Patterns and correlates of missed nursing care in inpatient oncology units

The holistic nursing competence and transition shock of newly graduated nurses as the determinants of missed nursing care: The mediation analysis

AIMS AND OBJECTIVE

To investigate the determinants of missed nursing care and to analyse the mediating effect of holistic nursing competence on the relationship between transition shock and missed nursing care.

BACKGROUND

Transition shock of newly graduated nurses is associated with missed nursing care. Previous studies have shown the determinants of missed nursing care among nurses, but little is known about the relationship between missed nursing care, transition shock and holistic nursing competence.

DESIGN

Descriptive and correlational design.

METHODS

The study was conducted among newly graduated nurses (n = 201) working in acute care hospitals for 1-12 months. The MISSCARE survey, Holistic Nursing Competence Scale and Nursing Transition Shock Scale were used for data collection, in addition to a sociodemographic question form. Data were analysed using Pearson correlation, multiple regression and mediation analyses. The study was reported following the STROBE checklist.

RESULTS

The determinants of missed nursing care among newly graduated nurses were sex, unit type, rotating shift work, holding a certificate, holistic nursing competence and transition shock. All these variables explain 35% of the variance in missed nursing care. Holistic nursing competence directly mediated 51.7% of the relationship between transition shock and missed nursing care.

CONCLUSIONS

Holistic nursing competence may decrease missed nursing care by reducing the effects of transition shock on newly graduated nurses.

RELEVANCE TO CLINICAL PRACTICE

The study highlighted that newly graduated nurses are an important population regarding missed nursing care. The determinants of missed care should be considered in the nursing care delivery to prevent missed care by newly graduated nurses. Based on the study findings, some recommendations were made for nurse managers and faculty for the orientation program and undergraduate nursing education.

Missed nursing care and stoma care: an Italian survey

BACKGROUND

In Italy, nursing research has paid special attention to 'missed nursing care'. The studies carried out, varying in tools and settings, describe considerable percentages of missed care. In the field of stoma care, the phenomenon has not been investigated to date.

AIM

To investigate the prevalence of missed nursing care (MNC) in the Italian ostomy patient population and the most relevant causes suggested for this by stoma care nurses.

DESIGN

Cross-sectional study.

METHOD

The Italian version of the MISSCARE survey was used with some questions related to the stoma care pathway. The survey was targeted at hospitals in the country with dedicated services and/or pathways for ostomy patients, between February and April 2023.

FINDINGS

A total of 461 questionnaires were sent out, 214 (53.3%) were analysed. The majority of the participants were female (160, 76.2%), median age of 50 years (35.0-53.8). The most common qualification was a Bachelor's degree (n=117; 54.9%) and work experience in stoma care was more than 10 years in 95 cases (50.3%). Prominent instances of MNC were identified, with hand washing (score 4.6 out of 5), compilation of nursing documentation and hygiene/skin care (score 4.5 out of 5) and patient/family education (score 4.4 out of 5) emerging as the most prevalent. The most notable omissions in the stoma care process encompassed educational facets, clinical monitoring, a comprehensive discharge plan, and diligent follow-up. Among the most frequent reasons were staff shortages (score 3.1 out of 4), unsuitable nurse-patient ratios (score of 3 out of 4) and insufficient numbers of experienced stoma care personnel (score of 3 out of 4).

CONCLUSION

A substantial number of basic and clinically relevant nursing interventions were perceived to be missed, and this may lead to an increase in negative outcomes for ostomy patients.

Development and Validation of the Missed Nursing Care Tool for Pre-Operative Patients with Lung Cancer in China

Introduction

Current research suggests that missed nursing care is widespread in preoperative lung cancer patients in China, and preoperative airway management nursing care for lung cancer patients is not standardized. Missed nursing care for preoperative lung cancer patients, on the other hand, is rarely investigated, particularly from the patient's perspective. This study aimed to develop and validate the MISSCARE Survey for pre-operative patients with lung cancer in China.

Methods

This study generated the preliminary draft of the MISSCARE Survey - Lung Cancer Patient (MS-LCP) and tested its reliability and stability through three rounds of lung cancer resection (494, 50, and 309 cases, respectively). 20 patients and 6 experts determined the face and content validity. EFA and CFA assessed construct and convergent validity. Internal consistency, including Cronbach's alpha, Spearman-Brown reliability, and re-test reliability, was also examined.

Results

The scale contained 15 items, including specific care, communicative care, timely care, and basic care. KMO was 0.932 (> 0.6), and Bartlett's Test of Sphericity showed P = 0.000 (<0.05). The attribution factor's item loads ranged from 0.765 to 0.853, accounting for 82.20% of the variation. The scale's Cronbach's alpha, Spearman-Brown, and retest reliability were 0.945, 0.879, and 0.824. CFA showed goodness of fit (RMSEA = 0.021, χ²/df = 1.138, GFI = 0.900, AGFI = 0.945, CFI = 0.996, NFI = 0.967, IFI = 0.996). For each dimension, AVE ranged from 0.555 to 0.717 (>0.50) and CR from 0.861 to 0.904 (>0.70).

Conclusion

The MS-LCP was reliable and valid in this study, making it appropriate for the Chinese lung cancer patient population. This tool is more objective in its presentation of missed nursing care, assisting nursing staff in optimizing nursing procedures before surgery, increasing the implementation of higher-quality tumor care, and promoting the recovery of lung cancer surgery patients.

Identifying gaps in global evidence for nurse staffing and patient care outcomes research in low/middle-income countries: an umbrella review

OBJECTIVE

To identify nurse staffing and patient care outcome literature in published systematic reviews and map out the evidence gaps for low/middle-income countries (LMICs).

METHODS

We included quantitative systematic reviews on nurse staffing levels and patient care outcomes in regular ward settings published in English. We excluded qualitative reviews or reviews on nursing skill mix. We searched the Cochrane Register of Systematic Reviews, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Medline, Embase and Cumulative Index to Nursing and Allied Health Literature from inception until July 2021. We used the A Measurement Tool to Assess Systematic Reviews -2 (AMSTAR-2) criteria for risk of bias assessment and conducted a narrative synthesis.

RESULTS

From 843 papers, we included 14 in our final synthesis. There were overlaps in primary studies summarised across reviews, but overall, the reviews summarised 136 unique primary articles. Only 4 out of 14 reviews had data on LMIC publications and only 9 (6.6%) of 136 unique primary articles were conducted in LMICs. Only 8 of 23 patient care outcomes were reported from LMICs. Less research was conducted in contexts with staffing levels that are typical of many LMIC contexts.

DISCUSSION

Our umbrella review identified very limited data for nurse staffing and patient care outcomes in LMICs. We also identified data from high-income countries might not be good proxies for LMICs as staffing levels where this research was conducted had comparatively better staffing levels than the few LMIC studies. This highlights a critical need for the conduct of nurse staffing research in LMIC contexts.

LIMITATIONS

We included data on systematic reviews that scored low on our risk of bias assessment because we sought to provide a broad description of the research area. We only considered systematic reviews published in English and did not include any qualitative reviews in our synthesis.

PROSPERO REGISTRATION NUMBER

CRD42021286908.

Antecedents of unfinished nursing care: a systematic review of the literature

BACKGROUND

Unfinished Nursing Care (UNC) concept, that express the condition when nurses are forced to delay or omit required nursing care, has been largely investigated as tasks left undone, missed care, and implicit rationing of nursing care. However, no summary of the available evidence regarding UNC antecedents has been published. The aim of this study is to identify and summarise antecedents of UNC as documented in primary studies to date.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, CINAHL, SCOPUS, and PROSPERO databases were searched for quantitative studies reporting the relationships between antecedents and UNC published after 2004 up to 21 January 2020. The reference lists of secondary studies have been scrutinised to identify additional studies. Two reviewers independently identified studies and evaluated them for their eligibility and disagreements were resolved by the research team. The quality appraisal was based on the Joanna Briggs Institute Critical Appraisal tools, according to the study designs. A data extraction grid was piloted and then used to extract data. The antecedents that emerged were thematically categorised with an inductive approach.

RESULTS

Fifty-eight studies were included; among them, 54 were cross-sectional, three were cohort studies, and one was a quasi-experimental study. They were conducted mainly in the United States and in hospital settings. The UNC antecedents have been investigated to date at the (a) unit (e.g., workloads, non-nursing tasks), (b) nurse (e.g., age, gender), and (c) patient levels (clinical instability).

CONCLUSIONS

At the unit level, it is highly recommended to provide an adequate staff level, strategies to deal with unpredictable workloads, and to promote good practice environments to reduce or minimise UNC. By contrast, at the nurse and patient levels, there were no clear trends regarding modifiable factors that could decrease the occurrence of UNC. The map of antecedents that emerged can be used to design interventional studies aimed at changing research from merely descriptive to that which evaluates the effectiveness of interventions.

Missed nursing care in a long-term rehabilitation setting: findings from a cross-sectional study

Background: There is a growing amount of literature that links missed nursing care (MNC) to negative patient outcomes, reduced patient safety, and poor quality of care. However, only few studies have investigated this phenomenon in long-term rehabilitation settings.Aim: To explore MNC occurrence, type, reasons, and predictors in three rehabilitation units.Design: A cross-sectional study was performed between August and September 2017.Method: 95 registered nurses and nursing assistants completed section A (interventions missed) and section B (perceived reasons for MNC) of the MISSCARE Survey tool. Descriptive, bivariate, and linear regression analyses were performed.Findings: The top missed elements were patient ambulation (score 2.4 out of 5, Standard Deviation [SD] 0.8), mouth care (2.3, SD 0.8), and participation to multidisciplinary meetings (2.3, SD 1.1). Lack of personnel was the most frequent reason reported for MNC with a score of 2.9 out of 4 (SD 0.9). At the linear regression analysis, advanced nursing education (β = 3.58, CI 95% 1.32-5.84) and inadequate handovers (β = 3.64, CI 95% 0.37-6.91) both increased the perception of MNC occurrence.Conclusion: MNC occurrence in rehabilitation settings appears to be lower than in other contexts; however, the most commonly missed elements are similar to those reported in other settings. As good strategies to detect the difference between expected nursing care and the one delivered to patients, advanced education and good quality handovers seem beneficial. Further research is needed to establish more evidence on predictors by developing longitudinal study designs.

Factors Contributing to Rationed Nursing Care in the Slovak Republic-A Secondary Analysis of Quantitative Data

Rationed nursing care is a significant problem in healthcare facilities worldwide. Awareness of contributing factors to rationed care might support the development and implementation of strategies for reducing this phenomenon from clinical practice. The study examined the association between selected hospital, unit, and staff variables and the prevalence of rationed nursing care. Secondary analysis of cross-sectional data collected between December 2017 and July 2018 from 895 registered nurses in seven acute care hospitals in the Slovak Republic was performed. Data were collected using the questionnaire Perceived Implicit Rationing of Nursing and analyzed by descriptive and inferential statistics in the statistical program SPSS 25.0. Statistically significant associations were found between rationed nursing care and unit type, education, shift type, nurses' experience in the current unit, overtime hours, missed shifts, intention to leave the position, perceived staff adequacy, quality of patient care, and job satisfaction. Differences in rating rationed nursing care, quality of patient care, and job satisfaction were identified based on hospital type. Together with top hospital management, nurse managers should develop targeted interventions focusing on mitigating rationed nursing care from the clinical practice with a focus placed on university hospitals. Quality and safe care might be ensured through constant monitoring of the quality of patient care and job satisfaction of nurses as these factors significantly predicted the estimates of rationed nursing care.

The relationship between organizational communication and missed nursing care in oncology wards in Taiwan

Aim

Unfavourable communication increases missed nursing care. Oncology wards have more communication complexity than general wards; therefore, creating a positive communication environment is important for ensuring quality care. This study aimed to understand the relationship between organizational communication satisfaction and missed nursing care in Taiwan.

Design

This cross‐sectional study was performed to measure organizational communication satisfaction and missed nursing care in six oncology wards at a stand‐alone cancer centre hospital in Taipei, Taiwan in December, 2018.

Methods

The study collected data using the Communication Satisfaction Questionnaire and the MISSCARE survey. The data were analysed using descriptive statistics, t test, analysis of variance and Pearson product–moment correlation analysis in December 16, 2018.

Results

A total of 111 questionnaires were collected, and the response rate was 92.5%. The study showed that nurses tended to miss nursing care when they were dissatisfied with the unit's manpower status organizational communication environment, horizontal and diagonal communication and informal communication.

Incidence and Predictors of Nonventilator Hospital-Acquired Pneumonia in a Community Hospital

BACKGROUND

Nonventilator hospital-acquired pneumonia (NV-HAP) is a common hospital-acquired condition that is amenable to basic nursing care interventions.

PURPOSE

The purpose of this study was to determine the incidence of NV-HAP in a California community hospital and to identify the patient and nursing care factors including missed nursing care associated with its development.

METHODS

A retrospective study identified possible NV-HAP cases with ICD-10 (International Classification of Diseases, Tenth Revision) codes and then validated cases using Centers for Disease Control and Prevention confirmatory criteria.

RESULTS

The incidence of NV-HAP in our hospital was 0.64 cases per 1000 patient-days. Patient factors most strongly associated with NV-HAP were age (each year of increased age was associated with a 4% increased likelihood of developing NV-HAP) (OR = 1.04-1.07) and the presence of underlying disease, which reduced odds of developing NV-HAP by 36% (OR = 0.36; 95% CI, 0.12-0.98). Head-of-bed elevation reduced by 26% the odds of developing NV-HAP (OR = 0.26; 95% CI, 0.07-0.08).

CONCLUSIONS

NV-HAP can be predicted and potentially prevented. Paradoxically, the presence of underlying disease was not positively associated with the development of NV-HAP in this study.

The association between care left undone and temporary Nursing staff ratios in acute settings: a cross- sectional survey of registered nurses

BACKGROUND

The shortage of health workers is a global phenomenon. To meet increasing patient demands on UK health services, providers are increasingly relying on temporary staff to fill permanent posts. This study examines the occurrence of 'care left undone', understaffing and temporary staffing across acute sector settings.

METHODS

"Secondary data analysis from an RCN administered online survey covering nurses from hospitals and trusts across all four UK countries. Staffing and 'care left undone' measures were derived from the responses of 8841 registered nurses across the UK. A locally smoothed scatterplot smoothing regression analysis (Loess) was used to model the relationship between any 'care left undone' events and full complement, modest and severely understaffed shifts, and proportions of temporary staff.

RESULTS

Occurrence of 'care left undone' was highest in Emergency Departments (48.4%) and lowest in Theatre settings (21%). The odds of 'care left undone' increase with increasing proportion of temporary staff. This trend is the same in all understaffing categories. On shifts with a full quota of nursing staff, an increase in the proportion of temporary staff from 0 to 10% increases the odds of care left undone by 6% (OR = 1.06, 95% CI, 1.04-1.09). Within the full quota staffing category, the difference becomes statistically significant (p < 0.05) on shifts with a proportion of temporary nursing staff of 40% or more. On shifts with a full quota of nursing staff the odds of a 'care left undone' event is 10% more with the proportion of temporary nursing staff at 50%, compared to shifts with modest understaffing of 25% or less with no temporary nursing staff (OR = 1.1, 95%CI, 0.96-1.25).

CONCLUSION

The odds of a 'care left undone' event are similar for fully staffed shifts with a high temporary nursing staff ratio compared to severely understaffed shifts with no temporary nursing staff. Increasing the proportion of temporary nurse staff is associated with higher rates of self-reported care left undone by nursing staff. This has significant implications for nurse managers and policy makers.

Factors influencing missed nursing care in public hospitals in Australia: An exploratory mixed methods study

BACKGROUND

Missed nursing care (MNC) is a significant health care issue that impacts on the quality of health care and patient safety. It refers to delayed or omitted aspects of nursing care (totally or partially). MNC is an under-researched area in the Australian health care context.

OBJECTIVE

This research sought to further explore the MNC phenomenon in the context of an acute care hospital and to identify its common elements and the factors influencing its occurrence.

DESIGN

A convergent parallel mixed methods design was employed involving secondary analysis of routinely collected hospital data and a survey of 44 nursing staff using the MISSCARE survey instrument. The two sources of data were converged to address the objective.

FINDINGS

The study found that the most common elements of missed nursing care include failure of patient ambulation, emotional support for patients and/or family, and the provision of full documentation. These elements are consistent with previous international studies conducted in acute care hospital settings. This study identified that local context impacting on MNC was also important and included interruptions to workflow, "perceived" lack of management support, poor handover, and communication breakdown between the nursing team and medical staff.

CONCLUSION

Consideration of the local health care context is foundational in understanding the MNC phenomenon. The findings of this research may help nursing managers mitigate the possible effects of MNC and therefore improve patient safety in their acute care environment. Additional multisite studies are required to further explore factors associated with MNC in both general and local contexts.

Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit

IMPORTANCE

Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen.

OBJECTIVE

To evaluate the association of NICU nurse workload with missed nursing care.

DESIGN, SETTING, AND PARTICIPANTS

A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018.

EXPOSURES

Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjective measure (the National Aeronautics and Space Administration Task Load Index [NASA-TLX]).

MAIN OUTCOMES AND MEASURES

Missed nursing care was measured by self-report of omission of 11 essential care practices. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care.

RESULTS

A total of 136 nurses provided reports of shift-level workload and missed nursing care for 418 infants during 332 shifts of 12 hours each. When workload variables were modeled independently, 7 of 12 models demonstrated a significant worsening association of increased infant-to-nurse ratio with odds of missed care (eg, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift [95% credible interval, 1.81-3.47]), and all 12 models demonstrated a significant worsening association of increased NASA-TLX subjective workload ratings with odds of missed care (eg, each 5-point increase in a nurse's NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment for his or her assigned infant[s] during the same shift [95% credible interval, 1.30-1.39]). When modeling all workload variables jointly, only 4 of 12 models demonstrated significant association of staffing ratios with odds of missed care, whereas the association with NASA-TLX ratings remained significant in all models. Few associations of acuity scores were observed across modeling strategies.

CONCLUSIONS AND RELEVANCE

The workload of NICU nurses is significantly associated with missed nursing care, and subjective workload ratings are particularly important. Subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study

Background

Low nurse staffing levels are associated with adverse patient outcomes from hospital care, but the causal relationship is unclear. Limited capacity to observe patients has been hypothesised as a causal mechanism.

Objectives

This study determines whether or not adverse outcomes are more likely to occur after patients experience low nurse staffing levels, and whether or not missed vital signs observations mediate any relationship.

Design

Retrospective longitudinal observational study. Multilevel/hierarchical mixed-effects regression models were used to explore the association between registered nurse (RN) and health-care assistant (HCA) staffing levels and outcomes, controlling for ward and patient factors.

Setting and participants

A total of 138,133 admissions to 32 general adult wards of an acute hospital from 2012 to 2015.

Main outcomes

Death in hospital, adverse event (death, cardiac arrest or unplanned intensive care unit admission), length of stay and missed vital signs observations.

Data sources

Patient administration system, cardiac arrest database, eRoster, temporary staff bookings and the Vitalpac system (System C Healthcare Ltd, Maidstone, Kent; formerly The Learning Clinic Limited) for observations.

Results

Over the first 5 days of stay, each additional hour of RN care was associated with a 3% reduction in the hazard of death [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.94 to 1.0]. Days on which the HCA staffing level fell below the mean were associated with an increased hazard of death (HR 1.04, 95% CI 1.02 to 1.07), but the hazard of death increased as cumulative staffing exposures varied from the mean in either direction. Higher levels of temporary staffing were associated with increased mortality. Adverse events and length of stay were reduced with higher RN staffing. Overall, 16% of observations were missed. Higher RN staffing was associated with fewer missed observations in high-acuity patients (incidence rate ratio 0.98, 95% CI 0.97 to 0.99), whereas the overall rate of missed observations was related to overall care hours (RN + HCA) but not to skill mix. The relationship between low RN staffing and mortality was mediated by missed observations, but other relationships between staffing and mortality were not. Changing average skill mix and staffing levels to the levels planned by the Trust, involving an increase of 0.32 RN hours per patient day (HPPD) and a similar decrease in HCA HPPD, would be associated with reduced mortality, an increase in staffing costs of £28 per patient and a saving of £0.52 per patient per hospital stay, after accounting for the value of reduced stays.

Limitations

This was an observational study in a single site. Evidence of cause is not definitive. Variation in staffing could be influenced by variation in the assessed need for staff. Our economic analysis did not consider quality or length of life.

Conclusions

Higher RN staffing levels are associated with lower mortality, and this study provides evidence of a causal mechanism. There may be several causal pathways and the absolute rate of missed observations cannot be used to guide staffing decisions. Increases in nursing skill mix may be cost-effective for improving patient safety.

Future work

More evidence is required to validate approaches to setting staffing levels. Other aspects of missed nursing care should be explored using objective data. The implications of findings about both costs and temporary staffing need further exploration.

Trial registration

This study is registered as ISRCTN17930973.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 38. See the NIHR Journals Library website for further project information.

Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms

Objective

This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs.

Materials and methods

A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts.

Results

Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001).

Discussion and conclusion

Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.

Missed nursing care and its relationship with confidence in delegation among hospital nurses

AIMS AND OBJECTIVES

To (i) identify the types and reasons for missed nursing care among Jordanian hospital nurses; (ii) identify predictors of missed nursing care based on study variables; and (iii) examine the relationship between nurses' confidence in delegation and missed nursing care.

BACKGROUND

Missed nursing care is a global concern for nurses and nurse administrators. Investigating the relation between the confidence in delegation and missed nursing care might help in designing strategies that enable nurses to minimise missed care and enhance quality of services.

METHODS

A correlational research design was used for this study. A convenience sample of 362 hospital nurses completed the missed nursing care survey, and confidence and intent to delegate scale.

RESULTS

The results of the study revealed that ambulating and feeding patients on time, doing mouth care and attending interdisciplinary care conferences were the most frequent types of missed care. The mean score for missed nursing care was (2.78) on a scale from 1-5. The most prevalent reasons for missed care were "labour resources, followed by material resources, and then communication". Around 45% of the variation in the perceived level of "missed nursing care" was explained by background variables and perceived reasons for missed nursing. However, the relationship between confidence in delegation and missed care was insignificant.

CONCLUSION

The results of this study add to the body of international literature on most prevalent types and reasons for missed nursing care in a different cultural context.

RELEVANCE TO CLINICAL PRACTICE

Highlighting most prevalent reasons for missed nursing care could help nurse administrators in designing responsive strategies to eliminate or reduces such reasons.

The association between nurse staffing and omissions in nursing care: A systematic review

AIMS

To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.

BACKGROUND

Research has established associations between nurse staffing levels and adverse patient outcomes including in-hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy.

DESIGN

Systematic review.

DATA SOURCES

We searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles.

REVIEW METHODS

Two reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.

RESULTS

Eighteen studies gave subjective reports of missed care. Seventy-five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care.

CONCLUSIONS

Low Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

Perspectives of Oncology Unit Nurse Managers on Missed Nursing Care: A Qualitative Study

Objective:

The main objective of this study was to explore factors affecting missed nursing care in oncology units from the perspective of nurse managers.

Methods:

Twenty nurse managers working at oncology units of referral teaching hospitals in Iran participated in this study. Data were collected through individual face-to-face and telephonic interviews using an interview guide. Focus groups were also conducted. Data were analyzed using conventional content analysis.

Results:

System structure, underlying factors, and barriers to missed-care reports were identified as factors that affect missed nursing care.

Conclusions:

Nurse managers should reduce the effects of nursing staff shortages and increased workloads in addition to providing materials and equipment. They need to distribute experienced staff according to the type of ward or patients' needs. Nurse managers should create a favorable environment for reporting missed nursing care by having an open relationship with nurses by teaching and emphasizing nursing practice. Moreover, using a nonpunitive managerial approach and minimizing the use of an apathetic management style can be helpful.

Effectiveness of a Web-Based Health Education Program to Promote Oral Hygiene Care Among Stroke Survivors: Randomized Controlled Trial

Background

Oral hygiene care is of key importance among stroke patients to prevent complications that may compromise rehabilitation or potentially give rise to life-threatening infections such as aspiration pneumonia.

Objective

The aim of this study was to evaluate the effectiveness of a Web-based continuing professional development (CPD) program on “general intention” of the health carers to perform daily mouth cleaning for stroke patients using the theory of planned behavior (TPB).

Methods

A double-blind cluster randomized controlled trial was conducted among 547 stroke care providers across 10 hospitals in Malaysia. The centers were block randomized to receive either (1) test intervention (a Web-based CPD program on providing oral hygiene care to stroke patients using TPB) or (2) control intervention (a Web-based CPD program not specific to oral hygiene). Domains of TPB: “attitude,” “subjective norm” (SN), “perceived behavior control” (PBC), “general intention” (GI), and “knowledge” related to providing oral hygiene care were assessed preintervention and at 1 month and 6 months postintervention.

Results

The overall response rate was 68.2% (373/547). At 1 month, between the test and control groups, there was a significant difference in changes in scores of attitude (P=.004) and subjective norm (P=.01), but not in other TPB domains (GI, P=.11; PBC, P=.51; or knowledge, P=.08). At 6 months, there were significant differences in changes in scores of GI (P=.003), attitude (P=.009), SN (P<.001) and knowledge (P=.001) between the test and control groups. Regression analyses identified that the key factors associated with a change in GI at 6 months were changes in SN (beta=.36, P<.001) and changes in PBC (beta=.23, P<.001).

Conclusions

The Web-based CPD program based on TPB increased general intention, attitudes, subjective norms, and knowledge to provide oral hygiene care among stroke carers for their patients. Changing subjective norms and perceived behavioral control are key factors associated with changes in general intention to provide oral hygiene care.

Trial Registration

National Medical Research Register, Malaysia NMRR-13-1540-18833 (IIR); https://www.nmrr.gov.my/ fwbLoginPage.jsp

Correlates and predictors of missed nursing care in hospitals

AIMS AND OBJECTIVES

To identify the contribution of hospital, unit, staff characteristics, staffing adequacy and teamwork to missed nursing care in Iceland hospitals.

BACKGROUND

A recently identified quality indicator for nursing care and patient safety is missed nursing care defined as any standard, required nursing care omitted or significantly delayed, indicating an error of omission. Former studies point to contributing factors to missed nursing care regarding hospital, unit and staff characteristics, perceptions of staffing adequacy as well as nursing teamwork, displayed in the Missed Nursing Care Model.

DESIGN

This was a quantitative cross-sectional survey study.

METHODS

The samples were all registered nurses and practical nurses (n = 864) working on 27 medical, surgical and intensive care inpatient units in eight hospitals throughout Iceland. Response rate was 69·3%. Data were collected in March-April 2012 using the combined MISSCARE Survey-Icelandic and the Nursing Teamwork Survey-Icelandic. Descriptive, correlational and regression statistics were used for data analysis.

RESULTS

Missed nursing care was significantly related to hospital and unit type, participants' age and role and their perception of adequate staffing and level of teamwork. The multiple regression testing of Model 1 indicated unit type, role, age and staffing adequacy to predict 16% of the variance in missed nursing care. Controlling for unit type, role, age and perceptions of staffing adequacy, the multiple regression testing of Model 2 showed that nursing teamwork predicted an additional 14% of the variance in missed nursing care.

CONCLUSIONS

The results shed light on the correlates and predictors of missed nursing care in hospitals. This study gives direction as to the development of strategies for decreasing missed nursing care, including ensuring appropriate staffing levels and enhanced teamwork.

RELEVANCE TO CLINICAL PRACTICE

By identifying contributing factors to missed nursing care, appropriate interventions can be developed and tested.

Oral Health Care Guidelines, Training, and Resources among Stroke Care Providers

During a stroke, the mouth tends to become an unhealthy place and may give rise to various life-threatening conditions. To this end, there have been repeated calls to incorporate oral hygiene guidelines and practices for hospitalized stroke patients to prevent aspiration pneumonia and improve patients' oral health. The objective of the study was to determine health care providers' practices of oral health care among patients hospitalized after an occurrence of stroke and to determine health care providers' background and work environment effect on these practices. A cross-sectional study was conducted among stroke care providers in 13 public hospitals in Malaysia. The questionnaires distributed were self-administered, where nursing staff provided details of their oral health care practices for stroke patients. Information on the background of health care providers and work environment was also collected. Overall, a total of 780 responses from the registered nurses were obtained. Almost half of the respondents (48.1%) reported that they recommended toothbrushing twice or more per day to stroke patients. Two-thirds (64.7%) reported that they performed daily mouthwashing on their patient, while less than half (38.8%) reported daily oral hygiene assistance. Result of the analysis revealed that oral hygiene practices were significantly associated with having working wards ( P < 0.05), level of qualification ( P < 0.05), having oral health care guidelines ( P < 0.001), specific resources ( P < 0.05), and attending previous training in oral care ( P < 0.001). Provision of oral hygiene practices for hospitalized stroke patients is important. A lack of oral health care guidelines, support from dental professionals, specific resources, training, and assistance in daily oral care for patients is evident and detrimental to oral hygiene practices. The current findings have significant implications for new initiatives to support health care providers, particularly the registered nurses performing oral health care for hospitalized stroke patients. Knowledge Transfer Statement: This study may provide a basis of information for improving the delivery of oral health care to stroke patients. Enhancement in the training and improvement in the existing guidelines and resources is pivotal for the provision of better oral health care for the potential benefits to these patients, including their improved quality of life and disease prevention.

Impact of teamwork on missed care in four Australian hospitals

AIMS AND OBJECTIVES

Investigate effects of teamwork on missed nursing care across a healthcare network in Australia.

BACKGROUND

Missed care is universally used as an indicator of quality nursing care, however, little is known about mitigating effects of teamwork on these events.

DESIGN

A descriptive exploratory study.

METHODS

Missed Care and Team Work surveys were completed by 334 nurses. Using Stata software, nursing staff demographic information and components of missed care and teamwork were compared across the healthcare network. Statistical tests were performed to identify predicting factors for missed care.

RESULTS

The most commonly reported components of missed care were as follows: ambulation three times per day (43·3%), turning patient every two hours (29%) and mouth care (27·7%). The commonest reasons mentioned for missed care were as follows: inadequate labour resources (range 69·8-52·7%), followed by material resources (range 59·3-33·3%) and communication (range 39·3-27·2%). There were significant differences in missed care scores across units. Using the mean scores in regression correlation matrix, the negative relationship of missed care and teamwork was supported (r = -0·34, p < 0·001). Controlling for occupation of the staff member and staff characteristics in multiple regression models, teamwork alone accounted for about 9% of missed nursing care.

CONCLUSION

Similar to previous international research findings, our results showed nursing teamwork significantly impacted on missed nursing care. Teamwork may be a mitigating factor to address missed care and future research is needed.

RELEVANCE TO CLINICAL PRACTICE

These results may provide administrators, educators and clinicians with information to develop practices and policies to improve patient care internationally.

Missed nursing care and predicting factors in the Italian medical care setting

Missed nursing care (MNC), such as nursing care omitted or delayed, has not been measured in the Italian context where several cost containment interventions affect the care offered in medical units. The aim of the study is to identify the amount, type, and reasons for MNC in the Italian medical care setting and to explore the factors that affect the occurrence of MNC. A 3-month longitudinal survey was carried out followed by a cross-sectional study design in 12 north eastern acute medical units. A total of 314 nursing staff members were involved. Multivariate logistic regression was performed to identify the predictors of MNC. Patient ambulation (91.4 %), turning the patient every 2 h (74.2 %), and right timing in administering medications (64.6 %) were the most perceived MNC. Among the most frequent reasons were the unexpected rise in patient volume or critical conditions (95.2 %), inadequate numbers of staff (94.9 %), and large numbers of admissions/discharges (93.3 %). The R (2) 33.2 % of the variance in MNC were explained by a full-time position (OR 4.743, 95 % CI 1.146-19.629), communication tensions between Registered Nurses and Nurses' Aides (OR 1.601, 95 % CI 1.020-2.515), the amount of experience in medical unit (OR 1.564, 95 % CI 1.021-2.397), and the amount of daily care offered by Nurses' Aides (1.039, 95 % CI 1.011-1.067). A substantial amount of basic and clinically relevant nursing interventions was perceived to be missed, and this may lead to an increase in negative outcomes for patients admitted to a medical unit. Appropriate standards of nursing care should be adopted urgently in medical units aiming to protect frail patients.

Factorial Validity of the Decisional Involvement Scale as a Measure of Content and Context of Nursing Practice

Decisional involvement is widely recognized as an essential component of a professional nursing practice environment. In recent years, researchers have added to the conceptualization of nurses' role in decision-making to differentiate between the content and context of nursing practice. Yet, instruments that clearly distinguish between these two dimensions of practice are lacking. The purpose of this study was to examine the factorial validity of the Decisional Involvement Scale (DIS) as a measure of both the content and context of nursing practice. This secondary analysis was conducted using data from a longitudinal action research project to improve the quality of nursing practice and patient care in six hospitals (N = 1,034) in medically underserved counties of Pennsylvania. A cross-sectional analysis of baseline data from the parent study was used to compare the factor structure of two models (one nested within the other) using confirmatory factor analysis. Although a comparison of the two models indicated that the addition of second-order factors for the content and context of nursing practice improved model fit, neither model provided optimal fit to the data. Additional model-generating research is needed to develop the DIS as a valid measure of decisional involvement for both the content and context of nursing practice.

Unfinished nursing care, missed care, and implicitly rationed care: State of the science review

OBJECTIVES

The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions.

METHODS

A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author).

RESULTS

Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave.

DISCUSSION & CONCLUSIONS

Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies.

A descriptive study of nurse-reported missed care in neonatal intensive care units

AIMS

The aims of this study are to describe: (1) the frequency of nurse-reported missed care in neonatal intensive care units; and (2) nurses' reports of factors contributing to missed care on their last shift worked.

BACKGROUND

Missed nursing care, or necessary care that is not delivered, is increasingly cited as a contributor to adverse patient outcomes. Previous studies highlight the frequency of missed nursing care in adult settings; the occurrence of missed nursing care in neonatal intensive care units is unknown.

DESIGN

A descriptive analysis of neonatal nurses' self-reports of missed care using data collected through a cross-sectional web-based survey.

METHODS

A random sample of certified neonatal intensive care nurses in seven states was invited to participate in the survey in April 2012. Data were collected from nurses who provide direct patient care in a neonatal intensive care unit (n = 230). Descriptive statistics constituted the primary analytic approach.

RESULTS

Nurses reported missing a range of patient care activities on their last shift worked. Nurses most frequently missed rounds, oral care for ventilated infants, educating and involving parents in care and oral feedings. Hand hygiene, safety and physical assessment and medication administration were missed least often. The most common reasons for missed care included frequent interruptions, urgent patient situations and an unexpected rise in patient volume and/or acuity on the unit.

CONCLUSION

We find that basic nursing care in the neonatal intensive care unit is missed and that system factors may contribute to missed care in this setting.