The association of teamwork and missed nursing care in acute care setting: A mixed-methods systematic review

AIM(S)

Teamwork among healthcare professionals is a key aspect of patient safety that influences the prevalence of missed nursing care. The association between teamwork and missed care in acute care hospitals is now well established in the literature. Therefore, this review aimed to synthesise the existing empirical evidence on the association between teamwork and missed care in the acute care setting.

DESIGN

A mixed-method systematic review study.

METHODS

The search was carried out in February 2023 in four scientific databases, PubMed, ProQuest, Web of Science and Scopus based on their institutional availability. The search produced 1542 studies. The method of thematic analysis was used in data synthesis.

RESULTS

A total of 18 studies were selected that revealed the relationship between teamwork and missed care. The teamwork score was weak to moderate but significantly associated with the overall score of missed care and was found to be a statistically significant predictor of missed care in an acute care setting. Additionally, teamwork represented an important reason for missed care, primarily in the context of poor communication, lack of trust and cooperation in the nursing team and lack of leadership.

CONCLUSION

The review findings contribute to a deeper understanding of the intricate dynamics between teamwork and missed care and provide valuable information to healthcare professionals and institutions looking to optimise teamwork and mitigate instances of missed care in the acute care setting.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Recognising how teamwork influences the occurrence of missed care, healthcare organisations can strategically implement targeted interventions to enhance collaboration, address communication gaps, foster trust, and provide effective leadership.

IMPACT

This review suggests that improving teamwork seems to be one of the most important strategies focused on mitigating missed care in acute care settings.

REPORTING METHOD

The reporting of this review followed the PRISMA 2020 checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The Relationship between Clinical Environment and Adverse Events Reporting: Evidence from Lithuania

BACKGROUND

The clinical environment plays a crucial role in patient safety, as it encompasses the physical, organizational, and cultural aspects of healthcare delivery. Adverse events, such as active errors, can often be attributed to systemic issues within the clinical environment. Addressing and improving environmental factors is essential for minimizing adverse events and enhancing overall patient care quality.

METHODS

A descriptive, cross-sectional design was applied. The study utilized two questionnaires: the Reporting of Clinical Adverse Events Scale (RoCAES) and the Revised Professional Practice Environment (RPPE) scale. A total of 1388 questionnaires were fully filled out, with a response rate of 71 percent.

RESULTS

Nurses who expressed higher levels of satisfaction with various aspects of the clinical environment were more inclined to indicate their intention to report adverse events in the future. These positive relationships suggest that a contented clinical environment fosters a greater willingness among nurses to report adverse event occurrences.

CONCLUSION

The findings of our study support the evidence that demonstrated that the clinical environment plays a significant role in influencing the reporting of adverse events in healthcare settings. It significantly influences nurses' attitudes, quality of care, and adverse event reporting rate.

The experience of nurses to reduce implicit rationing of nursing care: a phenomenological study

BACKGROUND

Implicit rationing of nursing care can adversely affect patient safety and the quality of care, and increase nurses' burnout and turnover tendency. Implicit rationing care occurs at the nurse-to-patient level (micro-level), and nurses are direct participants. Therefore, the strategies based on experience of nurses to reduce implicit rationing care have more reference value and promotion significance. The aim of the study is to explore the experience of nurses to reduce implicit rationing care, thereby to provide references for conducting randomized controlled trials to reduce implicit rationing care.

METHODS

This is a descriptive phenomenological study. Purpose sampling was conducted nationwide. There are 17 nurses were selected and semi-structured in-depth interviews were conducted. The interviews were recorded, transcribed verbatim and analyzed via thematic analysis.

RESULTS

Our study found that nurses' reported experience of coping with implicit rationing of nursing care contained three aspects: personal, resource, and managerial. Three themes were extracted from the results of the study: (1) improving personal literacy; (2) supplying and optimizing resources and (3) standardizing management mode. The improvement of nurses' own qualities are the prerequisites, the supply and optimization of resources is an effective strategy, and clear scope of work has attracted the attention of nurses.

CONCLUSION

The experience of dealing with implicit nursing rationing includes many aspects. Nursing managers should be grounded in nurses' perspectives when developing strategies to reduce implicit rationing of nursing care. Promoting the improvement of nurses' skills, improving staffing level and optimizing scheduling mode are promising measures to reduce hidden nursing rationing.

Rationing of nursing care: A concept analysis

Rationing of nursing care (RONC) refers to necessary nursing tasks that nurses refuse or fail to do because of limited time, staffing level, or skill mix. As an important process factor, it affects the quality of patient care. The concept of rationing of nursing care has not yet been clearly defined and analyzed and there are different views regarding this issue. Using Walker and Avant's eight-step method, this concept analysis was conducted to analyze the meaning, attributes, dimensions, antecedents, and consequences of nursing care rationing. The literature was collected by searching in electronic databases including PubMed, ScienceDirect, Web of Science, Scopus, and Google Scholar with no date limitation. Both qualitative and quantitative studies on rationing of nursing care, which were open-access and published in English, were included in this study. Thirty-three articles were investigated in the present study. The four defining attributes of RONC included the duty of performing nursing care, dealing with problems of doing nursing care, decision-making and prioritizing, and outcome. The antecedents included nurse-related, organization-related, care-related, and patient-related antecedents. A theoretical definition and a conceptual model of RONC were developed. The attributes, antecedents, and consequences of RONC identified in this study can be used in nursing education, research, and managerial and organizational planning.

Implicit rationing of nursing care reported by nurses from different types of hospitals and hospital units

AIMS AND OBJECTIVES

The study aimed to investigate differences in assessing implicit rationing of nursing care by Czech nurses with respect to the type of unit and type of hospital.

BACKGROUND

Implicit rationing of nursing care may differ across different types of hospitals and hospital units.

DESIGN

This study used a multicentre cross-sectional study design.

METHODS

The STROBE checklist for observational cross-sectional studies was followed for reporting of the research study. The sample included 8209 nurses providing direct care to medical and surgical patients in 14 acute care Czech hospitals. The main outcome was implicit rationing of nursing care as measured with a Czech version of the Perceived Implicit Rationing of Nursing Care (PIRNCA) instrument. Data were collected from September 2019 to October 2020.

RESULTS

The most frequently rationed nursing care activity was timely response to patient or family request/need, followed by emotional or psychological support and adequate supervision of delegated tasks. More implicitly rationed nursing care was reported in medical units. Statistical differences were found in rating 25 items and the PIRNCA total score. Nurses from middle-sized hospitals reported implicitly rationed care more frequently than those from large hospitals.

CONCLUSION

More rationed care was reported by nurses from medical units and nurses from middle-sized hospitals. Organisational variables (the type of unit and type of hospital) influence the implicit rationing of nursing care in our study.

RELEVANCE TO CLINICAL PRACTICE

The findings call for nursing managers to pay attention to organisational variables which may affect the implicit rationing of nursing care.

Assessment of The Effect of Stress, Sociodemographic Variables and Work-Related Factors on Rationing of Nursing Care

(1) Rationing of nursing care is withholding, limiting or not fulfilling the necessary nursing activities for patients. It may have a negative effect on patient safety and the quality of care. The aim of the present paper is the assessment of the effect of stress on the rationing of nursing care. (2) The current research has a cross-sectional, observational design. The study sample comprised 567 nurses. The following questionnaires were used in the study PIRNCA and PSS-10. (3) It was demonstrated that nurses with a high level of perceived stress rationed nursing care to a greater extent and showed lower assessment of nursing care and lower job satisfaction in comparison with nurses with average and low levels of perceived stress. (4) 1. Stress in nurses has a negative effect on rationing of nursing care and job satisfaction. It is recommended that actions aimed at developing effective stress coping skills be implemented as early as at the stage of training to become a nurse. 2. Factors such as marital status, sex, form of employment, place of employment and the level of professional burnout syndrome may have an influence on the level of experienced stress. In turn, the level of experienced stress, marital status, education, place of work as well as the place of residence may have an effect on rationing of nursing care and, consequently, affect the quality of care.

Experiences of intensive care unit nurses working with COVID-19 patients: A systematic review and meta-synthesis of qualitative studies

Objectives

Intensive Care Unit (ICU) nurses are at the forefront of fighting and treating the Coronavirus 2019 (COVID-19) pandemic and are often directly exposed to this virus and at risk of disease, due to their direct care for infected patients. This study aims to synthesize the experiences of ICU nurses working with COVID-19 patients.

Methods

A systematic review and meta-synthesis of qualitative studies were undertaken. A systematic literature search in four databases, including Web of Sciences, Scopus, Embase, and PubMed (including Medline), was performed. Original qualitative studies and the qualitative section of mixed method studies, written in English, which focused on the experiences of only ICU nurses working with COVID-19 patients, were included.

Results

Seventeen qualitative studies and two mixed-method studies were included in the review. As a result of the inductive content analysis, six main categories were identified, as follows: "distance from holistic nursing," "psychosocial experiences," "efforts for self-protection and wellbeing," "organizational inefficiency," "job burnout," and "emerging new experiences in the workplace."

Conclusions

The findings from this study suggest that healthcare authorities and policymakers can facilitate the provision of high-quality patient care during the COVID-19 pandemic through appropriate planning to provide adequate support and training, prevent shortages of nursing staff and equipment, and provide adequate attention to the psychological needs and job satisfaction of ICU nurses.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256070, identifier: CRD42021256070.

Exploring the role of communication in missed nursing care: A systematic review

AIMS

To systematically review the literature on relationships between communication issues and missed nursing care.

DESIGN

Systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Statement.

DATA SOURCES

EMBASE, Web of Science, CINAHL, PubMed and Cochrane databases were comprehensively searched from inception to December 2021.

REVIEW METHODS

Screening, data extraction and initial quality assessment were conducted independently by two reviewers. The JBI quality assessment tool was used for study appraisal and the certainty of evidence was assessed using the five Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Discrepancies were settled by consulting a third researcher.

RESULTS

A total of 18 articles were included. Missed nursing care was common and the status of communication was not optimistic in clinical. Nurses' sociodemographic characteristics and work environment both influenced missed nursing care and communication. Intrateam communication included three parts: doctors-nurses communication, nurses-nurses communication and nurses-patients communication, poor intrateam communication could contribute to missed nursing care. There was an interaction between missed nursing care and communication.

CONCLUSION

Promoting efficient intrateam communication, to acknowledge the importance of communication factors in reducing the incidence of missed nursing care in clinics is required. Future research can explore the impact of the internal dimension of communication on missed nursing care and consider interventions aimed at nurses' effective communication.

IMPACT

What problem did the study address? This study offers new evidence that the impact of intrateam communication on missed nursing care. What were the main findings? Effective intrateam communication can reduce the incidence of missed nursing care, there is mutual influence between communication and missed nursing care. Where and on whom will the research have an impact? Policymakers can provide positive interventions on communication problems in different populations (e.g. nurses-patients, nurses-nurses and doctors-nurses) to provide high-quality patient care.

Rationing Care, Job Satisfaction, Fatigue and the Level of Professional Burnout of Nurses in Urology Departments

The problem of rationing nursing care is common and present all over the world, which is a direct threat to the health and life of patients. The aim of the study was to assess the level of rationing care, fatigue, job satisfaction and occupational burnout and to assess the relationship between them and age, length of service and the number of jobs. A survey was performed among 130 Polish nurses in urology departments using the following questionnaires: Link Burnout Questionnaire, Job Satisfaction Scale, Nursing Care Rationing Scale and Modified Fatigue Impact Scale. Nursing care is rarely rationed-1.11 points; the experience of fatigue ranges between sometimes and often-52.58 points; and job satisfaction is at an average level-17.23 points. The level of rationing nursing care in urology departments is similar to that in other departments. This requires minor changes to the work of nurses to reduce the workload. Employers should develop implementation programs for young workers in order to avoid burnout and also invest in factors increasing nurses' satisfaction, such as the atmosphere at work.

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, nurse staffing levels and patient safety outcomes in low-income country acute care settings: An observational study

AIMS

The aim of this study was to measure the level of missed nursing care and determine its relationship with nurse staffing and patient safety outcomes in acute care settings in Ethiopia.

BACKGROUND

Missed nursing care in hospitals increases the likelihood of patient adverse events, complications, disability and death. However, little is known about the level of missed nursing care and its impact on patient outcomes in low-income countries.

METHODS

An observational study was conducted comprising of a survey of nurses at two time points (n = 74 and 80, respectively) and a medical record review of 517 patients in four units across two hospitals between September 2018 and March 2019.

RESULTS

The level of missed nursing care in the study units was very high. The hospital type and hours nurses worked during the last week were significantly associated with missed nursing care. A unit increase in missed nursing care score increased the incidence of adverse patient outcomes by 10%.

CONCLUSION

There was a higher level of missed nursing care in the study units compared with similar studies from high-income countries. Higher level of missed nursing care was significantly associated with higher incidence of adverse patient safety outcomes.

Rationing in the Pediatric Intensive Care Unit-ethical or unethical?

Rationing in health care is controversial, and even more so in pediatrics. Children are an inherently vulnerable group because they are reliant on their parents and caregivers to make decisions in their best interests and have no political voice. Historically, there has been general acceptance of the need to ration healthcare at a systems level, however there is controversy over whether healthcare professionals should be involved in rationing at the bedside. The COVID-19 pandemic has highlighted that bedside rationing is unavoidable, at least in times of extreme resource scarcity. Internationally, there has been significant ethical analysis and guideline development to guide intensive care rationing decisions in the event that resources are overwhelmed. This paper explores the principles underlying distributive justice in healthcare rationing and discusses how these were operationalized in ethical guidelines for the COVID-19 pandemic. In fact, rationing is unavoidable and occurs constantly in everyday nursing and medical ICU practice, often in mundane and uncontroversial ways. Some argue that these everyday decisions are not true rationing decisions, but resource allocation, or stewardship decisions. We argue there are no clear lines between resource allocation and rationing decisions, rather that they occur on a spectrum. These everyday rationing decisions are particularly susceptible to personal biases that are often implicit. Due to the subtle and constant nature of most everyday rationing decisions, specific guideline development will rarely be practical or appropriate. However, it is possible to develop other processes to improve decision making. There are a variety of strategies we recommend for this including, encouraging reflective practice; developing explicit frameworks that promote collaborative decision making; being transparent about resource allocation and rationing decisions with colleagues, patients, and families; and promoting a workplace culture of speaking up and accessing support in identifying and managing everyday rationing decisions.

Rationing of Nursing Care and Patient Safety

Background: Nursing care has a significant impact on patient safety, which affects clinical outcomes, patients’ satisfaction with the care received and nursing personnel’s satisfaction with the care provided. This study aimed to determine the extent of nursing care rationing and its relationship with patient safety including identification of the specific reasons.

Methods: This cross-sectional study involved 245 nurses and was performed between April–June 2019 in four hospitals in Wrocław, Poland. The standardized and relevant research tools such as Hospital Survey on Patient Safety Culture (HSOPSC) and the Perceived Implicit Rationing of Nursing Care (PIRNCA) were used. The data was submitted to hierarchical multiple regression analysis. The study was approved by the Bioethics Committee and was followed with the STROBE guidelines.

Results: The PIRNCA scores were negatively correlated with the HSOPSC subscales, which indicates that more frequent rationing of nursing care was associated with lower levels of patient safety parameters. It was shown that the highest level of unfinished nursing care was associated with decreases in patient safety factors linked with supervisor manager expectations actions promoting safety (rs = −0.321, p < 0.001), teamwork within hospital units (rs = −0.377, p < 0.001), feedback and communication about error (rs = −0.271, p < 0.001), teamwork across hospital units (rs = −0.221, p < 0.01), and hospital handoffs transitions (rs = −0.179, p < 0.01). Moreover, the strongest association was observed between the PIRNCA scores with patient safety grade (rs = 0.477, p < 0.001). Also, the PIRNCA scores among the internal unit were significantly higher than in the intensive care and surgical units.

Conclusion: Our study indicated the presence of nursing care rationing. Regarding patient safety, we found insufficient numbers of medical personnel and excessive personnel workload for providing safe care to patients, a lack of transparency in handling adverse event reports and analyses, and a lack of cooperation between hospital units regarding patient safety.

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.

Disjunction, tension and dissonance within nursing pain care provision for the older hospitalized person: A focused ethnographic insight

AIMS

This study presents an ethnographic insight into the older hospitalized persons' experiences on how nurses provide pain care provision. The older persons' perceptions of culturally mediated barriers and facilitators are presented.

DESIGN

Focused ethnography.

METHODS

Multi-site across eight acute care units within two tertiary referral hospitals on the east coast of Australia collected over a one-year period from 2014 to 2015. Semi-structured interviews (n = 12) of older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) registered nurses (12 hr 38 min). Participant observation (1,041 hr) during day, night and evening shifts.

RESULTS

The older person experienced disjunction within pain assessment by the reliance of nurses on objective measurement gained during functional task completion. Tension emerged during pain management when the older person was not included and/or options provided were not deemed effective. For some older persons this meant they undertook a decision to exclude their nurse from involvement in pain management. A thread woven throughout was a lack of communication, continuity of care and input from the older person.

CONCLUSION

This study has implications for the provision of nursing care of the older hospitalized person. Dissonance within pain care provision for the older person occurs during episodes of missed pain care. Understanding and insight is gained into aspects of missed communication opportunities between nurses and the experiences of missed pain care of the older person.

Hospital and unit variables of missed nursing care in acute care hospitals: A cross-sectional study

AIMS AND OBJECTIVES

To investigate hospital, unit and staff variables as the correlates of missed nursing care (MNC) in Czech hospitals.

BACKGROUND

There is a considerable variability in patterns of MNC across different hospital, unit and staff characteristics.

DESIGN

A cross-sectional study was conducted. The STROBE guidelines for reporting observational studies were followed for reporting of the research study.

METHODS

A sample of 513 nurses working in nine acute care hospitals was recruited. MNC activities were measured with the MISSCARE Survey. Data were analysed using descriptive statistics and univariate logistic regression.

RESULTS

Type of unit was confirmed as a significant predictor of MNC. Staff characteristics (nurses' work position, level of education and perceived adequacy of unit staff) and hospital variables did not contribute significantly to MNC.

CONCLUSIONS

The study replicated the patterns of MNC across different conceptual approaches. MNC was influenced by work environment characteristics rather than individual staff variables.

RELEVANCE TO CLINICAL PRACTICE

The results of this research showed that missed nursing care is influenced by work environment characteristics rather than individual staff variables.

The role of teamwork in the implicit rationing of nursing care: A systematic mixed-methods review

AIM

To systematically evaluate the role of teamwork in implicit rationing care and how to improve teamwork.

BACKGROUND

The implicit rationing of nursing leads to adverse effects for both patients and nurses. Therefore, how to reduce it has attracted increasing research attention. How teamwork may be an important factor in reducing implicit rationing care has become a focus of research.

METHODS

Data between May 2000 and May 2020 were collected from five databases. The study was guided by the framework of a mixed studies review.

RESULTS

Seventeen studies were chosen for review regarding efficient teamwork to reduce implicit rationing care. The following seven subthemes with positive effects that improve teamwork and reduce implicit rationing care were formed: (a) improving knowledge and skills; (b) promoting effective communication; (c) building mutual trust; (d) reducing turnover intention; (e) reasonable staffing; (f) division of responsibilities; and (g) cultivating team consciousness.

CONCLUSIONS

Teamwork can decrease implicit care and is influenced by many factors, but the intervention is singular. In the future, teamwork can be further improved to reduce implicit care.

IMPLICATIONS FOR NURSING MANAGEMENT

With more intervention research in the future, leadership and team-oriented roles can be used to complete all the care needed.

Zwischen Anspruch und Wirklichkeit - Perspektive von fallverantwortlichen Pflegefachpersonen zur Rationierung in der spitalexternen Pflege

Between demand and reality - Perspectives of case-leading nurses on rationing in home care Abstract. Background: The demand for home care services in Switzerland (Spitex) is growing at an annual rate of 8 %. With increasingly complex client situations, lack of time and professional resources, the risk of rationing care is rising. Objective: This study explores how case-leading nurses (CLNs) experience rationing of care and how they deal with this in their daily practice. Methods: We chose a qualitative approach with an interpretative description. Between September and December 2018, we conducted semi-structured interviews with 12 CLNs from seven Spitex organisations in the German-speaking part of Switzerland. The data were analysed according to the thematic analysis of Brown and Clarke. Results: CLNs often experience not having enough time to fully oversee a client's care plan from the assessment to the evaluation of care needed. They show a high level of commitment to providing good quality of care, but have to walk a tightrope between demand and reality. Additionally, they are under pressure to defend the financing of needed services from health insurance companies. Conclusions: Rationing is an everyday experience of CLNs' practice and they invest a lot of effort in reducing its effects for their clients. CLNs work under pressure, thus targeted measures are necessary both at the political and Spitex organizational level, to reduce rationing of care.

Strategies to prevent missed nursing care: An international qualitative study based upon a positive deviance approach

AIM

To identify the strategies to prevent missed nursing care (MNC) that can be implemented by nurse managers/directors on a daily basis.

BACKGROUND

Only few recommendations have been established to date aiming at supporting nurse managers/ directors in preventing MNC. However, several strategies are implemented on a daily basis, suggesting that a body of tacit, practical and wise knowledge is already in place.

METHOD(S)

An international qualitative descriptive study based on the positive deviance approach conducted in 2019-2020 and reported according to the Consolidated Criteria for Reporting Qualitative Research. A purposeful sample of 35 nurse managers/directors working in hospitals in Cyprus, Italy, Germany and Switzerland was involved. Codes were extracted from each country, and a thematic analysis was performed at the transnational level to identify strategies and interventions preformed to prevent MNC.

RESULTS

Eight strategies and 22 interventions, mainly with preventive intent and designed at the hospital level, affecting both the processes and the structural dimensions, have been reported as effective in preventing MNC.

CONCLUSION

Nurse leaders are involved daily in implementing strategies to minimise MNC at the nursing and at the hospital system levels, integrated with each other.

IMPLICATIONS FOR NURSING MANAGEMENT

Preventing MNC should be a core value of the entire hospital, and not merely a nursing issue. Therefore, complex interventions at the system level are required.

Interventions to prevent or reduce rationing or missed nursing care: A scoping review

AIMS

To collate and synthesize published research on interventions developed and tested to prevent or reduce the rates of rationed or missed nursing care in healthcare institutions.

BACKGROUND

Rationed and missed nursing care has been widely studied, including its predictors and associations with patient and nurse outcomes.

DESIGN

Scoping review.

DATA SOURCES

We searched for eligible studies, published between 1980-2019, in six electronic databases.

REVIEW METHODS

Researchers independently screened the abstracts of the retrieved studies using the inclusion and exclusion criteria. The decision of whether or not to include any given study was consensus-based.

RESULTS

The search yielded 1,815 records, of which 13 were included. Three studies reported structural interventions, namely increased nurse staffing and improved nursing teamwork, both resulted in significant reductions in the rates of rationed or missed nursing care. The remaining 10 studies reported on process interventions: four concerned reminders (via technology or designated persons) and seven described interventions to change or optimize the relevant care processes. All 10 process interventions contributed to significant reductions in the rates of missed nursing care.

CONCLUSIONS

The results of the scoping review indicate that specific interventions can positively influence the performance of a selected nursing care activity, for example fall prevention. There is no evidence of a global reduction of rationed and missed nursing care through these interventions.

IMPACT

Clinicians, managers and researchers can use the results for adapting and implementing interventions to reduce rationed and missed nursing care.

Measurement tools used to assess unfinished nursing care: A systematic review of psychometric properties

BACKGROUND

Different tools have been developed and validated to measure unfinished nursing care. However, no systematic review of the psychometric properties has been performed describing the quality of the methods used to estimate their validity.

AIMS

(a) To identify tools measuring unfinished nursing care that have undergone validation processes; (b) to evaluate critically the quality of the methods used in ascertaining their psychometric properties; and (c) to compare the estimated psychometric properties of these tools.

DESIGN

A systematic review of the psychometric properties also evaluating their methodological quality was performed by following the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline for systematic reviews.

DATA SOURCES

The databases Medline, the Cumulative Index to Nursing and Allied Health Literature, PubMed, Google and Google Scholar were searched up to 30 June 2018.

REVIEW METHODS

Data extraction was performed following the predetermined eligibility criteria. Eight properties and their methodological quality were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments criteria.

RESULTS

A total of 20 studies reported validation data regarding three family of tools: the Missed Care Survey (MISSCARE), the Basal Extent of Rationing of Nursing Care (BERNCA) and the Task Undone scale (TU-7). The most estimated psychometric properties across studies were internal consistency, followed by structural validity, content validity, and cross-cultural validity. The less evaluated psychometric properties were reliability, hypothesis testing and convergent and criterion validity.

CONCLUSION

The psychometric properties of the investigated tools showed a more than acceptable quality, as did the methodologies used to estimate these properties.

IMPACT

The MISSCARE survey is the most widely used tool validated across countries to date. Evaluating the concurrent reliability of the tools available is strongly recommended to assess their effectiveness in measuring the same phenomenon.

The globalization of missed nursing care terminology

AIM

To determine if there are cross-national differences in nurse understandings of the terms: missed care, rationed care and care left undone.

BACKGROUND

Nurse researchers from a number of countries have published studies on missed and rationed care. It is not clear if there are differences in understanding the key terms across various language groups.

DESIGN

A mixed method questionnaire was distributed to 26 member countries of a nursing research consortium in 2017.

METHODS

Forty-five responses to a qualitative questionnaire were received; 80% were nurse researchers. These responses were categorized into language groups and analysed for congruence and differences.

FINDINGS

There was congruence across all language groups in interpreting the three terms. Giddens' theory of globalization provides an explanation for this congruence.

CONCLUSION

Shared understandings are explained by the fact that the majority of participants are nurse researchers with knowledge of English and the research literature. Shared understanding within the globalized academic community does not necessarily translate for clinical or nurse managers, nor does it predetermine solutions.

Depicting clinical nurses' priority perspectives leading to unfinished nursing care: A pilot Q methodology study

AIMS

To highlight (a) trends common to all nurses on priorities attributed to interventions, and (b) whether there are profiles of nurses working in the same context who prioritize interventions in a similar way.

BACKGROUND

The underlying prioritization of interventions leading to unfinished nursing care has been minimally investigated.

METHODS

A 2017 pilot Q methodology study. Full-time nurses, with at least 6 months of experience in a surgical unit, were involved. Eleven nurses rated the priority given in daily practice (from -3 as the lowest to +3 as the highest) to 35 Q-sample statements representing nursing care, non-nursing and organisational interventions.

RESULTS

Overall, the intervention receiving the lowest priority was 'Providing patient hygiene', while the highest was 'Answering phone calls'. In the by-person factor analysis (total variance = 60.79%), three profiles of nurses emerged, (a) 'Patient safety-oriented' (variance = 31.66%); (b) 'Nursing task-oriented' (=16.32%); and (c) 'Team process-oriented' (=12.81%).

CONCLUSIONS

Three profiles of nurses emerged in the same setting with significant differences both in the statistical order of priorities and in their practical implications.

IMPLICATIONS FOR NURSING MANAGEMENT

Understanding levels of prioritization, which are not only affected by the unit but also by sub-groups of nurses who rank priorities in a similar way, can support nurse managers in their role.

Optimistic thinking, satisfaction with life and job and nursing care rationing: Multicentre study in Poland

AIMS

The aim was to examine whether the level of optimism and job and life satisfaction is a differentiating factor from the level of implicit rationing of nursing care in a sample of Polish registered nurses.

BACKGROUND

Satisfaction with life and job is reflected by greater effectiveness of nurses at work and creates a positive work environment, which in turn may modulate the level of implicit rationing of nursing care.

METHODS

A cross-sectional multicentre research design was adopted, employing a representative sample of 1,010 registered Polish nurses identified between the beginning of January and the end of June 2019. Four self-report scales were used in this study: Basel Extent of Rationing of Nursing Care, Satisfaction with Life Scale, Satisfaction with Job Scale and Life Orientation Test-Revised. The results were analysed using the k-means method, Student's t test and two-way ANOVA.

RESULTS

Optimistic thinking, and satisfaction with job and life exerted a significant effect on the level of implicit rationing of nursing care among Polish nurses. Nurses from the group 'pessimistic' were at higher risk of nursing care rationing than those from the group 'optimistic'.

CONCLUSION

Strengthening of the personal competencies, providing support and responding to all identified needs might increase job satisfaction of nurses and hence reduce the risk of nursing care rationing.

IMPLICATIONS FOR NURSING MANAGEMENT

Leadership modelling and training in positive thinking might be the methods to support nurses and to prevent nursing care rationing.

Analyzing the Job Demands-Control-Support Model in Work-Life Balance: A Study among Nurses in the European Context

The balance of personal life with professional life is a topical issue that is increasingly worrisome due to globalization, the rapid introduction of new technologies into all areas of human life, the overlap between time between work and family, new organizational systems, and changes in the nature of work. This problem is accentuated by professions subjected to intense labor demands, as is the case of nurses. Adopting the Job Demand–Control–Support model, the main purpose of this research is to analyze how these factors lead to a greater or lesser degree of work–life balance. The research proposes a logistic regression model, which was constructed with a sample of 991 nursing professionals from the V European Working Conditions Survey. The results obtained confirm, on the one hand, that there is a significant effect of physical demands (but not psychological demands) on work–life balance. On the other hand, the moderating effects of job control are partially confirmed for psychological demands, and those of supervisor support (but not co-worker support) are partially confirmed for physical demands. In conclusion, the present research shows that effective management of nurses’ work context can decisively contribute to finding the difficult balance between personal and professional time.

The association of nurse caring behaviours on missed nursing care, adverse patient events and perceived quality of care: A cross-sectional study

AIM

This study evaluated the role of nurse caring in predicting missed nursing care, adverse patient events and the quality of nursing care.

BACKGROUND

Missed nursing care is an issue essential in health care, as it is associated with adverse patient events. While studies have previously examined factors that result in missed nursing care activities and adverse events, the role of nurse caring itself in this context has not yet been explored.

METHODS

A cross-sectional research design was adopted, employing a convenience sample of 549 registered nurses from six hospitals in the Philippines identified between October 2018 and January 2019. Four self-report scales were used in this study as follows: the caring behaviour inventory, the missed nursing care scale, the adverse patient events scale and a single-item scale to measure the quality of nursing care.

RESULTS

Comforting or talking with patients and changing patients' positioning in bed were the most frequently missed care tasks, while patient/family complaints and patient/family verbal abuse were the most frequently reported adverse events. Nurse caring strongly predicted the quality of care, missed nursing care and patient adverse events.

CONCLUSION

Fostering caring behaviours among nurses has a profound effect on nurses' decision to omit or provide nursing care as well as on reducing adverse events and promoting quality nursing care.

IMPLICATIONS FOR NURSING MANAGEMENT

The adoption of strategies to improve caring behaviours among nurses is critically important to prevent or reduce the occurrence of errors and adverse events.

A revised MISSCARE survey: Results from pilot testing

BACKGROUND

Missed nursing care has been recognized as a universal patient care issue that affects outcomes for patients, nurses, and healthcare institutions. The MISSCARE Survey was developed to measure and determine the reasons for missed nursing care episodes. An extensive literature review and expert nurse opinion revealed five additional reasons for missing care that the authors utilized to revise the Survey.

METHODS

The revised MISSCARE Survey was pilot tested with a group of 145 nursing staff from a public, non-profit, acute care hospital in the Midwestern U.S.

RESULTS

Analysis indicated favorable results for the revised Survey's acceptability, reliability, and construct validity.

CONCLUSION

Based on the initial pilot study results, the authors recommend further use and study of the revised MISSCARE Survey with other nursing populations and additional psychometric testing.

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.

Validation of Polish version of the Basel Extent of Rationing of Nursing Care revised questionnaire

Development of simple, valid and reliable instruments to determine nursing care rationing is a subject of ongoing research. One such instrument, which is gaining popularity worldwide and has significant research applicability, is the Basel Extent of Rationing of Nursing Care (BERNCA) and its revised version, the BERNCA-R. The aim of this study was to translate and adapt the BERNCA-R into a Polish-language version and to assess its reliability and validity in evaluating the level of implicit rationing of nursing care in Poland. Standard methodological requirements were followed during translation and cultural adaptation of the English version of the BERNCA-R questionnaire into Polish. The cross-sectional validation study was conducted between May and September 2017, which included 175 nurses undergoing specialisation and qualification courses at the European Postgraduate Education Centre in Wrocław, Poland. Cronbach’s alpha and inter-item correlations were used to analyse the internal consistency of the Polish BERNCA-R questionnaire. The mean total BERNCA-R score was 1.9 points (SD = 0.74) on a scale of 0–4. Cronbach’s alpha for the unidimensional scale was 0.96. The mean inter-item correlation was 0.4 (range 0.1–0.84), which indicates high internal consistency. A single-factor solution demonstrated stable loadings above 0.5 for almost all items of the Polish BERNCA-R questionnaire. The study using the Polish BERNCA-R questionnaire demonstrated that the instrument is valid and reliable for use in investigating care rationing in groups of Polish nurses.

The effect of a teamwork intervention on staff perception of teamwork and patient care on a medical surgical unit

As a result of the ever-changing health care environment and patient complexity, it is difficult for nursing teams to provide safe quality care and complete all tasks, also known as missed nursing care. Missed nursing care is a global health care issue and defined as any aspect of care missed in part, in whole, or delayed. Teamwork has been found to not only positively impact the performance of a team, but also patient outcomes. Teamwork strategies are needed to help nursing teams provide the best care to their patients. Inpatient nursing teams work in complex environments and handle many patient issues making it difficult to find one workable solution. The purpose of this study was to determine if a teamwork intervention would impact the nursing team's perception of teamwork and missed nursing care on a medical surgical unit. In this quasi-experimental design study there was an increase in both teamwork and missed nursing care pretest and posttest survey scores. Despite the increase not being statistically significant, based on the staff feedback, the intervention shows promise to be a viable teamwork strategy. Future studies should include larger sample size and longer duration.

Description and Factors Associated With Missed Nursing Care in an Acute Care Community Hospital

OBJECTIVE

The aims of this study are to describe and evaluate the factors associated with missed nursing care in an acute care community hospital.

BACKGROUND

Despite RNs' accountability for high-quality patient care in hospitals, missed nursing care is widespread, jeopardizing patient safety and health system costs. Better understanding of the factors associated with missed nursing care may provide nurse leaders with opportunities for improvement.

METHODS

Using a cross-sectional correlational study design, 138 RNs were randomly sampled during May-June 2017.

RESULTS

The extent of missed nursing care is consistent with other studies, was greater on medical-surgical and telemetry units compared with specialty units, and was negatively associated with staffing/resources, satisfaction with current position, and collegial nurse-physician relationships.

CONCLUSION

Findings suggest urgent nurse leader action and future research.

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.

Resource allocation and rationing in nursing care: A discussion paper

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.

Association of the Nurse Work Environment, Collective Efficacy, and Missed Care

Missed nursing care is a significant threat to quality patient care. Promoting collective efficacy within nurse work environments could decrease missed care. The purpose was to understand how missed care is associated with nurse work environments and collective efficacy of hospital staff nurses. A cross-sectional, convenience sample was obtained through online surveys from registered nurses working at five southwestern U.S. hospitals. Descriptive, correlational, regression, and path analyses were conducted ( N = 233). The percentage of nurses who reported that at least one care activity was missed frequently or always was 94%. Mouth care (36.0% of nurses) and ambulation (35.3%) were missed frequently or always. Nurse work environments and collective efficacy were moderately, positively correlated. Nurse work environments and collective efficacy were associated with less missed care (χ² = 10.714, p = .0054). Fostering collective efficacy in the nurse work environment could reduce missed care and improve patient outcomes.

Equity in nursing care: A grounded theory study

BACKGROUND:

Equity in providing care is also a major value in the nursing profession. Equitable care aims to provide the entire population with safe, efficient, reliable, and quality nursing services at all levels of health.

OBJECTIVES:

This study was conducted to explain the process of the realization of equity in nursing care.

RESEARCH DESIGN:

This qualitative study uses Glaser's approach to grounded theory.

PARTICIPANTS AND RESEARCH CONTEXT:

Sample selection began with convenience sampling and continued with purposive sampling. A total of 27 people were ultimately selected as the study subjects. Data were mainly collected through unstructured in-depth individual interviews plus observation and field notes. The data were then analyzed using the "Six C's" coding family of Glaser.

ETHICAL CONSIDERATIONS:

The study protocol was approved by the Tehran University of Medical Sciences (91D1302870). Written informed consent was also obtained from all subjects.

FINDINGS:

According to the findings, participants' main concern in providing equitable care is the rationing of nursing care. The identification of participants' main concern led to the emergence of the core category of the study, that is, "nurses' domination." The other categories revolving around the core category were conceptualized according to the six C's coding family: "nurses being dominated," "nurses' ineffective power in the health system," "low attention to equitable care in health system," "lack of clarity in measuring equitable care," "the health structure's inconsistency with equity," and "the inefficiency of the care system."

CONCLUSION:

There is a mutual relationship between providing fair care and nurses' perceptions of equity. Nurses who have themselves experienced equity can provide their patients the experience of equity. This mutual relationship is actualized in a context in which fair care is clearly defined and demanded.

Improving Compliance in Obtaining Daily Weights in a Large Academic Children's Hospital

Noncompliance in obtaining daily weights leads to delays in establishing treatment and discharge plans in pediatric populations. An inpatient gastrointestinal and endocrine nursing unit aimed to increase compliance of obtaining daily weights from baseline of 38% to 80%. The time daily weights were obtained was changed from 8 AM to an interval of time 4 PM to 6 PM. The compliance rate increased to 96% and has been sustained at an average of 94% over 24 months. This report describes a low-risk intervention that took minimal effort to implement but yielded high results to exceed the goal.

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.

Nurses' oral hygiene care practices with hospitalised older adults in postacute settings

AIM AND OBJECTIVE

The purpose of this study was to explore how nurses provide bedtime oral hygiene care, how they decide on interventions provided, and what factors influence their ability to provide oral care.

BACKGROUND

Current evidence links poor oral hygiene to systemic and infectious diseases such as pneumonia. Hospitalised patients, who now retain their teeth into older adulthood, often rely on nurses to provide oral hygiene care. Nurses have the potential to impact oral health outcomes and quality of life by controlling plaque. However, oral hygiene care practices of nurses in postacute hospital settings are relatively unknown.

DESIGN

A qualitative, exploratory multiple-case study was conducted with 25 nurses working on five inpatient units at different hospitals.

METHODS

Nurses were accompanied on their evening rounds to observe oral care practices, the physical environment and workflow. Thematic analysis was used to analyse the case study data including transcripts of guided conversations, field notes and documents. Within-case analysis was followed by cross-case analysis.

RESULTS

Findings indicate that (i) nurses often convey oral hygiene care to their patients as being optional; (ii) nurses are inclined to preserve patient autonomy in oral hygiene care; (iii) oral hygiene care is often spontaneous and variable, and may not be informed by evidence; and (iv) oral hygiene care is not embedded into bedtime care routines.

CONCLUSIONS

Oral hygiene care is discretionary and often missed care.

IMPLICATIONS FOR PRACTICE

Nurses need knowledge of the health benefits of oral care, and skills related to assessment and approaches to oral care. Availability of effective products and supplies facilitates provision of oral care. The evidence for oral hygiene care practices, outcomes of nurse-administered oral care and nursing's role in influencing the oral health literacy of patients require further study.

Unmet Nursing Care Linked to Rehospitalizations Among Older Black AMI Patients: A Cross-Sectional Study of US Hospitals

BACKGROUND

Recent studies suggest that nurses may be unable to complete all aspects of necessary care due to a lack of time. Research is needed to determine whether unmet nursing care contributes to disparities in readmissions for vulnerable populations.

OBJECTIVES

To examine differences in the relationship between nursing care left undone and acute myocardial infarction readmissions among older black patients compared with older white patients.

RESEARCH DESIGN

Cross-sectional analysis of multiple datasets, including: 2006 to 2007 administrative discharge data, a survey of registered nurses, and the American Hospital Association Annual Survey. Risk-adjusted logistic regression models were used to estimate the association between care left undone and 30-day readmission. Interactions were used to examine the moderating effect of care left undone on readmission by race.

RESULTS

The sample included 69,065 patients in 253 hospitals in California, New Jersey, and Pennsylvania. Older black patients were 18% more likely to experience a readmission after adjusting for patient and hospital characteristics and more likely to be in hospitals where nursing care was often left undone. Black patients were more likely to be readmitted when nurses were unable to talk/comfort patients [odds ratio (OR), 1.09; 95% confidence interval (CI), 1.01-1.19], complete documentation (OR, 1.16; 95% CI, 1.01-1.32), or administer medications in a timely manner (OR, 1.26; 95% CI, 1.09-1.46).

CONCLUSIONS

Unmet nursing care is associated with readmissions for older black patients following acute myocardial infarction. Investment in nursing resources to improve the delivery of nursing care may decrease disparities in readmission.

Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals

BACKGROUND

As nurses are the principal care provider in the hospital setting, the completion or omission of nursing care is likely to have a sizable impact on the patient care experience. However, this relationship has not been explored empirically.

AIM

To describe the prevalence and patterns of missed nursing care and explore their relationship to the patient care experience.

METHODS

This cross-sectional study used secondary nurse and patient survey data from 409 adult non-federal acute care US hospitals in four states. Descriptive statistics were calculated and linear regression models were conducted at the hospital level. Regression models included controls for hospital structural characteristics.

RESULTS

In an average hospital, nurses missed 2.7 of 12 required care activities per shift. Three-fourths (73.4%) of nurses reported missing at least one activity on their last shift. This percentage ranged from 25 to 100 across hospitals. Nurses most commonly reported not being able to comfort or talk with patients (47.6%) and plan care (38.5%). 6 out of 10 patients rated hospitals highly. This proportion ranged from 33% to 90% across hospitals. At hospitals where nurses missed more care (1 SD higher=0.74 items), 2.2% fewer patients rated the hospital highly (p<0.001); a coefficient equivalent to a one-quarter SD change.

CONCLUSIONS

Missed nursing care is common in US hospitals and varies widely. Most patients rate their hospital care experience highly, but this also varies widely across hospitals. Patients have poorer care experiences in hospitals where more nurses miss required nursing care. Supporting nurses' ability to complete required care may optimise the patient care experience. As hospitals face changing reimbursement landscapes, ensuring adequate nursing resources should be a top priority.

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.

The ethical dimension of nursing care rationing: A thematic synthesis of qualitative studies

BACKGROUND

In the face of scarcity, nurses may inevitably delay or omit some nursing interventions and give priority to others. This increases the risk of adverse patient outcomes and threatens safety, quality, and dignity in care. However, it is not clear if there is an ethical element in nursing care rationing and how nurses experience the phenomenon in its ethical perspective.

OBJECTIVES

The purpose was to synthesize studies that relate care rationing with the ethical perspectives of nursing, and find the deeper, moral meaning of this phenomenon.

RESEARCH DESIGN

A systematic review and thematic synthesis of qualitative studies was used. Searching was based on guidelines suggested by Joana Brigs Institute, while the synthesis has drawn from the methodology described. Primary studies were sought from nine electronic databases and manual searches. The explicitness of reporting was assed using consolidated criteria for reporting qualitative research. Nine studies involving 167 nurse participants were included. Synthesis resulted in 35 preliminary themes, 14 descriptive themes, and four analytical themes (professional challenges and moral dilemmas, dominating considerations, perception of a moral role, and experiences of the ethical effects of rationing). Discussion of relationships between themes revealed a new thematic framework.

ETHICAL CONSIDERATION

Every effort has been taken, for the thoroughness in searching and retrieving the primary studies of this synthesis, and in order for them to be treated accurately, fairly and honestly and without intentional misinterpretations of their findings.

DISCUSSION

Within limitations of scarcity, nurses face moral challenges and their decisions may jeopardize professional values, leading to role conflict, feelings of guilt, distress and difficulty in fulfilling a morally acceptable role. However, more research is needed to support certain relationships.

CONCLUSIONS

Related literature is limited. The few studies found highlighted the essence of justice, equality in care and in values when prioritizing care-with little support to the ethical effects of rationing on nurses. Further research on ethical dimension of care rationing may illuminate other important aspects of this phenomenon.