Health Policy$ense

As nurses care for women in labor, is the care “just OK?"

Hospital work environment linked to missed nursing care

What if someone told you that the nurse who would be your main caregiver throughout your labor routinely missed necessary nursing care activities, like comforting or teaching patients? In a recent study, my colleagues Eileen Lake, Sindhu Srinivas, Kathleen O'Rourke, Jordan Sanders and I found that half of nurses surveyed who worked in labor and delivery in 247 hospitals in four large U.S. states had missed one or more care activities on their last shift. Although labor and delivery nurses are the frontline providers during labor, hospital organizational factors often prevent them from having sufficient time or resources to provide the care that is needed.

What makes a better nurse work environment?

• Work environment is measured with a validated instrument called the Practice Environment Scale of the Nursing Work Index.
• The index includes five subscales: Nurse Participation in Hospital Affairs, Nursing Foundations for Quality Care, Nurse Manager Ability, Leadership and Support; Staffing and Resource Adequacy, and Collegial Nurse-Physician Relations.
• Hospitals with “better” nurse work environments have at least four subscales above the sample median, while those with “poor” environments have one or no subscale above the median.

Our team also found that labor and delivery nurses who worked in hospital settings with better work environments, i.e., those that support professional nursing practice, missed fewer necessary care activities than nurses who worked in hospital settings with poor work environments. Across the 247 hospitals and 1,313 nurses in the study, an average of 12.5% of necessary nursing care activities were left undone on the last shift the nurse worked. However, only 8.5% of necessary care activities were left undone on units with better work environments, compared to 18% on units with poor work environments.

Of notable concern are the types of care that are most commonly missed, including 'comforting/talking with patients' (30.5%), 'teaching/counseling patients and family' (22.2%) and 'developing and updating care plans' (20.8%). The least commonly missed were 'treatments and procedures' (2.3%), 'skincare' (3.3%) and 'pain management' (4.0%). These findings reveal that activities in the psychological, emotional, and educational domains are more commonly missed than physical/technical activities. Acknowledging the importance of nursing care activities, especially those that are not as easily measured, is essential to mitigating missed care.

This research shows that the nurse work environment on labor and delivery units influences the frequency of missed care. Importantly, it suggests that hospital organizational features can be modified to improve patient care. These findings should be considered as nurse managers and hospital administrators seek to reduce the frequency of missed care on labor and delivery units. Leveraging the nurse work environment has the potential to transform the delivery of obstetric care received by millions of women and their families.

Rachel French, BSN, RN is a T32 doctoral research fellow in the Center for Health Outcomes and Policy Research (CHOPR) at the University of Pennsylvania School of Nursing, and an LDI Associate Fellow.