Missed nursing care and related factors: a cross-sectional study

Abstract

Background

Nurses facing numerous responsibilities in hospitals are often forced to prioritize nursing care. Missed nursing care affects nurses’ ability to effectively manage, oversee, and assess patient care interventions and may contribute to unfavorable patient outcomes. Awareness of missed nursing care is essential for improving patient care and nursing performance and optimizing the work environment. Research on the factors contributing to missed nursing care is essential for implementing targeted strategies. This study aimed to determine missed nursing care and its related factors in Iran.

Methods

This cross-sectional study involved 189 nurses. Two questionnaires on missed nursing care and related factors were used for the data collection. Mann-Whitney U test and one-way ANOVA or Kruskal-Wallis test were used to analyze the data.

Results

The mean (SD) of nurses’ age was 31.19 (6.4). The mean of missed nursing care was 6.4 (SD = 31.1), which was higher than the median of the questionnaire. The most frequently reported missed care was toilet monitoring (23.3%) and setting up food (19.6%). The total mean score of factors related to missed nursing care was 11.6 (SD = 68.7), which was lower than the median of the questionnaire. The factors related to missed nursing care included engaging the nurse with other actions (76.7%) and an inadequate number of staff (76.2%). There was a significant association between the mean MNC score and participants’ age (P < 0.001), work experience (P = 0.002), and employment type (P < 0.001).

Conclusion

Given the severe nursing shortage and its potential negative impact on patients, healthcare management and policymakers need to address missed nursing care. Proposed solutions to alleviate the nursing staff shortage include enhancing the work environment, increasing nurse recruitment opportunities, and improving their compensation and benefits packages. Additionally, there is a need for governmental and hospital initiatives to enhance the working conditions through increased financial investment and support programs for nurses. Management should focus on minimizing nurses’ non-essential responsibilities and supporting efforts to reduce missed nursing care occurrences.

Introduction

In healthcare settings, nurses serve as the initial point of contact, fulfilling multiple roles including care planning, coordination, delivery, and assessment [1]. Quality nursing care is the nurse’s response to the physical, psychological, emotional, social, and spiritual needs of patients so that they can return to their healthy and normal lives and satisfy both patients and nurses [2]. Appropriate nursing care should include safe, effective, patient-centered, timely, efficient, and equitable care [3].

Missed nursing care (MNC) is a concept, which was originally identified by Kalisch et al. [4]. refers to omitting or delaying the necessary nursing interventions that connect nursing staff performance to patient-related outcomes [5, 6]. It is characterized as a failure or negligence in care that could potentially jeopardize a patient’s well-being, as defined by international standards for patient safety and care quality [7]. Various concepts has been used such as ‘nursing care left undone’ [8], ‘unmet nursing care needs’ [9], ‘care left undone’ [10], and ‘implicit rationing of nursing care’ [11] in this line of research. Research indicates that a minimum of 75% of nurses have encountered instances of missed care [12]. A study conducted in a UK hospital revealed that 86% of nurses reported omitting at least one of 13 nursing care tasks due to time constraints during their work shifts [13]. The outbreak of MNC varies with the type of nursing care activity. In the studies conducted, care such as delaying the patient’s medication for more than 30 minutes, mouth care, changing the patient’s situation, monitoring the patient’s toilet, and attending in-ward sessions were identified as the most MNC [14,15,16]. Certainly, there are factors involved in the incidence of MNC related to humans, communication, and financial resources [17]. The results of these studies have reported factors such as unexpected increase in the volume of admission and discharge of patients, staff shortages, lack of availability of medicines and emergencies, high workloads, and attending some nurses in non-nursing affairs, having multiple jobs, shortages and defective equipment [1, 15, 18,19,20]. MNC can reduce patient safety and lead to adverse events such as medication errors, falls, infection, pressure ulcers, prolonged hospitalization, decreased satisfaction, delayed hospital discharge, and mortality [21,22,23]. In addition MNC affects human resources and healthcare including increased conflict and in the work environment, increased workload pressure on nurses, decreased job satisfaction among nurses, and an increased propensity to leave the profession [24, 25]. These complications are catastrophic and costly for hospitalized patients, individuals, hospitals, and the community. Studies have shown that attention to workload, organizational priorities, and communication is associated with reduced numbers of MNC [26]. Strengthening caring behaviors among nurses has a great impact on their decision to eliminate MNC, reduce side effects, and improve the quality of nursing care [27]. Therefore, given the significance of providing accurate and comprehensive nursing care in the process of patient recovery and treatment, as well as the limited research conducted in the field of missed nursing care in Iran, and considering the importance of planning to mitigate missed nursing care without understanding the factors influencing it. The primary objectives of this study were to determine the missed nursing care and its related factors. The secondary objective of the study was to determine the most frequently missed nursing care and its related factors according to the relevant dimensions.

The findings of this study can contribute to further research in this field and can also be utilized to develop strategies to reduce missed nursing care.

Methods

Study design and setting

The present study is a cross-sectional study. The study population consisted of nurses working in hospitals in Sirjan City (Imam Reza and Gharazi) in 2023. The two hospitals have general and specialized wards, which in total the number of beds in these two hospitals is 428 beds. Sirjan is the second most populous city in Kerman Province in southeastern Iran. Kerman is the largest province in Iran in terms of its area.

Sample size and sampling

The study population consisted of 382 nurses working at two hospitals in Sirjan City (Imam Reza and Gharazi). The number of nurses in Imam Reza Hospital was 242, and in Dr. Gharazi Hospital was 140. The sample size was identified to be 189 (Imam Reza (n = 119) and Dr. Gharazi (n = 70)) using the following sample size determination formula through a stratified random sampling method to ensure the representativeness of the sample. (Z = 1.96, σ = 0.505, d = 0.1σ) [19].

To this end, the researcher first estimated the number of samples needed from each ward according to the ratio of the number of nurses in the ward to the total sample size required. The required number of samples was then recruited from each ward using a random number table.

Of the 231 eligible nurses, 23 refused to participate. A total of 208 people returned completed questionnaires. Of these, 19 were excluded because they had filled out the questionnaires incompletely, and finally 189 questionnaires were finally analyzed. Reponse rate was 81.8%.

The inclusion criteria were having a bachelor’s degree in nursing or higher, having at least six months of nursing experience, and consent to participate in the research. Nurses were excluded if they withdrew from the study while completing the questionnaires, or if they answered the questionnaires incompletely.

In Iran, nurses working in hospitals have bachelor’s degrees in nursing and above. In addition, nursing assistants perform auxiliary tasks (other than professional nursing tasks). For this reason, nurses with a bachelor’s degree or higher were considered in this study.

Data collection

The data were collected from July 10 to September 10, 2023. Prior to the study, permission for data collection was obtained from selected hospital officials. Participation in the research was optional, and completing the full questionnaire was considered satisfactory. To adhere to the codes of ethics in the research, the names and surnames were not asked in the questionnaires. The confidentiality of the information was explained. After explaining the objectives of the study and accepting to attend, the questionnaire was given to the study participants in the hospital environment, and they were asked to complete the questionnaire at the end of the work shift and deliver it to the researcher.

Measurement

The tools used in this study were as follows:

• 1. The demographic and professional profile form included age, gender, marital status, educational degree, shift work, ward, work experience, and type of employment.

• 2. Missed Nursing Care Questionnaire (MISS CARE): This questionnaire was prepared by Kalisch in 2006 and was psychoanalyzed by the same author in 2009 [4, 28]. This questionnaire has been used in several studies and includes 24 items, such as patient movement, turning, assessment, teaching, discharge planning, and drug prescription [29]. For each item, four options were designed in a Likert format: “I rarely forget” score 1, “sometimes I forget” score 2, “I often forget” score 3 and “I always forget” score 4. The highest score was 96 and the lowest score was 24. A higher score indicates a higher possibility of forgetting care. This questionnaire has four subscales: assessment, individual needs interventions, basic needs interventions, and planning [30].

• 3. Questionnaire on factors related to missed care: This tool was designed in 2014 by Blackman et al. in Australia. This 17-item questionnaire includes three subscales: human resources, material resources, and communication “ [31]. In the study by Khajooee et al. [32], three items were added to this questionnaire, considering the differences in the nursing system in Iran, and a questionnaire with 20 items based on the Likert scale was considered insignificant (1), low significance (2), moderate significance (3), and highly significant (4). The highest score was 80, and the lowest score was 20, with a higher score indicating that the factor is related to missed care.

The validity of the questionnaires was evaluated by Khajooee et al. (2019). The content validity index for the missed nursing care questionnaire and its related factors was estimated 0.99 be 0.98, respectively [32]. In this study, the reliability of the Missed Nursing Care Questionnaire and its related factors was calculated using Cronbach’s alpha coefficient, which was 0.86 and 0.91, respectively.

Pilot study

A Pilot study was conducted to examine the tool’s readability, validity, and reliability. The process began with nursing experts assessing the questionnaire’s content validity. The survey was then administered to 23 nurses in a general hospital, with these responses later omitted from the final analysis. After this initial assessment, revisions were made to improve clarity, and the questionnaire was re-evaluated with the same group of nurses four weeks later. Test-retest stability for the two subscales fell between 0.78 and 0.83 (p < 0.001). The questionnaire’s internal consistency, measured by Cronbach’s alpha, was 0.86 for the first part (missed care) and 0.91 for the second part (reasons for missed care).

Data analysis

Descriptive statistics for categorical and continuous variables were presented as number (percent) and mean (standard deviation). The Shapiro-Wilk test was used to assess the normality and Levene test for equal variances of quantitative data. A Mann-Whitney U and One-way ANOVA or Kruskal-Wallis test were used to analyze the data. Two-sided significance was determined for all statistical tests and p < 0.05 was considered as statistically significant. All statistical analyses were performed using the Statistical Package of Social Science (IBM SPSS Statistics 19, New York, NY, USA). There was minimal missing data in this study; however, the approach of this study to missing data was to remove cases with missing data and analyze the remaining data.

Results

Most of the nurses (83.5%) were female, married (76.3%), with a bachelor’s degree (95.2%), in a nurse position (94.7%), in formal employment (52.9%), and in a rotating shift (86.8%). Of the nurses, 55.1% were in the range of 20–29 years. The highest percentage (52.9) of nurses had < five years of experience and worked in intensive care units (42.9%). The results indicated a significant association between the mean MNC score and participants’ age (P < 0.001), work experience (P = 0.002), and employment type (P < 0.001). The Mann-Whitney U test with Bonferroni correction revealed significant differences in MNC scores between the following groups: participants aged 20–30 years and those aged 30–40 years (P < 0.001) and over 40 years (P = 0.044); individuals with 0–5 years of work experience and those with 10–15 years (P = 0.011) and over 15 years (P = 0.024); and nurses with committed versus official employment (P < 0.001). The nurses’ demographic characteristics are presented in Table 1.

Table 1 The relationship between demographic characteristics with the mean score of MNC and RMNC

The percentages of responses for each nursing care element from the MISSCARE survey (MNC) are shown in Table 2. The findings of this study showed that the highest mean score of missed nursing care was for toilets within 5 min (23.3%) and setting up food (19.6%). The missed care elements reported as rarely missed were the assessment of each shift (94.7%) and IV site care (94.7%).

Table 2 Frequency of missed nursing care

The overall MNC score was 31.1 (SD = 6.4). Findings related to missed nursing care subscales showed that the highest mean was basic need interventions 1.5 (SD = 0.4), followed by individual need interventions 1.3 (SD = 0.4); planning 1.3 (SD = 0.4), and assessment 1.1 (SD = 0.2); basic need interventions and planning subscale scores initially showed statistical differences. Individual items and subscale scores are shown in Table 3. According to the One-way ANOVA test, the differences in the mean scores of the four scales of assessment, individual need interventions, basic need interventions, and planning were statistically significant (P < 0.001, F = 29.45). According to the Tukey test, this difference between all pairs of scales except basic need interventions and planning (P = 0.962) was statistically significant (P < 0.001).

Table 3 The mean (SD) of the most missed nursing care

Factors related to missed nursing care

The percentage of responses for each factor related to missed nursing care is shown in Table 4. Engaging nurses with other actions (76.7%) and an inadequate number of staff (76.2%) were reported as the most significant factors for missed care, and tension with medical staff (7.4%) and the caregivers off-unit/unavailable (6.9%) were reported as the least important factors for missed nursing care.

Table 4 Frequency of factors related to missed nursing care

The overall RMNC score was 68.7 (SD = 11.6). Findings related to the subscales of factors related to missed nursing care showed that the highest mean subscale scores were Labor resources 3.6 (SD = 0.5), 3.4 (SD = 0.7) and Communication 3.3 (SD = 0.8), respectively. The material and labor resources subscale scores initially showed statistically significant differences. The individual items and subscale scores are shown in Table 5.

Table 5 Mean (SD) of most factors related to missed nursing care

According to one-way ANOVA test, the differences in the mean scores of the three scales of communication, material resources, and labor resources were statistically significant (P = 0.001, F = 6.59). According to Tukey test, this difference between the pairs of communication and material resources scales (P = 0.023) and communication and labor resources (P = 0.002) was significant, but the difference between the mean score scales of material resources and labor resources scales was not statistically significant (P = 0.691).

Discussion

The findings of the present study showed that the highest frequency of MNC was allocated to setting up food and toilets within five minutes. In addition, IV-site care and assessment of each shift were identified as the least missed care.

In the present study, care related to monitoring nutrition and patient excretion were among the most MNC, which was consistent with the results of Kalisch (2006), Moreno (2015), Winsett (2016), and Khajoui et al. (2019) [4, 15, 32, 33]. Although nutrition and excretion are basic human needs, and meeting them should be prioritized, they have been missed more than any other care, and it is likely that doing more vital work that endangered the patient’s life had a high priority. Consequently, nurses’ engagement in these vital activities had an impact on their ability to provide other forms of care.

One other reason why this care is missed is that it is usually provided by the patient’s family. These findings suggest that nurses’ responses to missed care may reflect their perceptions of the scope of their responsibility for nursing care and that those perceptions are shaped by their health care system (e.g., skill mix) and culture (e.g., family caregiving) [21].

Regarding toilet monitoring, excretion disorders are one of the most common problems faced by hospital patients. Patients may also lose the ability to walk and use the toilet due to illness, injury, or surgery and may need the assistance of a nurse to defecate. Therefore, it is essential that nurses have the necessary knowledge and supervision in the field of excretion disorders in patients and the methods of using assistive devices applied in excretion and going to the toilet of the patient [34].

IV site care was the least missed care, which was consistent with the results of studies by Blackman (2015), Winsett (2016), Smith (2018) and Kalisch (2011) [15, 35,36,37]. The frequent examination of the venous injection site by nurses is probably the reason for fewer missing IV site care. According to existing protocols, the injection and drug therapy sites are controlled by the relevant nurse in terms of proper functioning and examination of any problems at the beginning and end of each shift. Nurses used the TLC method (TOUCH, LOOK, COMPARE) to control the IV site of patients. In addition, the IV injection site was recontroled before each fluid and drug injection procedure. Patients are also sensitive to this and inform the nurse when they encounter the slightest problem at the site of intravenous injection, which in turn helps nurses not to forget (miss) this care. Another reason for the lack of missing care could be the existence of a precise system for recording these cases in the file and daily chart of each patient, which helps staff remind them of doing this care. The accurate documentation system of patient information and the attention paid in this field also have a significant effect on the accreditation of hospitals. A low level of missed care for these care providers is expected. In addition, cases that were less missed are vital for the patient, and on the other hand, each shift is obliged to deliver such information to the next shift.

The results showed that the most important factors related to MNC were engaging nurses in other actions and an inadequate number of staff items. The least important factors were the caregiver off unit/unavailable and tension with medical staff.

In this study, nurses’ participation in other tasks was the most important factor related to missed care. Bekker et al. (2015) found that professional nurses conduct many non-nursing tasks, leaving several important nursing tasks undone [38]. Nurses are forced to perform tasks such as ordering medicines, setting up and delivering diets, and checking the operation of equipment and supplies, which are not part of nurses’ main care. Bekker et al. (2015) believe that non-nursing tasks, including carrying and receiving food trays, patient transportation, order supply, equipment supply, patient transfer and discharge coordination, and office tasks, can lead to missed important care activities. These non-nursing tasks lead to missed nursing tasks [38].

In the present study, as in similar studies, staff shortage is recognized as a factor in justifying missed care [26, 28, 32], In the studies by Kalish et al. (2011) and Dehghan-Nayeri et al. (2015), the reduction of manpower was also associated with an increase in missed care [14, 20]. Research has indicated that a lack of nursing staff hinders healthcare efficiency and quality [39,40,41]. In Iran, however, the primary reasons for the nursing shortage are diverse, including poor social recognition, occupational injuries, premature retirement, emigration, desire to change careers, pursuit of alternative professions, domestic responsibilities, low recruitment rates, and an expansion in the number of hospital beds [42]. Hernández (2014) writes in his study that’ missed nursing care mostly happens when there is an increase in task demand and the nurse is unable to meet this demand. A lack of human resources has the strongest impact on creating missed care [17]. Kalisch (2011) writes in a study:” an increase in manpower has led to decrease missed nursing cares and reducing such cares has been effective in reducing mortality, infection, pressure wound and falling down of patient from the bed. In many cases, these complications lead to longer hospital stay and increased patient costs. Increasing the workload of nurses (especially factors related to unbalanced tasks and inadequate support staff) also seems to be an important factor in creating missed nursing care [14]. Addressing the nursing shortage in Iran requires prioritizing improvements to the work environment, although current proposed strategies do not emphasize this approach. The second method suggested for tackling this issue in Iran involves increasing the number of nurses hired. However, due to the country’s centralized management structure, there are constraints on the recruitment process [43].

The results of this study showed a significant relationship between missed care and age, work experience, and employment type. Thus, nurses with less than five years of work experience and nurses between the ages of 20–30 years had more missed care. The characteristics of age and work experience are consistent with those reported by Christopher et al. (2013) [44]. Also, in the study of Kalish et al. (2011), the work experience of nurses was identified as one of the important predictors of missed care [14]. These results were also related to those of Kalish et al. (2010) in terms of work experience but were contradictory in terms of age [45]. In general, it can be said more cares is missed by nurses with less work experience and younger age. People with less work experience may not yet have adequate mastery of all the work in the ward, and sometimes they may be asked for non-nursing work due to their low work experience, or because of their low work experience and less working age, they may be given more responsibilities and tasks that each of these factors can lead to missing care. Project nurses (unemployed) also had more missed care than other nurses. A similar study was not found in this field, but the findings of the study by Dashti et al. (2019), which examined nurses’ reporting of medication errors, reported that the rate of medication errors in project nurses was higher. Nurses who work on the project are often novices, and at the beginning of the work, due to a lack of experience, they face problems that may affect how they work, including missing care. It should be noted that in Iran, graduate nurses are required to serve in public hospitals for one year prior to employment [46]. This in itself can be a justification for the existence of a significant relationship between work experience, age, and project nurses in that all three variables are related to each other.

This study underscores the critical need to address missed nursing care in Iranian hospitals. Hospital administrators should focus on enhancing interteam and interdepartmental communication. Modifications are necessary for task allocation and nursing compensation. Moreover, nursing supervisors can positively motivate their staff to minimize or prevent care omissions by fostering an organizational culture that values transparency and personal responsibility, while maintaining a non-punitive atmosphere. Recognizing how the identified factors contributing to missed care relate to actual healthcare scenarios will enable practitioners to create targeted solutions. By drawing practical implications for nursing practices, this research serves as a crucial resource for healthcare professionals aiming to enhance the quality of patient care.

Further research is needed to explore the underlying causes of missed nursing care and appropriate policies should be developed to improve hospital nursing care.

Limitations

The generalizability of the results may be impacted by variations in workload across medical surgical wards, special units, and emergency departments when determining sample size. Additionally, the study’s external validity is constrained by data collection from only two Iranian hospitals. The research relied on nurses’ self-reported information for all primary variables, rather than employing direct observation techniques. Consequently, like all survey-based studies, there is a possibility of response bias and social desirability bias.

Additional research is necessary to evaluate the consequences of missed care and its associated negative outcomes on patients, particularly focusing on satisfaction rates and hospital readmissions.

Conclusion

The majority of instances of missed nursing care were associated with physiological requirements. Factors contributing to this issue include nurses’ engagement in other duties and insufficient staffing levels. Given the severe nursing shortage in Iran and its potential negative impact on patients, healthcare management and policymakers need to address missed nursing care. Proposed solutions to alleviate the nursing staff shortage include enhancing the work environment, increasing nurse recruitment opportunities, and improving their compensation and benefits packages.

Additionally, there is a need for governmental and hospital initiatives to enhance the working conditions through increased financial investment and support programs for nurses. Management should focus on minimizing nurses’ non-essential responsibilities and supporting efforts to reduce missed nursing care occurrences. The implications of missed nursing care pose risks to patient safety and should be considered in global state and national policy development. Incorporating patients in decision-making processes places them at the center of safety concerns and may help reduce instances of missed care.

This issue requires careful practical attention, particularly among less experienced nurses, to prevent low job satisfaction, burnout, or attrition, which could exacerbate the nursing shortage. Understanding nurses’ perceptions of reasons for missed care can inform the development of targeted interventions and strategies. Regular assessment of missed nursing care elements could provide insights into the effectiveness of various interventions.