B., Landstrom, G., & Hinshaw, A. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509-1517.

 

Kalisch, B., Landstrom, G., & Williams, R. (2009). Missed nursing care: Errors of omission. Nursing Outlook, 57(1), 3-9.

 

Kalisch, B., & Williams, R. (2009). Development and psychometric testing of a tool to measure missed nursing care (MISSCARE Survey). Journal of Nursing Administration, 39(5), 211-219.

 

Shameful!, 8/11/2010
by: Olivia Suzanne Morrissette, RN, BSN
Rating: 5
This has got to be one of the saddest stories of a modern hospital admission I've ever read! None of this should have happened to you, Ms Kalisch, and possibly the only thing you did "wrong" was not throwing a nutty early in your stay. That entire hospital needs to be turned upside-down and shaken. Thank you for telling us about your experience. I don't know if I look forward to part two or not . . .
Same Experience, 8/11/2010
by: Delores A Price, BSN
Rating: 5
Unforuately, I have experienced the same conditions 3 times--first for myself, then for my mother and brother. If any of us had care, it was because I did it. Needless to say, I realized why I was being reprimanded for not being able to complete my assignment on time, and retired in 2000!
Sadly Experienced by TOO many patients, 8/11/2010
by: Caitanya N Turner
Rating: 5
This type of care is ever present. I have found that too many healthcare workers (i.e. nurse's, doctors, nursing assistants, etc) view patient care as a "job" and not the priviledge that it is. What a great honor to have the trust of our patients. What happen to the passion for the profession that everyone had when they went to school? When nurse's begin to loose that passion they should think back to why they became a nurse in the first place. Whether our patients are there for wellness visits or because they need our help in their healing it is essential that we value them as a whole being; spiritually, emotionally, holistically. They are not a paycheck, they are human beings. This has to stop! We, as nurse's, have to be proactive about the care that we give. We have to intervene when we witness poor care being administrated to patients (they are all our patients) We are, after all patient advocates.
Addendum to :Sadly Experienced by TOO many patients, 8/11/2010
by: Caitanya N Turner
Rating: 5
Please let us remember that our patients need us. It is our duty to provide quality, compassionate care. Care that is respectfully and tactfully delivered. Professionalism must be maintained. Caitanya Turner RN, BSN, CCRN, SRNA
OMG!!!!, 8/21/2010
by: Ms Therese B Pace
Rating: 5
Reading this truly makes me want to cry. I have seen glimpses of such behavior in individuals off and on over my many years in nursing, but nothing so severe, wicked and consistently system-wide as this. That facility needs to be shut down. What is really tragic is you desperately needed to stay there in that dump when they were trying to kick you out. AAHHH!
My experience...., 9/12/2010
by: Kathy S Mercer, RNC
Rating: 5
I've been a nurse for 31 years, and I have tried to see that my patients never experienced poor care. I've had two overnight stays this summer for diagnosis and treatment of SVT, and comparatively, my care was nowhere near as bad as the "care" given to you; however, there were still instances in which I couldn't believe what I was experiencing. Most of it centered around the use and care of my port through which I've received treatments for cancer for the past year. It seemed no one (except for one nurse who had a port herself) knew how to access it, keep it capped when not in use, nor flush it properly when de-accessing it. I got so frustrated because I had been a nurse educator in that hospital system a couple of years before, and I KNEW what the policy was, since I had been on that particular revision committee. I wasn't getting anywhere with questions or suggestions, so I finally kept quiet. I drove to see my chemo nurse after discharge and asked her to flush it properly;
K.Morris RN., MSNEd, 9/24/2010
by: Kathryn M Morris
Rating: 5
All I can add to this tragic account is that we had best be armed with educational goals when healthcare in our country changes over....it is all very frightening but at the same time challenging. We all need to be armed with awareness and this article certainly has all of the ingredients.
A foreign experience, 2/8/2011
by: meliott4@yahoo.com
Rating: 5
Recently my daughter was hospitalized in a German hospital. Very few of the healthcare staff spoke English and my daughter and I spoke extremely little German. The care was great. The staff found people to help us with the language difference and I was impressed that the nurses and doctor's listened to my 15 year old daughter and her wishes. There was a student nurse on the floor who spoke excellent English and she was assigned to assist us when needed. We were checked on quite frequently and extra effort was made to make sure she was comfortable. The expereince has opened my eyes and I will remember this care when i am taking care of my own patients.
No Time for Bedside Nursing, 6/20/2013
by: cori.cole@yahoo.com
Rating: 4
Unfortunately the author's experience is not unique. Nursing care has been replaced with electronic medical charting and limited resources. I work in a emergency department where the doctors are followed into the tight rooms with a scribe who charts for them. The poor patient is confused by the amount of people who enter the room. Often the doctor does not even touch the patient. Patients who are confused, in pain, or weak do not even understand what happened after the doctor, the computer on wheels, and the teenage looking scribe leave the room. When did nursing stop teaching pericare and bed baths? I do not want to blame entirely on the new generation of nurses caught searching their cell phones instead of caring for their patients but there is some reality in that comment. Everyone should experience the inpatients perspective. Thank you for sharing the important reminder our patients are people who require our complete attention.
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