A cross‐sectional study of ‘care left undone’ on nursing shifts in hospitals

Missed nursing care among nursing students: A scoping review

BACKGROUND

Nursing students report facing inconsistencies between theoretical knowledge and actualities of clinical practice, and research indicates they witness missed nursing care during clinical practice. Understanding nursing students' experiences can inform improved clinical learning environments and enhance patient care quality. Recently, research has focused on students' views regarding missed care, yet comprehensive understandings of this phenomenon are lacking.

OBJECTIVE

This review explored what is known about missed nursing care from perspectives of nursing students.

DESIGN

A scoping review according to Arksey and O'Malley's framework and Joanna Briggs Institute methodology was undertaken.

DATA SOURCES

Key databases were searched, including Medline, Embase, CINAHL, Scopus, ProQuest, PsycINFO and Web of Science in August 2023.

REVIEW METHODS

The review included qualitative, quantitative, and structured literature reviews published in English between 2006 and 2023. Inclusion and exclusion criteria and keywords guided the search. Data screening and extraction were independently performed by two reviewers. Included studies were analysed using descriptive statistics and narrative synthesis. Findings are reported in accordance with the PRISMA-ScR.

RESULTS

Of the 5873 articles identified, nine were included in the review. Studies were conducted in seven countries. Themes in students' perceptions included negligence of patients' rights and dignity, living in limbo, and pragmatic acceptance. Reasons for missed care included ineffective teamwork, lack of interest in caring, and inefficient leadership. Missed nursing care adversely affected patient health, hindered student learning and professional growth. Strategies for improvement included enhancing teamwork, enforcing ethical issues, increasing supervision, and creating commitment to work.

CONCLUSION

Missed nursing care affects patient safety and education of nursing students. Incorporating practical training modules into curricula, establishing preceptorship programs, and incorporating ethics education into clinical practice are crucial to address missed nursing care. Further research in diverse settings is warranted.

Oral health and oral care in patients in a surgical context: A quantitative study comparing patients' and nurses' assessments

AIMS

To investigate fundamental care delivery regarding oral care in a surgical context, and to compare patients' self-reported oral health with registered nurse assessments.

DESIGN

A descriptive and comparative study, with a consecutive selection.

METHODS

A patient oral health rating tool, including questions about performed oral care, was distributed to patients (n = 50), at four surgical wards in Sweden. The response rate was 72%. Oral health status was assessed by a registered nurse using the Revised Oral Assessment Guide (ROAG), and a comparison between patient and registered nurse assessment was performed by calculating Cohen's kappa coefficient and percentage agreement.

RESULTS

Patients (38%) reported severe oral symptoms, mostly dry lips and not an adequate amount of saliva, and 80% were not offered help with oral care. ROAG assessments revealed that 74% had problems with oral health. Almost half of the patients (48%) needed assistance with oral care but only 10% received help. Registered nurses assessed the patient's oral health as worse than the patient's self-assessment did.

CONCLUSION

There are deficiencies in fundamental care delivery regarding oral care in a surgical care context. Oral health assessments need to be performed by registered nurses. Routines for systematic oral assessments and for oral care need to be implemented by nurse managers to ensure that patients' fundamental care needs are fulfilled.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Oral health assessments need to be performed regularly by registered nurses since it is insufficient that patients self-assess their oral health. Nurse managers need to provide and implement routines for nurse assessments and oral care in surgical care contexts.

IMPACT

There are deficiencies in patients' oral health and oral care, and registered nurses need to perform oral health assessments. Nurse managers need to implement routines for registered nurse assessments and oral care.

PATIENT CONTRIBUTION

Patients admitted to a surgical ward were included in the study after being screened for inclusion criteria. After participants signed informed consent, they filled in a questionnaire about oral health and oral care, and a registered nurse performed an oral health assessment.

REPORTING METHOD

This study was carried out according to the STROBE checklist.

Factors associated with the disinfection of devices attached to peripheral intravenous catheters performed by the nursing team in pediatric units

Background

Peripheral intravenous catheterization, as well as drug administration through it, represents one of the most performed procedures by the Nursing team and, for that, precautions need to be adopted to offer harm-free care.

Objective

To verify the association of Nursing professionals' work shift and training time with proper disinfection of intravenous catheter devices in pediatric units.

Methods

A cross-sectional and analytical study conducted between June and August 2021 in three hospitalization units of a Pediatric Hospital. The inclusion criterion was drug administration via peripheral intravenous catheters performed by Nursing professionals. The data were analyzed according to inferential statistics, adopting p ≤ .05 as significance level.

Results

There were a total of 385 observations of drug administration procedures. The device was not disinfected in 60.3% of the cases, there was no friction at the suitable time in 86.3%, and the disinfectant was not allowed to dry in 72.5%. The work shift exerted no influence on performance of the disinfection procedure (p = .376). However, longer training time was associated with a lower rate in performing such procedure (p < .001).

Conclusion

Performing friction below the recommended time can cause a false sense of prevention of catheter-associated bloodstream infection; therefore, training sessions and strategies for adherence to the disinfection procedures should be considered, mainly for professionals with more training time.

Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme

BACKGROUND

Missed nursing care occurs globally, and the consequences are severe for the patients when fundamental care needs are not fulfilled, nor delivered in a person-centred way. This study aimed to investigate the occurrence and cause of missed nursing care, and the relationship between registered nurses' and nursing assistants' perceptions of missed nursing care, in a surgical care context.

METHODS

A quantitative study was performed using the MISSCARE survey, measuring missed nursing care and associated reasons, in three surgical wards with registered nurses and nursing assistants as the participants (n = 118), during May-November in 2022. The MISSCARE survey also covers background data such as job satisfaction and intention to leave. The survey was distributed paper-based and the response rate was 88%.

RESULTS

Aspects of nursing care rated to be missed the most were 'attending interdisciplinary care conferences', 'turning patient every 2 h', 'ambulation 3 times per day or as ordered', and 'mouth care'. Differences between registered nurse and nursing assistant ratings were detected for eight out of 24 items, where registered nurses rated more missed nursing care. The uppermost reasons for missed nursing care were 'inadequate number of staff' and 'unexpected rise in patient volume and/or acuity on the unit'. Registered nurses and nursing assistants rated differently regarding six of 17 items. Almost every fourth staff member (24.6%, n = 29) had the intention to leave within a year in the present department.

CONCLUSIONS

The occurrence of missed nursing care is frequent in the surgical context, and in combination with a high number of staff members intending to leave their employment, poses a hazard to patient safety. Registered nurses, holding higher educational levels, reported more missed care compared with the nursing assistants. The main reason for missed nursing care was an inadequate number of staff. These findings support a warranted investment in nursing within the organisation. The results can be used to form strategies and interventions, to reduce nurse attrition and optimise competence utilisation, and to achieve safe person-centered fundamental care.

Structural Equation Modeling of Associations Between Nursing Practice Environment And Missed Nursing Care: A Cross-sectional Study

BACKGROUND

Missed nursing care (MNC) negatively impacts the quality of patient care. There may be a relationship between the nursing practice environment (NPE) and MNC; however, this relationship has not been examined in developing countries during the COVID-19 pandemic.

PURPOSE

To determine the relationship between the NPE and MNC during the COVID-19 pandemic.

METHODS

A cross-sectional study of 300 participants was conducted in 4 teaching hospitals in Iran. Data were collected using a demographic and clinical form, the Nursing Professional Practice Environment Questionnaire, and MISSCARE survey and analyzed using structural equation modeling.

RESULTS

The hypothesized model was well fit, showing that 1 unit improvement of the NPE domains of patient-centered care , effective leadership , and policy transparency decreased MNC by 0.18, 0.12, and 0.05, respectively.

CONCLUSION

The model confirmed the association between the dimensions of the NPE and MNC. These findings can assist health policymakers and nursing managers in improving the NPE.

The Effects of Organizational Characteristics, Individual Nurse Characteristics, and Occupational Fatigue on Missed Care at Night

BACKGROUND

Missed care is defined as the omission or delay of necessary patient care and is internationally reported by nurses as a significant safety risk. Nurses working at night also report high levels of occupational fatigue that, coupled with inadequate staffing and practice environment support, may impede a nurse's ability to carry out the nursing process and lead to more missed care.

OBJECTIVE

The study's objective was to examine the interrelationships among organizational and nurse characteristics, occupational fatigue, and missed care among nurses working at night.

METHODS

A cross-sectional design was used. Participants included registered nurses (RNs) who worked at night in New Jersey acute care hospitals. Multiple linear regression and simple moderation analyses were performed to examine the associations.

RESULTS

Nurses reported missing necessary care at night. Unsupportive practice environments, high RN workloads, high patient-RN ratios, high chronic fatigue levels, and low intershift recovery were individually associated with missed care at night. High patient-to-RN ratios and chronic fatigue were independently associated with missed care. However, patient-to-registered-staffing levels had the most considerable effect on missed care at night. Nurses' years of experience and the number of hours of sleep between shifts were significant moderators of the relationship between occupational fatigue states and missed care.

DISCUSSION

This study is the first to examine the interrelationship between occupational fatigue levels, organizational and nurse characteristics, and missed care at night. There is an urgent need to implement strategies in hospital organizations that foster work schedules and adequate staffing patterns that lessen nurses' occupational fatigue levels to ensure our workforce's and patients' safety.

The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey

AIM

To describe Australian perioperative nurses' reported frequency and reasons for missed nursing care in the operating room.

DESIGN

Cross-sectional online survey conducted in March-April 2022.

METHODS

A census of Australian perioperative nurses who were members of a national professional body were invited to complete a survey that focussed on their reported frequency of missed nursing care and the reasons for missed nursing care in the operating room using the MISSCare Survey OR.

RESULTS

In all, 612 perioperative nurses completed the survey. The perioperative and intraoperative nursing care tasks reported as most frequently missed included time-intensive tasks and communication with multiple surgical team members present. The most frequently reported reasons for missed care were staffing-related (e.g. staff number, skill mix, fatigue and complacency) and affected teamwork. There were no significant differences in the frequency of missed care based on perioperative nurse roles. However, there were statistically significant differences between nurse management, circulating/instrument nurses and recovery room nurses in reasons for missed care.

CONCLUSIONS

Much of the missed care that occurs in the operating room is related to communication practices and processes, which has implications for patient safety.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the types of nursing care tasks being missed and the reasons for this missed care in the operating room may offer nurse managers deeper insights into potential strategies to address this situation.

REPORTING METHOD

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Nurses' Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study

Background

Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated.

Objective

To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia.

Methods

An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses' documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study.

Results

In this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%-35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36-7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85-6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14-3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11-7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13-6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69-7.52]) were significantly associated with proper nursing care documentation practices.

Conclusion

Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses' knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.

Evaluation of lay health workers on quality of care in the inpatient setting

AIMS

To evaluate the impact of a lay health worker support role in the inpatient setting.

BACKGROUND

Healthcare systems are facing critical nursing and nurse assistant staffing shortages. These disciplines can be challenging to recruit and retain, leading healthcare leaders to identify innovative staffing models. Whereas lay health workers have been used in the community and low-income setting, there is scant evidence of their use in the inpatient setting. We implemented a lay health worker role, called Patient Attendant Service Aides (PASAs), on two medical/surgical units at a community hospital.

METHODS

A pre/post-implementation design was used for this study. An online survey was provided to nurses, nursing assistants, and PASAs on the two medical/surgical units to assess their satisfaction and perceptions of the role. Nursing quality metrics, patient satisfaction, and nursing and nursing assistant turnover were evaluated before and after implementing the role.

RESULTS

The online survey showed that nurses and nursing assistants felt that PASAs helped offload their workload, allowing them to focus on nursing-related tasks. PASAs felt supported by the team and believed they were making a meaningful contribution to the unit. There were slight improvements in patient satisfaction, although not significant. There was a significant improvement in nursing turnover on Unit A, from 71.1% to 21.6% (p = 0.009).

CONCLUSIONS

This is one of the first studies to evaluate the use of lay health workers in the inpatient setting; we found this role to be a feasible way to offload tasks from clinical staff. This role may serve as a pathway for workforce development, as several PASAs are now enrolled in nursing assistant training. Nurse managers may consider using lay health workers in the inpatient setting as they face severe clinical staff shortages.

Pediatric vital signs monitoring in hospital wards: Recognition systems and factors influencing nurses' attitudes and practices

AIMS

To describe: 1) systems in place for recognition and response to deteriorating children in Italy, 2) attitudes and practices of registered nurses (RN) towards vital signs (VS) monitoring in pediatric wards, 3) the associations of nurses attitudes and pratices with nurses' and organizational characteristics.

DESIGN AND METHODS

A multicentre cross-sectional correlational study. Data were collected between January-May 2020 using: an adapted version of the 'Survey on Recognition and Response Systems in Australia', and the 'Ped-V Scale'. Descriptive and adjusted linear regression analysis was performed, accounting for clustering.

RESULTS

Ten Italian hospitals participated, 432 RNs responded to the Ped-V scale (response rate = 52%). Five (50%) hospitals had a VS policy in place, three hospitals (30%) had a Pediatric Early Warning System (PEWS), almost all hospitals had a system in place to respond to deteriorating children. Following multivariate regression analysis, having a PEWS was significantly associated with Ped-V scale 'Workload', 'Clinical competence', 'Standardization' dimensions; gender was associated with 'key indicators' and pediatric surgical ward with 'Clinical competence'.

CONCLUSIONS

The use of VS policies and PEWS was not consistent across hospitals caring for children in Italy. Nurses' attitudes and practices (i.e., perception of workload, and clinical competence) were significantly lower in hospitals with increased complexity of care/PEWS. Gender was significantly associated with knowledge scores.

PRACTICE IMPLICATIONS

System strategies to improve nurses' attitudes and practices towards VS monitoring and education are warranted to support effective behaviors towards VS monitoring, their interpretation, and appropriate communication to activate the efferent limb of the rapid response system.

Healthcare-associated infections in adult intensive care units: A multisource study examining nurses' safety attitudes, quality of care, missed care, and nurse staffing

OBJECTIVES

This study examined the association between safety attitudes, quality of care, missed care, nurse staffing levels, and the rate of healthcare-associated infection (HAI) in adult intensive care units (ICUs).

METHODS

A cross-sectional study was conducted in five hospitals. Nurses completed a validated survey on safety attitudes, quality of care, missed care, nurse staffing levels, and the frequency of HAIs. Secondary data were collected on the incidence of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP) in participating units. Descriptive analysis and generalized linear models were performed.

RESULTS

A total of 314 nurses from eight ICUs participated in this study. The mean safety culture score was 60.85 (SD = 3.53). ICUs with strong job satisfaction had lower incidence and nurse-reported frequency of CLABSI, CAUTI, and VAP. Missed care was common, with 73.11% of nurses reporting missing at least one required care activity on their last shift. The mean patient-to-nurse ratio was 1.95. Increased missed care and higher workload were associated with higher HAIs. Nurses' perceptions of CLABSI and VAP frequency were positively associated with the actual occurrence of CLABSI and VAP in participating units.

CONCLUSION

Positive safety culture and better nurse staffing levels can lower the rates of HAIs in ICUs. Improvements to nurse staffing will reduce nursing workloads, which may reduce missed care, increase job satisfaction, and, ultimately, reduce HAIs.

IMPLICATIONS FOR CLINICAL PRACTICE

Higher levels of job satisfaction among ICU nurses, lower proportions of missed nursing care and higher nurse staffing are associated with lower rates of HAIs. Nurse-reported HAI frequency was positively associated with the incidence of HAIs; therefore, nurses provide reliable data on infection control outcomes in ICU settings.

Nurse staffing levels in critical care: The impact of patient characteristics

BACKGROUND

Intensive care is one of the most resource-intensive forms of care because seriously ill patients are cared for in units with high staffing levels. Studies show that the number of registered nurses (RNs) per patient and nurse education level affects patient outcome. However, there is a lack of studies that consider how nurses/patient ratio with an advanced educational level of specialized nurses in intensive care, affect the intensive care performed in different patient populations.

AIM

To investigate if differences in patient characteristics and nurse-patient ratio have an impact on the quality of care.

STUDY DESIGN

This is a retrospective observational study with a review of all patients >15 years receiving care at two general intensive care units with different nurse/patient ratio (unit A, 1:1 nurse/patient ratio and unit B, 0.5:1 nurse/patient ratio).

RESULTS

There was no significant difference in the initial severity of illness between the units. However, younger patients, male patients and patients requiring surgery entailed a higher workload and a longer intensive care unit (ICU) stay despite a 1:1 critical care nurse/patient ratio. A small difference, but not significant, with more unplanned re-intubations occurred at unit A compared with unit B.

CONCLUSION

The differences in the nurse/patient ratio did not reflect a difference in the severity of illness among admitted patients but might be explained by patient characteristics with different needs.

RELEVANCE TO CLINICAL PRACTICE

Health care managers should consider not only the number of nurses but also their educational level, specific competencies and skills mix and nursing-sensitive measures to provide high-quality ICU care in settings with different patient characteristics. Nursing-sensitive patient outcomes should be considered in relation to nurse/patient ratio, as important to measure to ensure a high quality of patient care in the ICU.

Nurses' strategies for overcoming barriers to fundamental nursing care in patients with COVID-19 caused by infection with the SARS-COV-2 virus: Results from the 'COVID-NURSE' survey

AIMS

To identify strategies used by registered nurses and non-registered nursing care staff in overcoming barriers when providing fundamental nursing care for non-invasively ventilated inpatients with COVID-19.

DESIGN

Online survey with open-ended questions to collect qualitative data.

METHODS

In August 2020, we asked UK-based nursing staff to describe any strategies they employed to overcome barriers to delivering care in 15 fundamental nursing care categories when providing care to non-invasively ventilated patients with COVID-19. We analysed data using Framework Analysis.

RESULTS

A total of 1062 nurses consented to participate in our survey. We derived four themes. 1) Communication behaviours included adapting verbal and non-verbal communication with patients, using information technology to enable patients' significant others to communicate with staff and patients, and establishing clear information-sharing methods with other staff. 2) Organizing care required clustering interventions, carefully managing supplies, encouraging patient self-care and using 'runners' and interdisciplinary input. 3) Addressing patients' well-being and values required spending time with patients, acting in loco familiae, providing access to psychological and spiritual support, obtaining information about patients' wishes early on and providing privacy and comforting/meaningful items. 4) Management and leadership behaviours included training, timely provision of pandemic information, psychological support, team huddles and facilitating regular breaks.

CONCLUSIONS

Our respondents identified multiple strategies in four main areas of clinical practice. Management and leadership are crucial to both fundamental care delivery and the well-being of nurses during pandemics. Grouping strategies into these areas of action may assist nurses and leaders to prepare for pandemic nursing.

IMPACT

As these strategies are unlikely to be exclusive to the COVID-19 pandemic, their global dissemination may improve patient experience and help nurses deliver fundamental care when planning pandemic nursing. However, their effectiveness is unknown. Therefore, we are currently evaluating these strategies in a cluster randomized controlled trial.

Job satisfaction among small rural hospital nurses: A cross-sectional study

PURPOSE

To explore the relationships between job satisfaction, community satisfaction, practice environment, burnout, and intention to leave of nurses working in Australian small rural hospitals.

DESIGN

A national cross-sectional survey of 383 nurses from Australian rural public hospitals of less than 99 beds during 2018.

METHODS

Job satisfaction was measured on a four-point Likert scale. Factors associated with community satisfaction, practice environment, burnout and intention to leave were analyzed using multiple linear regression to explore the predictors of job satisfaction.

FINDINGS

Overall job satisfaction was positive, with most nurses moderately (n = 146, 38.1%) or very satisfied (n = 107, 27.9%) with their current job. Emotional exhaustion, nurse manager ability, leadership and support of nurses were the most significant predictors of job satisfaction.

CONCLUSION

This study provides new insight into the factors impacting the job satisfaction of nurses working in rural hospitals. The knowledge gained is important to inform strategies to retain nurses in rural areas and, in turn, ensure rural communities have access to quality health care.

CLINICAL RELEVANCE

The impact of nurses' job satisfaction on burnout, patient safety, and intention to leave is well recognized; however, there is limited understanding of job satisfaction in a rural hospital context. This study provides an understanding of the factors that impact job satisfaction of nurses working in small rural hospitals and highlights the importance of improving the practice environment to reduce the high attrition rates of this workforce.

Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data

BACKGROUND

Medication errors regardless of the degree of patient harm can have a negative emotional impact on the healthcare staff involved. The potential for self-victimization of healthcare staff following medication errors can add to the moral distress of healthcare staff. The stigma associated with errors and their disclosure often haunts healthcare professionals, leading them to question their own professional competence. This paper investigates the negative emotions expressed by healthcare staff in their reported medication administration error incidents along with the immediate responses they received from their seniors and colleagues after the incident.

METHOD

This is a retrospective study using a qualitative descriptive design and text mining. This study includes free-text descriptions of medication administration error incidents (n = 72,390) reported to National Reporting & Learning System in 2016 from England and Wales. Text-mining by SAS text miner and content analysis was used to analyse the data.

RESULTS

Analysis of data led to the extraction of 93 initial codes and two categories i.e., 1) negative emotions expressed by healthcare staff which included 4 sub-categories of feelings: (i) fear; (ii) disturbed; (iii) sadness; (iv) guilt and 2) Immediate response from seniors and colleagues which included 2 sub-categories: (i) Reassurance and support and (ii) Guidance on what to do after an error.

CONCLUSION

Negative emotions expressed by healthcare staff when reporting medication errors could be a catalyst for learning and system change. However, negative emotions when internalized as fear, guilt, or self-blame, could have a negative impact on the mental health of individuals concerned, reporting culture, and opportunities for learning from the error. Findings from this study, hence, call for future research to investigate the impact of negative emotions on healthcare staff well-being and identify ways to mitigate these in practice.

Registered nurses' experiences of caring for patients in hospitals transitioning from curative to palliative care: A qualitative study

The aim of this study was twofold: to illuminate registered nurses' experiences of palliative care and of caring for patients transitioning from curative to palliative care in hospitals. A qualitative descriptive design was used. Group interviews were conducted with 11 registered nurses in three different hospital settings. Content analysis was performed. The results are presented in four themes: "Understanding palliative care in a hospital setting"; "Involving, supporting, and caring for patients and families"; "Striving for consensus and common goals of care"; and "Struggling with the hospital environment." The registered nurses described struggling with the interpretation of palliative care and with how to transfer it into clinical practice in their specific care settings. Teamwork and collaboration were challenging and goals of care incongruent within the team. Further implementation of a palliative care approach, with core components symptom relief, teamwork, communication and relationship, and family support, is crucial to improve both patient care and the conditions enabling registered nurses to provide good care for the patients and their families in hospital settings.

Consequences of understaffing on type of missed community care- a cross-sectional study

BACKGROUND

Resource cuts to primary and community care in combination with a decline of those working in community settings is compromising quality of care and patient safety in the UK. It is reported that the negative consequences of understaffing and underfunding have worsened due to the COVID-19 pandemic.

OBJECTIVE

This is a cross-sectional study that aimed to examine short and long-term District and Community nursing working conditions. The objectives were to assess the prevalence of understaffing and missed care and the relationship between individual and organisational factors and their association with missed care outcome. We further explored the relationship between additional caseload, staffing levels and missed care.

METHODS

We developed a questionnaire based on the validated MISSCARE survey. Outcome measures were, number of vacancies per team, staffing levels, reported incidence of missed care, type of missed care, length of shift and overtime.

RESULTS

Only 23% of teams reported having no vacancies. The mean staffing ratio was reported at 60%, including agency/bank staff (0.59±1.5). Prevalence of missed care was relatively high (60%≈). The distribution of types of missed care was spread evenly across all types of nursing care. A backward stepwise regression analysis showed that the Proportion of Permanent staff capacity OR=7.9 (95% CI 0.09-0.65), Active Caseload Size OR= 5.5 (95% CI: 1.0 - 1.003), Number of RNs on the team (OR 4.8 (95% CI:1.003-1.058) and Amount of Overtime worked (OR= 3.9 (95% CI:0.98-1.0) variable are statistically significant predictors of missed care. The analysis showed an increase in additional allocated cases per RN as the permanent staff proportion decreased to 70%, at which point the likelihood of reported Missed Care outcome peaks.

CONCLUSION

The compromised quality of care related to human resources and organisational aspects of the nursing process. Where RNs worked longer hours to make up for the backlog of cases, the prevalence of missed care was more likely. Longer working hours in the community increased the risk of compromised care and sub-optimal patient care. The aspects of the nursing process identified as 'missed' related to The World Health Organisation's three main pillars of community nursing (health promotion, patient education and screening). As such, significant components of the two first pillars are, according to these data, being undermined.

Expanding the theoretical understanding in Advanced Practice Nursing: Framing the future

AIM

We aimed to discuss the importance of the integration of nursing theories in advanced nursing to meet future demands.

BACKGROUND

Nursing studies reporting a lack of professional care have increased in recent years and indicate a global complex socioecological problem. The lack of a clear theoretical understanding in education, research and practice makes Advanced Practice Nursing invisible and vulnerable.

DESIGN

A theoretical paper was selected to stimulate vital reflexion and debate about the importance of theory integration.

METHODS

The selection of nursing theories represents the position of some theorists based on our experiences with national and international research and personal leadership in a master's degree program.

IMPLICATIONS FOR NURSES

For nurses to continue to make a difference in the lives of their patients, practitioners, and researchers need to practice and expand theoretical understanding within their fields. This would enable them to be visible and at the forefront of the wider changes in health care owing to their central position and connection to health organizations.

CONCLUSION

Nursing theories are essential to the continuing evolution of the discipline of nursing. Postgraduate programs in nursing and research must be encouraged to use and further develop nursing theories to facilitate the advancement of nursing care in education, research, and practice.

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.

Effects of nursing support workers participation on negative emotions, quality of life and life satisfaction of patients with cerebral hemorrhage: a quasi-experimental study

BACKGROUND

Due to the high nursing pressure of patients with cerebral hemorrhage and the general shortage of clinical nurses, nursing support workers often participate in clinical nursing work, but the influence of nursing support workers' participation on the negative emotion, quality of life and life satisfaction of patients with intracerebral hemorrhage is unknown.

METHODS

This quasi-experimental study was conducted with a pretest-posttest design. A total of 181 ICH patients admitted to our hospital from January 2022 to April 2022 were enrolled, including 81 patients receiving conventional care (CG control group) and 80 patients receiving nursing support worker participation (RG research group). All patients were recorded with self-perceived Burden Scale (SPBS), Hamilton Depression Scale (HAMD), Quality of Life Scale (SF-36), Somatic Self rating Scale (SSS), Patient self-care ability assessment scale (Barthel) and Satisfaction with life scale (SWLS) scores.

RESULTS

Patients with high negative emotion were more willing to participate in clinical nursing work (p < 0.05). Nursing support workers involved in cerebral hemorrhage patients can alleviate negative emotions, improve life quality, improve life satisfaction (p < 0.05).

CONCLUSION

The participation of nursing support workers can alleviate the negative emotions of ICH patients, enhance their self-management ability, and improve their life quality.

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.

Frequency, reasons, correlates and predictors of missed nursing care in Turkey: A multi-hospital cross-sectional study

AIM

We aimed to examine the frequency, reasons, correlates and predictors of missed nursing care in Turkey.

METHODS

This descriptive and cross-sectional study sample consisted of 1310 nurses working in inpatient units of 10 public, university and private hospitals in Istanbul. Data were collected using the Nursing Teamwork Survey-Turkish and the MISSCARE Survey-Turkish between February and June 2019. Descriptive analysis, parametric comparative analysis, correlational analysis and regression analysis were used to analyse the data.

RESULTS

The total occurrence of missed nursing care was 2.93 (on a scale of 1.00-4.00), which differed across 21 nursing care elements. The most frequently missed care was turning patients every 2 hours. Multiple regression analysis determined that nurses' tenure in the profession, patient-nurse ratio, days absent in the last 3 months and nursing teamwork significantly affected missed nursing care. Nursing teamwork alone accounted for 23.6% of the variance in missed nursing care.

CONCLUSIONS

The level of missed nursing care was found to be high, and labour resources issues were the most important reason. Nurse professionals should apply interventions to improve nurses' work environment factors such as patient-nurse ratio and nursing teamwork to reduce the incidence of missed nursing care.

Influence of the Workload and Years of Experience of Nurses on Hemodialysis Quality Using Korean National Hemodialysis Adequacy Evaluation Data

The aim of this study is to examine the influence of nurses’ workload and years of experience on the rate of patients with normal calcium–phosphorus products levels and the adequacy evaluation grade of hemodialysis (HD) facilities using 2015 and 2018 national HD adequacy evaluation data. The data of 616 hospital-level outpatient HD facilities were analyzed using multiple linear regression and ordinal logistic regression. A higher rate of nurses with ≥2 years of HD experience was correlated with a higher rate of patients with normal calcium–phosphorus levels. As the average daily number of HD cases per nurse increased, the probability of HD facilities’ receiving the higher adequacy evaluation grade decreased by 83% (odds ratio (OR)=.17, 95% confidence interval (CI)=.14–.22), whereas it increased by 4% as the rate of nurses with ≥2 years of HD experience increased by 1%p (OR=1.04, 95% CI=1.03–1.05). Reducing the nursing workload by maintaining sufficient nurses and increasing the rate of nurses with ≥2 years of HD experience would improve the quality of HD and patient outcomes.

Sociodemographic and work environment correlates of missed nursing care at highly specialized hospitals in Mexico: A cross-sectional study

BACKGROUND

Despite its direct relevance to quality of care, little is known about missed nursing care or its sociodemographic and work environment correlates at highly specialized hospitals in low- and middle-income countries.

OBJECTIVE

To analyze the frequency of missed nursing care among Mexican nursing professionals, and to assess its associated sociodemographic and labor-related predictors.

DESIGN AND METHODS

A cross-sectional, observational study based on data collected from 315 nursing professionals in 11 highly specialized public hospitals in Mexico. We assessed missed nursing care both as a total figure and according to the four dimensions of the MISSCARE inventory. We estimated its sociodemographic and work-related predictors using fractional logistic analysis.

RESULTS

The global score for missed nursing care was 15.21%: 7.94% concerned individual needs, 9.37% discharge planning and patient education, 18.10% basic care, and 1.59% care under continuous assessment. The odds of engaging in missed nursing care increased with age and were higher among women and night-shift workers. In contrast, they decreased among nursing professionals who were satisfied with their jobs, and among those working in suitable environments.

CONCLUSIONS

Missed nursing care in highly specialized public hospitals is associated with the sociodemographic characteristics and labor-related conditions -including the work environments- of the nurses. Given its impact on both health-care users and institutions, further research on the subject is urgently needed. It is essential to improve the design, implementation and evaluation of comprehensive strategies aimed at reducing the frequency of missed nursing care and achieving universal health coverage.

Missed nursing care and complexity theory: a conceptual paper

Background

Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care.

Aim

This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory.

Methods

The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare.

Results

We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care.

Conclusions

This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Fundamental nursing care in patients with the SARS-CoV-2 virus: results from the 'COVID-NURSE' mixed methods survey into nurses' experiences of missed care and barriers to care

BACKGROUND

Patient experience of nursing care is associated with safety, care quality, treatment outcomes, costs and service use. Effective nursing care includes meeting patients' fundamental physical, relational and psychosocial needs, which may be compromised by the challenges of SARS-CoV-2. No evidence-based nursing guidelines exist for patients with SARS-CoV-2. We report work to develop such a guideline. Our aim was to identify views and experiences of nursing staff on necessary nursing care for inpatients with SARS-CoV-2 (not invasively ventilated) that is omitted or delayed (missed care) and any barriers to this care.

METHODS

We conducted an online mixed methods survey structured according to the Fundamentals of Care Framework. We recruited a convenience sample of UK-based nursing staff who had nursed inpatients with SARS-CoV-2 not invasively ventilated. We asked respondents to rate how well they were able to meet the needs of SARS-CoV-2 patients, compared to non-SARS-CoV-2 patients, in 15 care categories; select from a list of barriers to care; and describe examples of missed care and barriers to care. We analysed quantitative data descriptively and qualitative data using Framework Analysis, integrating data in side-by-side comparison tables.

RESULTS

Of 1062 respondents, the majority rated mobility, talking and listening, non-verbal communication, communicating with significant others, and emotional wellbeing as worse for patients with SARS-CoV-2. Eight barriers were ranked within the top five in at least one of the three care areas. These were (in rank order): wearing Personal Protective Equipment, the severity of patients' conditions, inability to take items in and out of isolation rooms without donning and doffing Personal Protective Equipment, lack of time to spend with patients, lack of presence from specialised services e.g. physiotherapists, lack of knowledge about SARS-CoV-2, insufficient stock, and reluctance to spend time with patients for fear of catching SARS-CoV-2.

CONCLUSIONS

Our respondents identified nursing care areas likely to be missed for patients with SARS-CoV-2, and barriers to delivering care. We are currently evaluating a guideline of nursing strategies to address these barriers, which are unlikely to be exclusive to this pandemic or the environments represented by our respondents. Our results should, therefore, be incorporated into global pandemic planning.

Rationing of Nursing Care and Professional Burnout Among Nurses Working in Cardiovascular Settings

Introduction: Nursing needs close interpersonal contact with the patient and emotional involvement, therefore can contribute to professional burnout and rationing of nursing care.

Aim: Assessing the relationship between the rationing of nursing care and professional burnout in nursing staff.

Materials and Methods: The study included a group of 219 nurses working in cardiovascular facilities. This was a cross-sectional study designed to investigate the relationship between factors of the care rationing and professional burnout. The survey data was collected with standardised and research instruments such as the revised Basel Extent of Rationing of Nursing Care questionnaire (BERNCA-R) and the Maslach Burnout Inventory (MBI).

Results: The total mean BERNCA-R score was 1.38 (SD = 0.62), while the total MBI score amounted to 38.14 (SD = 22.93). The specific components of professional burnout yielded the values: emotional exhaustion (M = 44.8), job dissatisfaction (M = 40.66), and depersonalisation (M = 28.95). Multiple linear regression showed that independent predictors of BERNCA-R score were emotional exhaustion, depersonalisation, job dissatisfaction, and multi-jobs activity (p < 0.001).

Conclusion: The level of rationing of nursing care in cardiovascular facilities increases along with emotional exhaustion, depersonalisation and job dissatisfaction, and multi-jobs activity.

Patient safety, quality of care and missed nursing care at a cardiology department during the COVID-19 outbreak

Aim

To evaluate missed nursing care and patient safety during the first wave of the COVID‐19 pandemic at in‐patient cardiology wards.

Design

A cross‐sectional design with a comparative approach.

Method

Registered nurses and nurse assistants at a cardiology department were invited to answer the MISSCARE Survey‐Swedish version, and questions on patient safety and quality of care during the COVID‐19 pandemic. The data were compared with a reference sample.

Results

A total of 43 registered nurses and nurse assistants in the COVID‐19 sample and 59 in the reference sample participated. The COVID‐19 sample reported significantly more overtime hours and more absence from work due to illness in comparison with the reference sample. The patient safety and quality of care were perceived significantly worse, 76.7% (N = 33) versus 94.7% (N = 54), and 85.7% (N = 36) versus 98.3% (N = 58, respectively. The COVID‐19 sample reported more missed nursing care in wound care and in basic nursing.

Nurses’ views of fundamental relational skills used in clinical practice: a cross-sectional pilot study

Objective

Effective communication skills are one of the core competencies of nursing curricula internationally. Nurses are generally regarded as proficient. Despite our complete trust in the profession, deficiencies and gaps exist. However, it is not clear to which extent nurses use key communication skills in practice, and whether or not confident in using these skills compounds environmental issues that occur. This study explored nurse's confidence and application of relational skills competencies in nursing practice.

Methods

A 13-item online survey was used to collect data.

Results

Being self-aware on key areas where there was more uncertainty. Nurses also lacked confidence in exploring the impact of their personal feelings and values on their interactions. Nurses were also less confident on responding appropriately to instances of unsafe or unprofessional practice and using information and communication systems and technology.

Conclusions

Given the potential impact of poor relational skills on quality client care, an increased emphasis on caring and compassion, and the ever-expanding use of communication technologies, there is a need to explore the need for reflective practice to enhance continuous professional development for nurses to enhance their relational skills.

Missed nursing care in hospital environments during the COVID-19 pandemic

BACKGROUND

Studies performed in Central European countries showed a high prevalence of missed nursing care in various clinical settings before the COVID-19 pandemic.

AIMS

The aim of the study was to investigate which domains of the work environment were significant predictors of missed nursing care activities in Czech hospitals during the COVID-19 pandemic.

METHODS

A cross-sectional study was used. The RANCARE guideline and STROBE checklist were followed for reporting in the study. The sample consisted of 371 nurses from four acute care hospitals. The MISSCARE Survey and the Practice Environment Scale of the Nursing Work Index questionnaires were used to collect data. The data were analyzed using multiple linear and logistic regression analyses.

RESULTS

Nurses reporting unfavorable environments consistently describe a higher frequency of episodes of missed care. Prevalence estimates of missed care in Czech acute care hospitals during the COVID-19 pandemic was predicted from the overtime work, the nurses' perception of the "Nursing foundations for the quality of care," and their satisfaction with their current position.

CONCLUSIONS

Missed nursing care could be mitigated by improving the nurses' work environment. Domains of the nurse work environment are known as structural modifiable factors and their refinement could be a cornerstone for interventions to reduce the prevalence of missed nursing care.

IMPLICATIONS FOR NURSING POLICY

Monitoring the conditions and aspects of the nurse work environment in hospitals and considering nurses' concerns about the work environment on an ongoing basis are important strategies for nurse supervision as well as for policymakers.

Missed nursing care and its relationship with perceived ethical leadership

BACKGROUND

Determination of the factors affecting missed nursing care and the impact of ethical leadership is important in improving the quality of care.

AIM

This study aims to determine the missed nursing care and its relationship with perceived ethical leadership.

RESEARCH DESIGN

A cross-sectional study.

PARTICIPANTS AND RESEARCH CONTEXT

The sample consisted of 233 nurses, of whom 92.7% were staff nurses and 7.3% were charge nurses, who work in three different hospitals in Turkey. The study data were collected using a personal and professional characteristics data form, the Missed Nursing Care Survey, and the Ethical Leadership Scale.

ETHICAL CONSIDERATIONS

The study was approved by the non-interventional ethics committee of Dokuz Eylül University Ethics Committee for Noninvasive Clinical Studies. All participants' written and verbal consents were obtained.

FINDINGS

The most missed nursing care practices were ambulation, attending interdisciplinary care conferences, and discharge planning. According to the logistic regression analysis, sex, the number of patients that the nurse is in charge of giving care, the number of patients discharged in the last shift, and satisfaction with the team were determined as factors affecting missed care. No significant relationship was found between ethical leadership and missed nursing care (p > 0.05), and a weak but significant relationship was found between the clarification of duties/roles subscale and missed nursing care (r = -0.136, p < 0.05).

DISCUSSION

Ethical leaders should collaborate with policy-makers at an institutional level to particularly achieve teamwork that is effective in the provision of care, to control missed basic nursing care, and to organize working hours and at the country level to determine roles and to increase the workforce.

CONCLUSION

The results of this study contribute to the international literature on the most common type of missed nursing care, its reasons, and the relationship between the missed care and ethical leadership in a different cultural context.

The effect of data aggregation on estimations of nurse staffing and patient outcomes

OBJECTIVE

To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity.

DATA SOURCES/STUDY SETTING

Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system.

RESEARCH DESIGN

This retrospective observational study used unit-level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month-long and a year-long period, with and without fixed effects.

DATA COLLECTION

We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month.

PRINCIPAL FINDINGS

Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity.

CONCLUSIONS

Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.

Nursing staff ratio and skill mix in Swedish emergency departments: A national cross-sectional benchmark study

AIM

The aim of this study is to describe ratio and skill mix for nursing staff in Swedish emergency departments over a specific 24-h period.

BACKGROUND

The link between number of patients per nursing staff and missed nursing care is well described within the in-hospital setting, showing association with negative outcomes such as increased mortality. Potential association within the emergency department setting is still unexplored.

METHOD

This is a national descriptive cross-sectional benchmark study.

RESULTS

The majority (n = 54; 89%) of Swedish emergency departments participated. The patients-per-registered nurse ratio varied between the shifts, from 0.3 patients to 8.8 patients (mean 3.2). The variation of patients per licenced practical nurse varied, from 1.5 to 23.5 patients (mean 5.0). The average skill mix was constant at around 60% registered nurses and 40% licenced practical nurses.

CONCLUSION

The varying ratios for patient per registered nurse and licenced practical nurse in Swedish emergency departments are noteworthy. Furthermore, the patient flow and nursing staff numbers did not match one another, resulting in higher nursing staff ratios during the evening shift.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings can be used to improve rosters in relation to crowding, to manage the challenging recruitment and retention situation for nursing staff and to improve patient safety.

Missed nursing care during the COVID-19 pandemic: A comparative observational study

Aim

To evaluate frequencies, types of, and reasons for missed nursing care during the COVID‐19 pandemic at inpatient wards in a highly specialized university hospital.

Background

Registered nurse/patient ratio and nursing competence is known to affect patient outcomes. The first wave of the COVID‐19 pandemic entailed novel ways for staffing to meet the expected increased acute care demand, which potentially could impact on quality of care.

Methods

A comparative cross‐sectional study was conducted, using the MISSCARE Survey. A sample of nursing staff during the first wave of the COVID‐19 pandemic (n=130) was compared with a reference sample (n=157).

Results

Few differences between samples concerning elements of missed care, and no significant differences concerning reasons for missed care were found. Most participants perceived the quality of care and the patient safety to be good.

Conclusion

The results may be explained by three factors: maintained registered nurse/patient ratio, patients’ dependency levels and that nursing managers could maintain the staffing needs with a sufficient skill mix.

Implications for nursing management

Nursing managers impact on the occurrence of MNC; to provide a sufficient registered nurse/patient ratio and skill mix when staffing. They play an important role in anticipatory planning, and during infectious diseases outbreaks.

Mealtime and patient factors associated with meal completion in hospitalised older patients: An exploratory observation study

AIMS AND OBJECTIVES

To examine mealtime and patient factors associated with meal completion among hospitalised older patients. We also considered contextual factors such as staffing levels and ward communication.

BACKGROUND

Sub-optimum nutrition is a modifiable risk factor for hospital associated decline (HAD) in older patients. Yet, the quality of mealtime experiences can be overlooked within ward routinised practice.

DESIGN

Cross sectional, descriptive observation study.

METHODS

We undertook structured observation of mealtimes examining patient positioning, mealtime set-up and feeding assistance. The outcome was meal completion categorised as 0, 25%, 50%, 75% or 100%. Data were collected on patient characteristics and ward context. We used mixed-effects ordinal regression models to examine patient and mealtime factors associated with higher meal completion producing odds ratios (OR) and 95% confidence intervals (CI). The study was reported as per STROBE guidelines.

RESULTS

We included 60 patients with a median age of 82 years (IQR 76-87) and clinical frailty score of 5 IQR (4-6). Of the 279 meals, 51% were eaten completely, 6% three quarters, 15% half, 18% a quarter and 10% were not eaten at all. Mealtime predictors with a weak association with less-meal completion were requiring assistance, special diets, lying in bed, and red tray (indicator of nutrition risk), but were not statistically significant. Significant patient-level factors were higher values for frailty (OR 0.34 [0.11-1.04]) and Malnutrition Universal Screening Tool (OR 0.22 [0.08-0.62]). The average nurse-to-patient ratio was 1:5.5.

CONCLUSION

Patient factors were the strongest predictors for meal completion, but mealtime factors had a subtle influence. The nursing teams' capacity to prioritise mealtimes above competing demands is important as part of a comprehensive nutrition strategy.

RELEVANCE TO CLINICAL PRACTISE

Nurses are central to optimising nutrition for frail older patients. It requires ward leadership to instil a culture of prioritising assisted mealtimes, improved communication, greater autonomy to tailor nutrition strategies and safe staffing levels.

Missed Nursing Care Among Patients With Dementia During Hospitalization: An Observation Study

Patients with dementia (PwD) are characterized as a vulnerable group as they are unable to communicate their needs, putting them at risk for care omissions. The current study aimed to explore care toward PwD and detect if any aspects of care are omitted. An observation study was conducted in three medical-surgical adult wards of an acute general hospital. Data were collected by an observer, through field notes, and were analyzed with content analysis. A face scale was used to assess PwD's mood. Thirteen PwD were observed for 90 hours. Four thematic areas were identified: (a) Unmet Fundamental Patient Needs, (b) Human Right to Dignity and Respect, (c) Communication Deficiencies, and (d) Implementation of Nursing Interventions. Nurse-patient contact lasted from 5 to 7 minutes and numerous care omissions were noted. The face scale assessment revealed that most PwD looked very sad after nursing care. This study enriches insight for the care of PwD during hospitalization and emphasizes the need for health care workers' education and support. [Research in Gerontological Nursing, 14(3), 150-159.].

Care left undone and work organisation: A cross-sectional questionnaire-based study in surgical wards of Estonian hospitals

BACKGROUND

Care left undone is a worldwide problem for both the quality of health care and the safety of patients. In surgical nursing, care left undone is a critical issue arising from the intensive pace of work, invasive procedures and the pressure for efficiency. Previous knowledge about care left undone in surgical contexts is missing.

OBJECTIVE

To describe care left undone and its relationship to nursing and organisational characteristics in the surgical wards of regional and central hospitals in Estonia.

METHODS

A cross-sectional study with an online questionnaire took place from June to October of 2018. The target population (N = 570) consisted of nurses working in the surgical wards of two regional and three central hospitals at the time of the study. The data were analysed using descriptive statistics and Fisher's exact test. The open-ended questions were analysed with deductive content analysis.

RESULTS

Nursing care in the surgical wards was reported as having been left undone sometimes or often by 88% of the nurses. Most often, the documentation and evaluation of care plans (33%) were reported as undone and most rarely, disinfection measures were left undone (5%). Nurses with a shorter employment history left care undone more frequently, and when the number of patients per nurse increased, the amount of care left undone increased as well. More than half of the participants (59%) considered work organisation to be the cause of care left undone.

CONCLUSIONS

Work organisation and staffing in surgical wards require more attention at the management level, as nursing care left undone occurred to a significant degree in the investigated wards, and more than half of the nurses considered work organisation to be the reason for care left undone.

[Relationships among Non-Nursing Tasks, Nursing Care Left Undone, Nurse Outcomes and Medical Errors in Integrated Nursing Care Wards in Small and Medium-Sized General Hospitals]

PURPOSE

This study aimed to identify the degree of non-nursing tasks and nursing care left undone in integrated nursing care wards, and examine their relationships with nurses' burnout, job satisfaction, turnover intentions, and medical errors.

METHODS

A cross-sectional questionnaire survey was conducted. Data were collected using self-report questionnaires from 346 nurses working in 20 wards of seven small and medium-sized general hospitals, and analyzed using multiple regression and multiple logistic regression analysis with the SPSS WIN 25.0 program.

RESULTS

The mean score for non-nursing tasks was 7.32±1.71, and that for nursing care left undone was 4.42 ± 3.67. An increase in non-nursing tasks (β = .12, p = .021) and nursing care left undone (β = .18, p < .001) led to an increase in nurses' burnout (F = 6.26, p < .001). As nursing care left undone (β = .13, p = .018) increased, their turnover intentions also (F = 3.96, p < .001) increased, and more medical errors occurred (odds ratio 1.08, 95% confidence interval 1.02~1.15).

CONCLUSION

Non-nursing tasks and nursing care left undone are positively associated with nurses' burnout, turnover intentions, and the occurrence of medical errors. Therefore, it is important to reduce non-nursing tasks and nursing care left undone in order to deliver high quality nursing care and in turn increase patient safety.

Effects of Work Environments and Occupational Fatigue on Care Left Undone in Rotating Shift Nurses

PURPOSE

This study aimed to examine the effects of work environments and occupational fatigue on care left undone in rotating shift nurses, and to identify the indirect (mediation) effect of work environments on care left undone through nurses' occupational fatigue in South Korean acute care hospitals.

DESIGN

This study employed a cross-sectional design using an online survey to collect data from 488 rotating shift nurses of acute care hospitals in Korea between November and December 2018.

METHODS

A mobile schedule management application for shift nurses was used to advertise the study and to send a link to the online survey. The survey included questions on the nurses' work environment characteristics, care left undone activities, and the Korean version of the Occupational Fatigue Exhaustion/Recovery scale. Poisson regression was used to explore the relationships among work environments, occupational fatigue, and care left undone. Hayes' Model 4 and a bootstrapping analysis were used to identify the mediating effect of occupational fatigue on the relationship between work environments and care left undone.

FINDINGS

The average number of tasks left undone was 3.45 (SD = 2.19). The higher the acute and chronic fatigue levels noted among nurses, the higher were the occurrences of care left undone. Conversely, the higher the intershift recovery level, the lower were the occurrences of care left undone. The results showed a positive relationship between care left undone and overtime hours and the number of patients per nurse. Moreover, nurses' occupational fatigue mediated the relationship between work environments and care left undone. Night shifts per month and the number of consecutive days off had an indirect effect on care left undone through occupational fatigue.

CONCLUSIONS

High levels of occupational fatigue and poor intershift recovery among nurses can lead to care left undone. Nurses' occupational fatigue mediates the effect of work environment on care left undone.

CLINICAL RELEVANCE

It is crucial for healthcare administrators and leaders to develop policies and mandatory regulations to facilitate better working conditions for nurses, consequently reducing their occupational fatigue and decreasing the occurrence of care left undone in acute care hospitals.

Perceptions of the cancer care left undone in primary and community services: A mixed methods evaluation

Primary and community care in the United Kingdom are under increasing workforce and time pressures. How these pressures affect the delivery of cancer care has rarely been explored. This service evaluation aimed to elucidate some of the views of the workforce in this sector of what work in cancer care is left undone, and what they would like to be able to offer more of. An exploratory sequential design was taken including a questionnaire and interviews asking primary and community care staff in London about their workload in cancer care. Surveys were analysed using descriptive statistics. The evaluation revealed a perception from primary and community care that there is work in cancer care that is currently being left undone. 64% of the workforce across all professions reported that they worked 10 or more hours of unpaid overtime per week. Respondents identified psychological care for people with cancer (PWC), and bereavement care for families and carers of PWC as the most common areas that were left undone. They would like to do more proactive work, in place of the current reactive 'fire-fighting' they are doing. For example, signposting available services to PWC and access to nutritional support. There was a desire for acknowledgement of the time and workforce pressures in primary and community care, and how these are hindering the delivery of care for PWC.

Anticipated nursing care: findings from a qualitative study

Background

Contrary to Missed Nursing Care, some anecdotal data and sparse evidence has documented the tendency of nurses to anticipate some nursing interventions. However, no study has been conducted to date with the purpose of understanding this phenomenon and its underlying mechanisms and consequences. The aim of this study was to describe the phenomenon of delivering anticipated nursing care, its antecedents and consequences as perceived by nurses.

Method

A descriptive qualitative study. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed. A purposeful sample of 17 clinical nurses and nurse managers working in three Italian hospitals were interviewed in depth in 2019. The audio-recorded interviews were verbatim transcribed and thematically analysed.

Results

‘Anticipated Nursing Care’ is delivered significantly earlier than when expected by nurses in their care plan, by patients, by caregivers and by other members of the team. Medication administration, mobilisation of patients, hygiene care, changes of dressing, vital parameter monitoring, blood sampling and administrative activities were reported as interventions delivered before rather than when expected. Clinically stable patients have been reported to be at risk of receiving anticipated nursing care. Individual values and attitudes, group attitudes of being always ready for the “unexpected”, implicit group norms to “leave the patients and the unit in order”, high workloads, intertwined activities and work processes inside the units, have been reported as reasons for Anticipated Nursing Care. Effects of this phenomenon have been reported at the patients’ and at the nurses’ level.

Conclusion

Anticipated Nursing Care occurs when nurses perform interventions earlier than expected according to an implicit or explicit decision and not as a consequence of a request. The phenomenon requires future studies to detect its diffusion and to accumulate evidence. Its presence in daily practice, if confirmed, suggests that Missed Nursing Care studies should also consider the combined effect of these two phenomena as, on one hand, there may be the tendency to postpone and, on the other hand, the tendency to anticipate interventions.

Translation, culture adaption and psychometric testing of the MISSCARE Survey-Swedish version

AIM

To translate the MISSCARE Survey into Swedish and establish its validity and reliability by evaluating its psychometric properties.

BACKGROUND

Missed nursing care is defined as any aspect of required nursing care that is omitted or delayed. The consequence of missed nursing care is a threat to patient safety. The MISSCARE Survey is an American instrument measuring missed nursing care activities (part A) and its reasons (part B).

METHODS

The translation was accomplished according to World Health Organization guidelines, focusing on a culture adaptation. Acceptability, construct validity, test-retest reliability and internal consistency were analysed. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) was used as reporting checklist.

RESULTS

The translation and culture adaptation needed several revisions. A total of 126 nurses answered the test and retest which showed acceptability of missing data. The factor analysis revealed a lack of fit to data for the original factorial structure in part B, while further analysis provided results suggesting a modification based on omitting six items. The internal consistency for part B and its subscales showed good results.

CONCLUSIONS

The MISSCARE Survey-Swedish version is a reliable and valid instrument, with good psychometric properties.

RELEVANCE TO CLINICAL PRACTICE

More reliable language versions of the instrument enable national and international comparisons that could be valuable for nursing managers and/or directors of nursing who are responsible for quality of care and patient safety in the strategic care planning process.

Nurses' Perceptions of the Extent and Type of Missed Perioperative Nursing Care

Missed nursing care is a concern on inpatient hospital units but has not been adequately explored in the perioperative setting. This cross-sectional study used results from a survey of 1,693 AORN members to investigate the amount and type of missed perioperative nursing care and evaluate associations between reported missed care and facility and nurse characteristics. The survey asked OR nurses how frequently specific care items were missed by themselves or others. Overall, nurses' perceptions of the frequency of missed care was 0.84 on a scale of 0 to 4 (0 = never, 4 = always). The survey items were categorized into five subscales: legal requirement, preparation, safety, communication, and closing routine. Nurses reported most missed care in the communication and preparation categories. The number of ORs at a facility, nurse education and job title, and perceptions of staffing adequacy were significantly associated with the perceived amount of missed perioperative nursing care.

Missed nursing care and nurses' intention to leave: An integrative review

AIM

To identify the factors that are associated with missed nursing care and the nurses' intention to leave.

BACKGROUND

Errors and mistakes are an inevitable part of work, but there is increased evidence that missed care is a concerning issue affecting nurses' ability to effectively coordinate, provide and evaluate care interventions delivered to patients globally.

EVALUATION

An integrative review of qualitative and quantitative studies examining the consequences of missed nursing care, including intention to leave.

KEY ISSUES

Eight papers met the inclusion criteria. Thematic analysis generated three themes: Prevalence of missed nursing care, Factors associated with missed nursing care, Factors that impact on missed care and influence the intention to leave.

CONCLUSION

The outcomes of this review demonstrate the need for critical interventions to address the factors that can impact the provision of high-quality nursing care.

IMPLICATIONS FOR PRACTICE

Missed nursing care is not only a patient safety issue but may also contribute to the inadequate staffing levels. And, better understanding of the factors that affect the intention to leave by nurse managers can stimulate the development of appropriate leadership styles in combination with adjustment of workplace to prevent intention to leave.