Abstract

The соnсeрt of missed nursing саre addresses nursing саre оmissiоns in the рrосess of delivering nursing саre. Missed nursing саre leads to diminished quality of саre and рооr раtient оutсоmes. The Аim of the study: This study аimed to determine the levels and types of missed nursing саre and to identify рrediсtоrs of “missed nursing саre” based on bасkgrоund variables, and рerсeived reasons for missed саre. Research design: Quantitative descriptive сrоss-seсtiоnаl соrrelаtiоnаl research design. Setting: This study was соnduсted 10 hоsрitаls in Makkah region, Saudi Аrаbiа. Sample: 309 Раrtiсiраnts was recruited using а nоnрrоbаbility соnvenienсe sampling methods. Tооls of data соlleсtiоn: The MISSСАRE Survey was utilized to measure nursing staff рerсeрtiоns of both аmоunts of missed nursing саre and the reasons for missed nursing саre. Result: The result shows that аmbulаtiоn of раtients was the most frequently reроrted element of missed саre followed by emоtiоnаl suрроrt to раtient and/or family, feeding раtient when the fооd is still warm, setting up meals for раtient who feeds themselves, resроnse to саll light is initiated within 5 minutes, and attend interdisсiрlinаry саre соnferenсes. The study аlsо revealed that inadequate lаbоr resources were the most reason of missed саre followed by material resources and соmmuniсаtiоn. Соnсlusiоn: This study соnсluded the роint to the need to асknоwledge сertаin аsрeсts of missed nursing саre and the different roles within nursing. Highlighting the most relevant reasons for missed nursing саre might help nurse аdministrаtоrs in preparing resроnsive strategies to eliminate such reasons.

1. Introduction

The concept of missed nursing care speaks to nursing care omissions when providing patient care by the nurses. The omission of nursing care is often an unknown error affecting the safety of patients. These errors pose significant risks such as failure to rescue, malnutrition, and reduced mobility ¹. Errors of omission are defined as the failure to do what is right, and errors of commission do something wrong. Both of these types of errors have the potential to lead to unintended consequences ². Until recently, mistakes in errors of omission, such as failure to do the right thing, not taking medication, and not responding to the patient call, and patient repositioning received little attention to patient safety and standardized literature, which have mainly focused more on missed nursing care such as administering the wrong medication to a patient. According to the Agency for Healthcare Research and Quality missed nursing care is more difficult to recognize and likely represents a larger problem than the omission of care ³.

Kalisch, Landstrom ⁴ coined the term “missed nurse care,” defined as any aspect of patient care that is omitted or severely delayed. Kalisch, Landstrom ⁴ later showed a concept analysis of the missed care. Missed nursing care was initiated with the conduct of the MISSCARE Survey. This tool compares staff reports on missed nursing care items and reasons for missed nursing care ⁴. The MISSCARE study is a reliable and valid method of unfinished nursing care. Non-invasive nursing studies have revealed a large number of missed care ³. In a study of 3 hospitals with a sample of 459 nurses, the six most reported aspects of missed nursing care were patient ambulation (84%), medication administration (83%), patients being turned in every 2 hours (82%), oral care (82%), patient teaching (80%), medication administration time (80%) ⁵ The second study of ten hospitals and more than 4000 nursing staff members produced similar results. The most common exceptions of missed care were ambulation of patients (76.1%), attendance of interdisciplinary rounds (65.5%), oral care (64.5%), medication administration within 30 minutes of their scheduled time (59.8%), and turning patients every 2 hours (59.4%) ⁶. found similar results in a study of reports by a nurse and a nurse assistant on missed nursing care. ⁷

Missed nursing care affecting the quality of care and patient outcomes. Kalisch, Tschannen ⁶ found that the missed nursing care mediates the relationship between staffing levels and inpatient falls. Examination of patient reports of missed care revealed that the most missed nurse care was reported by patients who also reported skin deformities, medication errors, new infections, arterial run veins, intravenous arteries, and other adverse events while hospitalized.

Globally, many studies have been conducted in missed nursing care, with no studies to date have explored missed nursing care in Saudi Arabia yet. Therefore, the principal aim of this study was to identify the amount, type, and reasons for care being missed in Saudi Arabia. The secondary aim to identify predictors of “missed nursing care” based on background variables, and perceived reasons for missed care.

2. Research Aims and Objectives

The aims of the current study were to identify: (1) the levels and types of missed nursing care and the reasons for missed care across hospitals. (2) Identify predictors of “missed nursing care” based on background variables, and perceived reasons for missed care.

3. Research Questions

1. What is the amount of nursing care being missed in hospitals?

2. What are the reasons identified by nursing staff for missed nursing care?

3. What characteristics of the nursing unit’s staff members, work schedules, perceptions of staffing adequacy and job satisfaction that are predict missed nursing care?

4. Research methodology

The design of this study is a descriptive cross-sectional study design. A non-probability convenient sample of 309 participants was included from 10 hospitals in Makkah region Saudi Arabia.

5. Data Collection Tools

The MISSCARE Survey was utilized to measure nursing staff perceptions of both amounts of missed care (part A) and the reasons for missed care (part B) ⁴. In part A, nurses were asked to identify how frequently elements of nursing care are missed using a 4-point Likert scale, with anchors rarely missed to always missed ⁴. In part B, nurses identified the reasons why nursing care is missed using anchors, not a reason and significant reason. In addition, the demographic form was being developed by the researcher which included nurse profile data: age, gender, marital status, education level.

6. Data Collection Methods

The data was collected by using an anonymous online survey. The email was sent to all nurses by explaining the purpose of the study and it included the link to access the online survey, provided instructions on how to complete the survey, detailed confidentiality regulations, and offered contact information of the principal investigator. The email was mentioned that the study is voluntary and anonymous, and also explains the process of disseminating the results. The researcher’s contact details were be provided in the email for those who sought more information on the study or to address any questions. No explicit consent was taken.

7. Validity and Reliability

A pilot testing of the instrument was conducted on 10 nurses from each hospital to determine the clarity of the questionnaire and to estimate the time needed to fill the questionnaire. The pilot was excluded from the study lastly, the instrument reliability was assessed by evaluating internal consistency through Cronbach’s alpha which considered the most common method. The Cronbach alpha was 0.95 and 0.97 for missing care and its reasons respectively. On the other hand, the validity of the instrument was tested by using exploratory factor analysis and face validity by three experts in the field of research and nursing.

8. Ethical Considerations

The researchers were committed to all ethical considerations required to conduct the research. Before data collection, the researchers obtained official permission from IRB at King Abdullah medical city Research Center. Confidentiality was respected throughout the research steps.

All subject nominative data are removed; all data files are secured and only used by researcher and after concluding the research all data will be deleted.

9. Statistical Techniques

Data were analyzed using SPSS V22. Descriptive statistics in form of frequency, percentage, mean, and standard deviation were used to describe the study variables. An independent t-test was used to test the difference between two means of continuous variables. ANOVA test was used to test the difference between more than two means of continuous variables. Linear regression analysis was utilized to identify predictors of missed nursing care. Statistically significant was considered as (p-value< 0.01 &0.05).

10. Results

Table 1 illustrates the general missed care among the studied nurses was 36.35±11.65. Ambulation of patients 3 times per day (or as ordered) was the most frequently reported element of missed care, with (7.4%) of nurses reporting this action being frequently or always missed, followed by emotional support to patient and/or family (4.5%), after that three elements; feeding patient when the food is still warm, setting up meals for the patient who feeds themselves, response to call light is initiated within 5 minutes, and attend interdisciplinary care conferences were (4.2%).

Table 2 illustrates that the studied nurses perceived that inadequate labor resources were the most reason for missed care (79.3%), followed by material resources (79.0%) and communication (71.8%). Within the labor resources elements, an unexpected rise in patient volume and/or acuity on the unit was the highest reason of missed care (82.8%), followed by an inadequate number of staff (80.2%), and heavy admission and discharge activity (80.2%). Regarding material resources, supplies/ equipment not functioning properly when needed was the top reason for missed care (79.7%) followed by medications were not available when needed (79.3%). Within communication elements, unbalanced patient assignments (80.9%) was the top reason for missed nursing care followed by inadequate hand-off from previous shift or sending unit (78.9%), and other departments did not provide the care needed (78.6%).

Table 3 illustrates the majority of the studied nurses’ age (68.6%) was between 25-34 years. female (81.9 %), married (69.6%), having bachelor degree in nursing science (80.3%). Of the 309 participants, 69.5%, and 68.2 of the studied nurses had 2-10 years of experience as a nurse and in their current unit respectively, also 72.8% of the nurses perceived 50-75% staffing adequacy. There was no statistically significant difference within the missed nursing care score related to nurses’ characteristics (p>0.05).

Table 4 show that of 309 participants, 61.8% was satisfied with their current position, also 72.8%, and 73.5% of the studied nurses were satisfied with being nursing staff and teamwork level respectively. Also, 66.3% of the studied nurses do not plan to leave their position. There was a statistically significant difference in missed nursing care in keeping with nurses’ satisfaction with teamwork (p<0.05).

Table 5 illustrates that nurses’ satisfaction with teamwork correlated negatively with missed nursing care and explained 2.8% of the variance.

11. Discussion

Missed nursing had negative consequences on patient status and health care organization, therefore our study aims to explore predictors of missed nursing care for avoiding and stop its negative outcomes. To attain the aim of the study, the findings are discussed in main parts:

Part I: nurses’ perception of missed nursing care

The present study revealed that missed nursing care was at a low level among the studied nurses, this might result in an electronic health care system, double check-up of nursing care or effective collaboration and communication between health care providers. Also, nursing staff perceived that labour resources can contribute to missed nursing care, followed by material resources and communication/teamwork. These results supported by Saqer and AbuAlRub ⁸ who found missed nursing care was at low level among convenience nurses who were providing direct look after patient in Jordanian private and governmental hospitals.

On an Individual level, the results of current study revealed the foremost frequent missed nursing care as followed ambulation of patients 3 times per day (or as ordered), emotional support to patient and/or family, feeding patient when the food continues to be warm, putting in place meals for patient who feeds themselves, followed by response to call light is initiated within 5 minutes, and attends interdisciplinary care conferences. These results are in line with other studies conducted previously ^{6, 7, 8, 9, 10, 11}. The possible explanation of such results that nurses staff could perceived these styles of nursing tasks as not important. Saqer and AbuAlRub ⁸ explained that such tasks may well be prevented by improving the documentation process to assist to forestall missed nursing care. Furthermore, other missed care tasks could also be seen by nurses as not their main job like feeding patient, fixing meals which usually delivered by other staff, this might be reason nurses reported this as missed care.

In this study, the foremost reason for missed nursing care was labour resources followed by material and communication. The findings also agreed with the study of Moreno-Monsiváis, Moreno-Rodríguez ¹² that reported nursing personnel indicated there have been fewer care omissions in continuous evaluation interventions. Also mentioned the foremost perceived factor contributing to missed nursing care was labour resources, followed by material resources and communication teamwork among health care providers. Kalisch, Tschannen ⁶ and Kalisch ¹³ also found that inadequate labour resources was the foremost often cited reason for missed care, followed by material resources and communication between health care providers. The previously reported reasons by nurses can be reduced by providing education courses for nurses regarding time management and communication skills, improve nurse teamwork, managing work schedule.

Part II: predictors of missed nursing care

Our study failed to predict nurses’ age, gender, education, marital status, experience additionally to staffing adequacy additionally to their satisfaction with being nursing staff, their current position and intention to depart their jobs as predictors of missed nursing care. But nurses’ satisfaction with teamwork was the sole predictor of missed nursing care. This leads to the identical line with Kalisch and Lee ¹⁴ who reported teamwork act as a predictor of missed nursing care, also found nurses’ with high experience and perceived their unit staffing level to be high reported less missed nursing care than staff who felt staffing was inadequate. The findings disagreed with Kalisch, Tschannen ⁶ found that eight variables were significantly related to missed care: sex, age, job title, shift worked, years of experience, perceived adequacy of staffing, and a number of patients cared for. Blackman, Henderson ¹⁵ found that the nurses’ satisfaction with their current job, their intention to stay working, shift type, nursing resource allocation, professional person communication, workload intensity, and workload predictability were predictors of missing nursing care. Saqer and AbuAlRub ⁸ also found that teamwork, age, female gender, education and job satisfaction were predictors of missing nursing care among nurses who were providing direct look after patient. Bragadóttir, Kalisch ⁵ revealed that Missed nursing care was significantly associated with hospital and unit type, participants’ age and role and their perception of adequate staffing and level of teamwork.

12. Conclusion

The findings of this study point to the requirement to acknowledge certain aspects of missed nursing care and also the different roles within nursing. The result concluded that the foremost missed care in Saudi hospitals were ambulation of patients, emotional support to patient and/or family, feeding patient when the food remains warm, putting in meals for patient who feeds themselves, response to call light is initiated within 5 minutes, and attend interdisciplinary care conferences. The result also showed that the foremost reasons of missed care was labour resources followed by material and communication. Highlighting most prevalent reasons for missed nursing care could help nurse administrators in designing responsive strategies to eliminate or reduces such reasons. Lastly, the result showed that nurses’ satisfaction with teamwork was the sole predictor of missed nursing care.

13. Limitations of the Study

A limitation of this study that the sample was convenience, and the response rate was very low, and this could limit the generatability of the study findings. The study relies on self-reported online survey data and the chance for reporting bias are possible.

14. Recommendation

The study findings show that missed nursing care is common among nurses. This study showed that human resource issues were the most frequently reported reason for missed nursing care, which were associated with sudden increases in workload and/or critical cases. Thus, nursing manger should try to support the units with high workloads with staff and material resources as this could help to reduced missed nursing care. Nurse manger and other leader can also try to implement some intervention that helps to reduce missed care such as leadership round where they talk to patient and staff to understand their issue. Nurse leader can also start unit-based practice council where the staff have chance to discuss patient issues and develop strategies to solve them. Nurses also can help patient and educate them about the importance of the ambulation. The MISSCARE is valid and reliable tool and can be used regularly for evaluation purposes to identify missed care and enhance nursing care.

Acknowledgements

We would like to thank all nursing staff at Makkah region for their help and support during data collection. We want to express our wholehearted appreciation to the executive’s board of King Abdullah Medical City, Makkah, and therefore the institutional review board for granting permission to conduct the study.

References