Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Missed nursing care, non-nursing tasks, staffing adequacy, and job satisfaction among nurses in a teaching hospital in Egypt

Missed nursing care, non-nursing tasks, staffing adequacy, and job satisfaction among nurses in a... Background: Missed nursing care (MNC) has been linked to patient harm in a growing body of literature. However, this issue is still not adequately investigated in developing countries. The aim of the study is to measure the extent of missed nursing care, to identify its types, and to determine factors contributing to missed nursing care. Methods: A cross-sectional design was used. The study was conducted among 50 units at 1762-beds teaching Hospital in Alexandria that employs 1211 nurses in inpatient areas. A sample of 553 nurses were interviewed using the MISSCARE and the N4CAST survey. The MISSCARE survey measured the amount of missed nursing care (MNC) that was experienced on the last worked shift by each nurse. The N4CAST survey was used to collect data about level of non-nursing work carried out by nurses and the nurses’ job satisfaction. Results: The overall mean score for the missed nursing care was 2.26 ± 0.96 out of 5, with highest mean score attributed to “Planning” and lowest mean score attributed to “Assessment and Vital Signs” (2.64 and 1.96, respectively). Missed nursing care was significantly associated with number of patients admitted and cared for in the last shift and perceived staffing adequacy. Almost all non-nursing care tasks and most of satisfaction elements showed negative weak correlation with overall missed nursing care. Conclusion: Missed Nursing Care is common in study hospital which may endanger patient safety. MNC Missed Nursing Care is positively associated with nursing adequacy. There is no association between MNC and neither nurses’ job satisfaction nor non-nursing tasks. Nursing leaders should monitor missed nursing care and the environmental and staffing conditions associated with it in order to design strategies to reduce such phenomena. Keywords: Missed nursing care, Staffing adequacy, Non-nursing tasks, Egypt 1 Introduction significant problem in hospitals; 55–98% of nurses The term “missed nursing care” (MNC), introduced reporting missing one or more items of required care in 2006 [1], has been defined as “any aspect of re- during thetimeof assessment(frequently thelast quired patient care that is omitted (either in part or shift worked) [3]. Themostfrequentlyidentified in whole) or delayed” [2]. In a systematic review of missed items were ambulating and turning patients, 42 studies, four studies concluded that MNC is a mouth care, feeding patients on time, comfort talk with patient and family, patient teaching, medication * Correspondence: rashaazm@yahoo.com administration on time, and documentation [4–6]. High Institute of Public Health, Alexandria University, 165 El-Horeya Road, Al Studies investigating reasons for MNC, as men- Ibrahimeyah Qebli WA Al Hadrah Bahri, Qism Bab Sharqi, Alexandria tioned by nurses, concluded that inadequate labor Governorate, Egypt Full list of author information is available at the end of the article resources was the most frequently cited reason, © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 2 of 9 followed by material resources then communication. significant predictor of intention to leave, but not of The most frequently reported items in labor re- turnover [18]. Another study in the USA identified sources were unexpected rise in patient volume and/ MNC as a significant predictor of job satisfaction; nurses or acuity and inadequate number of staff, those in who reported less MNC were more satisfied in their material resources were unavailability of medications current position and occupation [19]. when needed, and unavailability of supplies and Literature search identified four Egyptian studies on equipment, while the most common items reported MNC; all conducted in critical care units, and based on in communication were unbalanced patient assign- a small sample of nurses [20–23]. This research is a ments, and breakdowns in communication with med- hospital-wide study to identify level and types of MNC ical staff [4, 6–8]. and to determine factors contributing to missed nursing Studies examining the relationship between nurse care, so that appropriate interventions can be developed staffing and MNC, used different staffing measures, and to reduce care omissions and thus improve quality and reported inconsistent findings. Using the objective mea- safety of care. sures of hours per patient day (HPPD), registered nurse hours per patient day, and skill mix, one study con- 2 Methods ducted in 10 hospitals in the USA identified HPPD as 2.1 Study design and setting the only significant predictor of MNC [9], while another The study was conducted among 50 units at 1762 beds study in 11 hospitals in the USA reported that none of teaching hospital that employs 1211 nurses in inpatient the measures was a significant predictor [5], and a third areas. A cross-sectional design was used. The study study in two hospitals in the USA reported that these population was nurses working in inpatient units who measures were not predictors of patient-reported MNC have been working in the hospital for a minimum of 3 [10]. Another study comparing MNC in high- vs. low- months. staffing units in South Korea revealed that nurses work- ing in high-staffing units had a significantly lower mean 2.2 Sample score of MNC than those in low-staffing units [11]. The following assumptions were used to calculate the Nursing perceived level of adequate staffing was found required sample size of nurses to estimate the mean of to be a significant independent predictor in a study con- MNC score: 95% confidence interval for mean ± 0.1 and ducted in the USA, where those who perceived their standard deviation of 1.2 [20]. The minimum required staffing as adequate more often reported less MNC [4], sample size is 553 nurses (1.96*1.2/0.1). Units were ran- while the same measure was not a significant predictor domly selected from all hospital inpatient units, and all in another study conducted in eight hospitals in Iceland nurses who fulfilled the inclusion criteria in each se- [12]. Four studies, using patient-to-nurse ratio as a lected unit were invited to participate using convenient measure of staffing, reported conflicting findings. Two sampling, until the required sample size was reached. In- studies, one conducted in 488 hospitals across 12 Euro- clusion criteria were nurses working in inpatient units of pean countries and the other conducted in 10 acute care the study hospital who have been working in the hos- hospitals in the USA, concluded that higher patient-to- pital for a minimum of 3 months. nurse ratio was a significant predictor of MNC [4, 13], while another study reported that a higher patient-to- 2.3 Data collection nurse ratio was a significant predictor of less MNC in an A structured interview schedule was prepared to collect Italian medical care setting [6], and a fourth study con- data from nurses about level of overall and specific ele- ducted in Lebanon revealed that the patient-to-nurse ra- ments of MNC, unit characteristics, nurse characteris- tio was not an independent predictor of MNC [14]. tics, nurse staffing measures, and nurse outcome Several studies identified nurses spending their time measures. performing non-nursing tasks (NNT) as an important rea- The interview schedule consisted of two tools, the son for MNC. NNT include all tasks that are not related MISSCARE survey and the N4CAST survey. The MISS to direct patient care or tasks not requiring professional CARE survey [24] measures the amount of MNC that nursing skills [15–17]. In a study conducted in 55 private was experienced on the last worked shift by each re- hospitals and seven public hospitals in South Africa, nurs- spondent. It is composed of 24 items, belonging to four ing tasks left undone were related to three non-nursing areas as follows: assessment and vital signs (8 items); in- tasks, namely, “delivering and retrieving food trays,”“rou- terventions and individual needs (6 items); intervention/ tine phlebotomy/blood drawing for tests,” and “cleaning basic needs (7 items); and planning (3 items). For each patients’ rooms and equipment” [17]. item, respondents are asked to identify the frequency of As regards the impact of MNC on nurses, a study con- care being missed using a 5-point Likert scale from ducted in 10 hospitals in the USA identified MNC as a never missed to always missed. The mean of all 24 items Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 3 of 9 is used as a total score for the scale, and the potential and that it will be used for research purposes only. The range of scores is 1 to 5, with higher scores indicating researchers declare no conflict of interest. more MNC. The questionnaire also collects data about work and demographic characteristics of nurses. The 3 Results N4CAST survey [25] was used to collect data about level The majority of the study sample were females (94.4%), of NNT carried out by nurses. This section contains a in the age category 30 < 50 years (60.6%), working in list of nine tasks, and each nurse was required to indi- surgical units (60.6%), holding a nursing diploma degree cate the frequency with which she/he performed each (68.0%), and working as a “Practical Nurse” (66.5%). task during the most recent shift, on a 3-point scale of never, sometimes, and often (scored as 0, 1 and 2, re- As for workload of nurses at study hospital, the ma- spectively). The items for NNT were the following: deliv- jority of nurses worked for more than 30 h per week ering food trays, performing non-nursing care, arranging (89.0%) and cared for more than 10 patients per discharge referrals and transportation, phlebotomy, shift (43.4%) with a mean of 11.94 patients. Highest transporting patients within the hospital, cleaning pa- percentage of the nurses had 0-5 patients admitted tients’ rooms, filling-in for non-nursing services, obtain- and discharged during the last shift (84.6% and ing supplies, and performing clerical duties. The 89.5%). As for perceived staff adequacy, around N4CAST survey was also used to measure level of one-third of the sample perceived the staff to be ad- nurses’ job satisfaction. Each nurse was required to indi- equate 50% of time and 16.1% perceived that the cate the level of satisfaction with the current job on a 4- staff was never adequate. point scale of very dissatisfied, dissatisfied, satisfied, and very satisfied (scored as 1, 2, 3, and 4, respectively). The The overall mean score for the MNC was 2.26 with items for satisfaction were the following: work schedule highest mean score attributed to “Planning” and lowest flexibility, opportunities for advancement, independence mean score attributed to “Assessment and Vital Signs” at work, professional status, salary, educational oppor- (2.64 and 1.96, respectively). Item with the highest mean tunities, and annual sick and study leaves. scores was attending “conferences” (2.84), whereas items The study tools were translated to Arabic by the re- with the least mean score was “IV site care,”“Vital signs search team and then reviewed by a professional transla- assessed as ordered(1.74 ± 1.32),” and “Full documenta- tor. The tool was assessed for face validity by a panel of tion of all necessary data” ) (1.76±1.36) (Table 1). experts. The questionnaire was piloted on 20 nurses to MNC was not significantly associated with any of the assure understandability and relevance of items. There work and demographic characteristics except the unit were no changes in the tool and the 20 questionnaires where the ICU was the unit with the lowest mean score were included in the sample. as compared to the medical and surgical units (1.91 ver- sus 2.48 and 2.30, respectively) (Table 2). MNC was significantly associated with number of pa- 2.4 Statistical analysis tients admitted and cared for in the last shift and per- Data was entered and analyzed using SPSS (Statistical ceived staffing adequacy. The higher the patients Package for Social Sciences) version 21. Descriptive sta- admitted and cared for the last shift, and the lower the tistics (frequencies, percentages, and means) were per- perceived staff adequacy, the higher the overall MNC formed. T test was used for comparison of means score (Table 3). between two groups and one-way ANOVA for compari- Unexpectedly, almost all non-nursing care tasks son of means of more than two groups. The 5% level showed negative weak correlation with overall MNC. was used as a cut-off point value for statistical signifi- This means that the more the non-nursing tasks, the cance. Spearman rank-order correlation was used to as- lower the overall MNC score (Table 4). sess the correlation between MNC and non-nursing Most of satisfaction elements showed negative weak tasks and nurses’ job satisfaction. Spearman rank-order correlation with the overall MNC. This means that the correlation was selected as the data was not normally higher the satisfaction, the lower the overall MNC score distributed. (Table 5). 2.5 Ethical considerations 4 Discussion Approvals of Ethics Committee of High Institute of Pub- The overall MNC in the current study is much higher lic Health and the Director of Central Administration of than a study comparing the MNC in the USA and Alexandria Hospitals were obtained. Verbal consent was Lebanon (2.26 for the current study versus 1.71 and obtained from participants in the study, who were as- 1.31 in the USA and Lebanon, respectively) [14]. sured of confidentiality and anonymity of information Similarly, in another study conducted in a public Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 4 of 9 Table 1 Mean scores of missed nursing care among inpatient nurses in a teaching hospital in Alexandria, Egypt Elements of MISSCARE survey Total (n = 553) Assessment and vital signs (overall) 1.96 ± 1.07 Full documentation of all necessary data 1.76 ± 1.36 IV site care and assessment according to hospital policy 1.70 ± 1.31 Monitoring intake/output 1.90 ± 1.30 Vital signs assessed as ordered 1.74 ± 1.32 Focused reassessment according to patient condition 2.47 ± 1.54 Hand washing 1.99 ± 1.43 Bedside glucose monitoring as ordered 1.88 ± 1.38 Patient assessments performed each shift 2.26 ± 1.55 Interventions and individual needs (overall) 2.19 ± 0.98 Assessing effectiveness of medications 2.30 ± 1.44 PRN medication requests acted up on within 15 min 2.06 ± 1.41 Medications administered within 30 min before or after scheduled time 1.96 ± 1.28 Assist with toileting needs within 5 min of request 2.44 ± 1.40 Response to call is provided within 5 min 2.0 ± 1.34 Emotional support to patient and/or family 2.41 ± 1.47 Intervention /basic needs (overall) 2.48 ± 1.17 Ambulation three times per day or as ordered 2.72 ± 1.48 Turning patient every 2 h 2.44 ± 1.49 Mouth care 2.64 ± 1.56 Feeding patient when the food is still warm 2.58 ± 1.53 Patient bathing 2.65 ± 1.62 Setting up meals for patients who feed themselves 2.29 ± 1.58 Skin/wound care 2.01 ± 1.37 Planning (overall) 2.64 ± 1.08 Patient teaching 2.59 ± 1.36 Attending interdisciplinary care conferences whenever held 2.84 ± 1.42 Ensuring discharge planning 2.50 ± 1.52 Overall missed care 2.26 ± 0.96 Score (1–5) with higher score indicating higher MNC level hospital in South Korea, the overall MNC was 1.39 and which did not require teamwork were less fre- for high staffing units (7 patients per RN) versus 1.51 quently missed. On the other hand, care items, for low staffing units (17 patients per RN) [6]. How- which may be perceived as less serious, although ever, the results were comparable to the overall mean linked to patients’ outcomes, for example, mouth scores in four public hospitals in Australia where the care and those that often require teamwork (such as mean scores ranged from 2.02 in ICU units to 2.40 in ambulation) were more likely to be missed [7]. An- the medical units [26]. other possible explanation is that least frequently re- The overall dimensions “assessment and vital ported elements of MNC as vital signs, monitoring signs” and “interventions and individual needs” had intake/output, and glucose monitoring are routinely less missed opportunities when compared to the recorded in nursing documentation and hence recog- overall dimensions “basic needs” and “planning.” nized by others if the medical file was audited. Con- This result is consistent with the results of other versely, ambulation of patients, patients’ bathing, studies [4, 7, 27]. Possible explanations for the MNC mouth care, and turning patients are nursing duties items is that those tasks that respondents perceived not routinely recorded in nursing documentation, as important (e.g., vital sign and glucose monitoring) and there is less opportunity for others to perceive Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 5 of 9 Table 2 Association between overall missed nursing care and demographic and work characteristics Characteristic Overall MNC Test of Sig. p Mean ± SD Sex 1.15 0.24 Male 2.45 ± 0.84 Female 2.24 ± 0.84 Age group (years) 1.70 0.14 < 20 2.30 ± 0.88 20 to < 30 2.25 ± 0.88 30 to < 40 2.12 ± 0.86 40 to < 50 2.27 ± 0.99 ≥ 50 2.43 ± 1.11 Unit 14.31 0.000 Medical unit 2.48 ± 0.77 Surgical unit 2.30 ± 0.87 ICU 1.91 ± 1.06 Professional qualification (highest degree) 1.42 0.22 Nursing diploma (high school equivalent) 2.29 ± 0.94 Nursing technician diploma 2.29 ± 1.19 BSN (bachelor’s degree) 2.04 ± 0.75 Postgraduate diploma 1.94 ± 0.78 Master’s degree or more 2.70 Job title 1.22 0.30 Head nurse (head of unit) 1.98 ± 0.90 Nurse supervisor (BSN) 2.14 ± 0.78 Nurse technician 2.29 ± 1.19 Practical nurse (high school equivalent) 2.28 ±0.93 Shift worked 1.80 0.14 Morning 2.32 ± 1.05 Evenings 2.26 ± 0.92 Nights 1.94 ± 0.65 Rotates 2.20 ± 0.87 P value < 0.05 (T test was used for comparison of means between two groups and one-way ANOVA for comparison of means of more than two groups) this care as missed. Increased attention to these ele- degree in nursing. In addition, the nurse to patient ments, including a refocus of existing documentation ratio is usually 1:1 or 1:2 in ICU which reduce the systems, is a necessity [27]. workload on nurses and hence reduce the missed Hospital unit was significantly associated with the care. overall MNC score where the ICU had a lower over- Higher mean scores of MNC were significantly as- all MNC score when compared to the medical and sociated with increasing number of patients cared surgical units (1.91 versus 2.48 and 2.30, respect- for and admitted in the last shift and nurses’ per- ively) (P < 0.000). This result is consistent with the ceived inadequacy of staffing. Several studies con- results of a study conducted in eight hospitals in ducted in the USA and South Korea, demonstrated Iceland and another study conducted in four hospi- the association between nurses’ workload and staff- tals in Australia and among ICU units in two teach- ing adequacy and MNC [11, 12, 26, 28]. In other ing hospitals in Egypt [7, 12, 20]. The better scores studies, staffing adequacy had a positive impact on in the ICU can be explained by the fact that ICU reducing instances of failure to rescue, inpatient has skilled nursing staff who hold at least bachelor mortality, postoperative mortality, and length of Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 6 of 9 Table 3 Association between overall missed nursing care and staffing adequacy, workload, and intention to leave Characteristic Total (n = 553) Overall Test p MNC of No. % Mean ± Sig. SD No. of working hours/week 0.69 0.48 ≥ 30 h 492 89.0 2.17 ± 0.99 < 30 h 61 11.0 2.26 ± 0.96 No. of patients cared for/last shift 17.49 0.00 0-5 213 38.5 1.97 6-10 100 18.1 2.26 > 10 240 43.4 2.49 Mean ± SD 11.94 ± 11.30 No. of patient admissions/last shift 4.32 0.01 0-5 468 84.6 2.20 6-10 78 14.1 2.54 > 10 7 1.3 2.45 Mean ± SD 3.17 ± 2.74 No. of patient discharges/last shift 2.27 0.10 0-5 495 89.5 2.27 6-10 49 8.9 2.23 > 10 9 1.6 1.58 Mean ± SD 2.50 ± 2.81 Perceived staffing adequacy 7.88 0.00 100% of the time 47 8.5 2.27 ± 1.00 75% of the time 130 23.5 2.04 ± 0.81 50% of the time 158 28.6 2.07 ± 0.80 25% of the time 129 23.3 2.41 ± 1.10 0% of the time 89 16.1 2.64 ± 1.03 Work retention plan 1.65 0.09 Plan to leave work within 6 months 137 24.8 2.38 ± 1.15 No plan to leave work within 6 months 416 75.2 2.21 ± 0.88 P value < 0.05 (T test was used for comparison of means between two groups and one-way ANOVA for comparison of means of more than two groups) Table 4 Spearman rank-order correlations between overall missed nursing care and non-nursing tasks Non-nursing task Total (n = 553) Overall MNC Mean (SD) Delivering and retrieving food trays 0.79 (0.81) −0.133 Performing non-nursing care 1.14 (0.70) −0.017 Arranging discharge referrals and transportation (including long-term care) 1.43 (0.68) −0.077 Routine phlebotomy/blood draw for tests 1.72 (0.53) −0.041 Transporting patients within hospital 1.36 (0.65) −0.085 ** Cleaning patient rooms and equipment 1.45 (0.68) −0.259 Filling in for non-nursing services and available on off hours 0.96 (0.78) 0.027 Obtaining supplies or equipment 1.53 (0.63) −0.085 Answering phones, clerical duties 0.79 (0.81) 0.056 Spearman correlation coefficient P value < 0.05 ** Spearman Correlation Coefficient P value < 0.01 Scores (0-2) Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 7 of 9 Table 5 Spearman rank-order correlations between missed nursing care and satisfaction Satisfaction dimension Total (n = 553) Overall MNC Mean (SD) ** Work schedule flexibility 2.49 ± 0.90 −0.136 ** Opportunity for advancement 2.47 ± 0.92 −0.110 ** Professional status 2.49 ± 0.96 −0.186 Salary 1.82 ± 0.88 −0.103 Educational opportunities 2.25 ± 0.91 0.015 Annual leave 2.26 ± 0.90 0.054 ** Sick leave 1.99 ± 0.92 −0.119 Study leave 2.05 ± 0.91 −0.001 Current job 2.87 ± 0.85 −0.066 Independence at work, be a nurse or technician 2.83 ± 0.88 −0.095 Team work and co-operation within department/unit 2.89 ± 0.88 −0.079 ** Overall 2.40 ± 0.56 −0.170 Spearman correlation coefficient P value < 0.05 ** Spearman Correlation Coefficient P value < 0.01 Scores (1–4) hospital stay [29–31]. Thus, adequacy of staffing is the fact that people respond positively and with more of paramount importance in ensuring patient safety motivation to do a good job when they witness their and reducing missed nursing care. Thus, it is recom- constituents benefiting from their efforts. In the case of mended to use a staffing approach which accounts nursing, unlike some other occupations, the providers for individual patient variation in need as alterna- have direct and many times immediate knowledge about tives to, or in conjunction with, minimum staffing the effect of the quality of their work on their patients. levels based entirely on patient volumes which is Thus, nurses are fully cognizant of the impact of missing used in public hospitals in Egypt [32]. care for their patients, and when the effect is negative In the current study, only two non-nursing tasks [19, 35]. This was supported by a study conducted in the correlated positively with missed nursing care: clean- USA where each one unit increase in missed nursing ing patients’ rooms and filling in for non-nursing ser- care was associated with a 0.26 decrease in job enjoy- vices and available on off hours. Both correlations ment [36]. The second possible explanation is that the were weak and non-significant. This unexpected find- dissatisfied nurse is more prone to miss elements of ing could be explained by the fact that nurses may nursing care. Further research should explore the causa- consider all the other non-nursing tasks to be part of tive relation between MNC and nurses’ satisfaction. their workload. Studies pointed out that nurses accept performing non-nursing duties, because these roles 4.1 Limitations are founded on organizational as well as individual The current study addresses the concept of MNC in one patient relationships [33]. of the largest teaching hospitals in Egypt. It sets a basis The current study showed transporting patients in for further assessments and suggestions for improve- hospital correlated negatively and significantly with cer- ment. Further research studying the link between MNC tain missed nursing care elements. The rationale for this and adverse events is recommended. might be that when patients are transferred outside of The current study used subjective measures of missed the unit, it is crucial that all procedures are done before care, with most relying on retrospective reports by leaving the unit [17]. nurses. Further studies using objective measures as dir- Overall satisfaction showed a negative weak significant ect observation of nursing care are recommended to correlation with overall MNC. This is consistent with evaluate the current study findings. The study was con- the results of two studies conducted in the USA where ducted in a teaching hospital which limits the nurses who perceived less MNC on the patient care unit generalization of the results to other settings as private, where they work are more satisfied in their current pos- Ministry of Health and Insurance settings. ition and occupation [19, 34]. This can have two possible explanations in the present study. First, is that when 5 Conclusions nurses see that the elements of nursing care are missed, The missed nursing care is relatively higher when com- they become more dissatisfied. This can be explained by pared to other settings. The dimensions which are Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 8 of 9 frequently missed are “basic needs” and “planning.” The 2. Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509–17. mean missed care was lower in the ICU as compared to 3. Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and the medical and surgical units. Nursing staffing adequacy implicitly rationed care: state of the science review. Int J Nurs Stud. 2015; and number of patients cared by nurse were factors as- 52(6):1121–37. 4. Kalisch BJ, Tschannen D, Lee H, Friese CR. Hospital variation in missed sociated significantly with higher score of missed nursing nursing care. Am J Med Qual. 2011;26(4):291–9. care. Non-nursing tasks and nurses’ job satisfaction 5. Kalisch BJ, Lee KH. Missed nursing care: magnet versus non-magnet showed negative weak correlation with the overall MNC. hospitals. Nurs Outlook. 2012;60:e32–9. 6. Palese A, Ambrosi E, Prosperi L, Guarnier A, Barelli P, Zambiasi P, et al. Missed nursing care and predicting factors in the Italian medical care Abbreviation setting. Intern Emerg Med. 2015;10(6):693–702. MNC: Missed nursing care 7. Chapman R, Rahman A, Courtney M, Chalmers C. Impact of teamwork on missed care in four Australian hospitals. J Clin Nurs. 2017;26(1-2):170–81. Acknowledgements 8. Moreno-Monsiváis MG, Moreno-Rodríguez C, Interial-Guzmán MG. Missed The authors would like to express their gratitude for the nurses who agreed nursing care in hospitalized patients. Aquichan. 2015;15(3):318–28. to conduct the interview and the hospital administration who facilitated the 9. Kalisch BJ, Tschannen D, Lee KH. Do staffing levels predict missed nursing conduction of the research. care? Int J Qual Health Care. 2011;23(3):302–8. 10. Dabney BW, Kalisch BJ. Nurse staffing levels and patient-reported missed Authors’ contributions nursing care. J Nurs Care Qual. 2015;30(4):306–12. MH has made substantial contributions to or acquisition and interpretation 11. Kim YS, Yeon KN, You SJ, Lee ID. Effects of increasing nurse staffing on of data. WG has made substantial contributions to conception and design, missed nursing care. Int Nurs Rev. 2015;62:267–74. analysis, and interpretation of data. RM has contributed to analysis and 12. Bragadóttir H, Kalisch BJ, Tryggvadóttir GB. Correlates and predictors of interpretation of data and drafted the manuscript. The authors read and missed nursing care in hospitals. J Clin Nurs. 2017;26(11-12):1524–34. approved the final manuscript. 13. Ausserhofer D, Zander B, Busse R, Schubert M, De Geest S, Rafferty AM, et al. Prevalence, patterns and predictors of nursing care left undone in European Funding hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ There was not any funding agency for this research. Qual Saf. 2014;23(2):126–35. 14. Kalisch BJ, Doumit M, Lee KH, Zein JE. Missed nursing care, level of staffing, Availability of data and materials and job satisfaction: Lebanon versus the United States. J Nurs Adm. 2013; The data are available from the corresponding author on reasonable request. 43(5):274–9. 15. Al-Kandari F, Thomas D. Perceived adverse patient outcomes correlated to Declarations nurses’ workload in medical and surgical wards of selected hospitals in Kuwait. J Clin Nurs. 2008;18:581–90. Ethics approval and consent to participate 16. Aiken LH, Clarke SP, Sloane DM, Sochalski JA, Busse R, Clarke H, et al. Nurses’ The manuscript was approved by the ethics committee of the High Institute reports on hospital care in five countries. Health Aff (Millwood). 2001;20(3): of Public Health, Alexandria University and the Director of Central 43–53. Administration of Alexandria Hospitals (The Ethics Committee does not 17. Bekker M, Coetzee SK, Klopper HC, Ellis SM. Non-nursing tasks, nursing tasks provide a reference number). Verbal consent was obtained from nurses. The left undone and job satisfaction among professional nurses in South African ethics committee approved this type of consent. The purpose of the study hospitals. J Nurs Manag. 2015;23(8):1115–25. was explained to the nurses and they were assured of confidentiality and 18. Tschannen D, Kalisch BJ, Lee KH. Missed nursing care: the impact on anonymity of information and that it will be used for research purposes only. intention to leave and turnover. Can J Nurs Res. 2010;42(4):22–39. Verbal consent was approved by the ethics committee. Following this verbal 19. Kalisch B, Tschannen D, Lee H. Does missed nursing care predict job explanation, a study information sheet was given to the nurses and they satisfaction? J Healthc Manag. 2011;56:117–31. were allowed enough time to consider whether or not to participate in the 20. Abd Elrehem MAE, Abd El Fatah MA, Seloma YA. Correlates of missed study. nursing care in selected medical intensive care units, Egypt. J Biol Agric Procedures for the ensuring nurses confidentiality were taken. Identification Healthc. 2014;4:88–105. code numbers were used on the questionnaires instead of personal 21. Attia NM, Abdeen MA, El Sayed SH. Impact of nursing teamwork on missed identifiers. Access to research data was limited to the research team. nursing care in intensive care units at Zagazig University Hospitals. Zagazig Nurs J. 2014;10(2):201–17. Consent for publication 22. Mohamed SA, Abed F. Perception of teamwork and missed nursing care Not applicable. among nurses in intensive care units at South Valley University Hospitals. IOSR J Nurs Health Sci. 2016;5:89–97. Competing interests 23. El Rehem MAE, Elhamid MA, Elsalam YA. Missed nursing care: observation Dr. Rasha Mosallam is a co-author of this study and editorial board member versus perception in selected medical intensive care units, Egypt. Int J of the journal. She declares a competing interest for this submission. She has Health Wellness Soc. 2017;7(1):31–47. not handled this manuscript. The rest of the authors have no conflict of 24. Kalisch BJ, Williams RA. Development and psychometric testing of a tool to interest to declare. measure missed nursing care. J Nurs Adm. 2009;39(5):211–9. 25. Report of the Irish RN4CAST study 2009-2011. [Cited 2017 Nov 8]. Available Author details from: http://doras.dcu.ie/19344/1/RN4CAST_FINAL_report_18_April_2013_ Ministry of Health, 97 El-Horeya Road, Qism Bab Sharqi, Wabour Al Meyah, DORAS.pdf Alexandria Governorate, Egypt. High Institute of Public Health, Alexandria 26. Orique SB, Patty CM, Woods E. MNC and unit-level nurse workload in the University, 165 El-Horeya Road, Al Ibrahimeyah Qebli WA Al Hadrah Bahri, acute and post-acute settings. J Nurs Care Qual. 2016;31(1):84–9. Qism Bab Sharqi, Alexandria Governorate, Egypt. 27. Kalisch BJ, Xie B. Errors of omission: missed nursing care. West J Nurs Res. 2014;36(7):875–90. Received: 22 July 2020 Accepted: 22 June 2021 28. Tubbs-Cooley HL, Mara CA, Carle AC, Mark BA, Pickler RH. Association of nurse workload with missed nursing care in the neonatal intensive care unit. JAMA Pediatr. 2019;173(1):44–51. References 29. Ball JE, Bruyneel L, Aiken LH, Sermeus W, Sloane DM, Rafferty AM, et al. 1. Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006; RN4Cast Consortium. Post-operative mortality, missed care and nurse 21(4):306–13. Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 9 of 9 staffing in nine countries: a cross-sectional study. Int J Nurs Stud. 2018;78: 10–5. 30. Clarke SP, Aiken LH. Failure to rescue: needless deaths are prime examples of the need for more nurses at the bedside. Am J Nurs. 2003;103(1):42–7. 31. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195–204. 32. Griffiths P, Saville C, Ball J, Jones J, Pattison N, MonksT, et al. Safer Nursing Care Study Group. Nursing workload, nurse staffing methodologies and tools: a systematic scoping review and discussion. Int J Nurs Stud. 2019;103: 33. Allen D. Re-conceptualising holism in the contemporary nursing mandate: from individual to organisational relationships. Soc Sci Med. 2014;119:131–8. 34. Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care community hospital. J Nurs Adm. 2018;48(7-8): 361–7. 35. Grant AM. Relational job design and the motivation to make a prosocial difference. Acad Manag Rev. 2007;32(1):393–417. 36. Smith JG, Rogowski JA, Lake ET. Missed care relates to nurse job enjoyment and intention to leave in neonatal intensive care. J Nurs Manag. 2020;00:1–8. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Missed nursing care, non-nursing tasks, staffing adequacy, and job satisfaction among nurses in a teaching hospital in Egypt

Loading next page...
 
/lp/springer-journals/missed-nursing-care-non-nursing-tasks-staffing-adequacy-and-job-tCMug38Ild
Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2021
eISSN
2090-262X
DOI
10.1186/s42506-021-00083-0
Publisher site
See Article on Publisher Site

Abstract

Background: Missed nursing care (MNC) has been linked to patient harm in a growing body of literature. However, this issue is still not adequately investigated in developing countries. The aim of the study is to measure the extent of missed nursing care, to identify its types, and to determine factors contributing to missed nursing care. Methods: A cross-sectional design was used. The study was conducted among 50 units at 1762-beds teaching Hospital in Alexandria that employs 1211 nurses in inpatient areas. A sample of 553 nurses were interviewed using the MISSCARE and the N4CAST survey. The MISSCARE survey measured the amount of missed nursing care (MNC) that was experienced on the last worked shift by each nurse. The N4CAST survey was used to collect data about level of non-nursing work carried out by nurses and the nurses’ job satisfaction. Results: The overall mean score for the missed nursing care was 2.26 ± 0.96 out of 5, with highest mean score attributed to “Planning” and lowest mean score attributed to “Assessment and Vital Signs” (2.64 and 1.96, respectively). Missed nursing care was significantly associated with number of patients admitted and cared for in the last shift and perceived staffing adequacy. Almost all non-nursing care tasks and most of satisfaction elements showed negative weak correlation with overall missed nursing care. Conclusion: Missed Nursing Care is common in study hospital which may endanger patient safety. MNC Missed Nursing Care is positively associated with nursing adequacy. There is no association between MNC and neither nurses’ job satisfaction nor non-nursing tasks. Nursing leaders should monitor missed nursing care and the environmental and staffing conditions associated with it in order to design strategies to reduce such phenomena. Keywords: Missed nursing care, Staffing adequacy, Non-nursing tasks, Egypt 1 Introduction significant problem in hospitals; 55–98% of nurses The term “missed nursing care” (MNC), introduced reporting missing one or more items of required care in 2006 [1], has been defined as “any aspect of re- during thetimeof assessment(frequently thelast quired patient care that is omitted (either in part or shift worked) [3]. Themostfrequentlyidentified in whole) or delayed” [2]. In a systematic review of missed items were ambulating and turning patients, 42 studies, four studies concluded that MNC is a mouth care, feeding patients on time, comfort talk with patient and family, patient teaching, medication * Correspondence: rashaazm@yahoo.com administration on time, and documentation [4–6]. High Institute of Public Health, Alexandria University, 165 El-Horeya Road, Al Studies investigating reasons for MNC, as men- Ibrahimeyah Qebli WA Al Hadrah Bahri, Qism Bab Sharqi, Alexandria tioned by nurses, concluded that inadequate labor Governorate, Egypt Full list of author information is available at the end of the article resources was the most frequently cited reason, © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 2 of 9 followed by material resources then communication. significant predictor of intention to leave, but not of The most frequently reported items in labor re- turnover [18]. Another study in the USA identified sources were unexpected rise in patient volume and/ MNC as a significant predictor of job satisfaction; nurses or acuity and inadequate number of staff, those in who reported less MNC were more satisfied in their material resources were unavailability of medications current position and occupation [19]. when needed, and unavailability of supplies and Literature search identified four Egyptian studies on equipment, while the most common items reported MNC; all conducted in critical care units, and based on in communication were unbalanced patient assign- a small sample of nurses [20–23]. This research is a ments, and breakdowns in communication with med- hospital-wide study to identify level and types of MNC ical staff [4, 6–8]. and to determine factors contributing to missed nursing Studies examining the relationship between nurse care, so that appropriate interventions can be developed staffing and MNC, used different staffing measures, and to reduce care omissions and thus improve quality and reported inconsistent findings. Using the objective mea- safety of care. sures of hours per patient day (HPPD), registered nurse hours per patient day, and skill mix, one study con- 2 Methods ducted in 10 hospitals in the USA identified HPPD as 2.1 Study design and setting the only significant predictor of MNC [9], while another The study was conducted among 50 units at 1762 beds study in 11 hospitals in the USA reported that none of teaching hospital that employs 1211 nurses in inpatient the measures was a significant predictor [5], and a third areas. A cross-sectional design was used. The study study in two hospitals in the USA reported that these population was nurses working in inpatient units who measures were not predictors of patient-reported MNC have been working in the hospital for a minimum of 3 [10]. Another study comparing MNC in high- vs. low- months. staffing units in South Korea revealed that nurses work- ing in high-staffing units had a significantly lower mean 2.2 Sample score of MNC than those in low-staffing units [11]. The following assumptions were used to calculate the Nursing perceived level of adequate staffing was found required sample size of nurses to estimate the mean of to be a significant independent predictor in a study con- MNC score: 95% confidence interval for mean ± 0.1 and ducted in the USA, where those who perceived their standard deviation of 1.2 [20]. The minimum required staffing as adequate more often reported less MNC [4], sample size is 553 nurses (1.96*1.2/0.1). Units were ran- while the same measure was not a significant predictor domly selected from all hospital inpatient units, and all in another study conducted in eight hospitals in Iceland nurses who fulfilled the inclusion criteria in each se- [12]. Four studies, using patient-to-nurse ratio as a lected unit were invited to participate using convenient measure of staffing, reported conflicting findings. Two sampling, until the required sample size was reached. In- studies, one conducted in 488 hospitals across 12 Euro- clusion criteria were nurses working in inpatient units of pean countries and the other conducted in 10 acute care the study hospital who have been working in the hos- hospitals in the USA, concluded that higher patient-to- pital for a minimum of 3 months. nurse ratio was a significant predictor of MNC [4, 13], while another study reported that a higher patient-to- 2.3 Data collection nurse ratio was a significant predictor of less MNC in an A structured interview schedule was prepared to collect Italian medical care setting [6], and a fourth study con- data from nurses about level of overall and specific ele- ducted in Lebanon revealed that the patient-to-nurse ra- ments of MNC, unit characteristics, nurse characteris- tio was not an independent predictor of MNC [14]. tics, nurse staffing measures, and nurse outcome Several studies identified nurses spending their time measures. performing non-nursing tasks (NNT) as an important rea- The interview schedule consisted of two tools, the son for MNC. NNT include all tasks that are not related MISSCARE survey and the N4CAST survey. The MISS to direct patient care or tasks not requiring professional CARE survey [24] measures the amount of MNC that nursing skills [15–17]. In a study conducted in 55 private was experienced on the last worked shift by each re- hospitals and seven public hospitals in South Africa, nurs- spondent. It is composed of 24 items, belonging to four ing tasks left undone were related to three non-nursing areas as follows: assessment and vital signs (8 items); in- tasks, namely, “delivering and retrieving food trays,”“rou- terventions and individual needs (6 items); intervention/ tine phlebotomy/blood drawing for tests,” and “cleaning basic needs (7 items); and planning (3 items). For each patients’ rooms and equipment” [17]. item, respondents are asked to identify the frequency of As regards the impact of MNC on nurses, a study con- care being missed using a 5-point Likert scale from ducted in 10 hospitals in the USA identified MNC as a never missed to always missed. The mean of all 24 items Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 3 of 9 is used as a total score for the scale, and the potential and that it will be used for research purposes only. The range of scores is 1 to 5, with higher scores indicating researchers declare no conflict of interest. more MNC. The questionnaire also collects data about work and demographic characteristics of nurses. The 3 Results N4CAST survey [25] was used to collect data about level The majority of the study sample were females (94.4%), of NNT carried out by nurses. This section contains a in the age category 30 < 50 years (60.6%), working in list of nine tasks, and each nurse was required to indi- surgical units (60.6%), holding a nursing diploma degree cate the frequency with which she/he performed each (68.0%), and working as a “Practical Nurse” (66.5%). task during the most recent shift, on a 3-point scale of never, sometimes, and often (scored as 0, 1 and 2, re- As for workload of nurses at study hospital, the ma- spectively). The items for NNT were the following: deliv- jority of nurses worked for more than 30 h per week ering food trays, performing non-nursing care, arranging (89.0%) and cared for more than 10 patients per discharge referrals and transportation, phlebotomy, shift (43.4%) with a mean of 11.94 patients. Highest transporting patients within the hospital, cleaning pa- percentage of the nurses had 0-5 patients admitted tients’ rooms, filling-in for non-nursing services, obtain- and discharged during the last shift (84.6% and ing supplies, and performing clerical duties. The 89.5%). As for perceived staff adequacy, around N4CAST survey was also used to measure level of one-third of the sample perceived the staff to be ad- nurses’ job satisfaction. Each nurse was required to indi- equate 50% of time and 16.1% perceived that the cate the level of satisfaction with the current job on a 4- staff was never adequate. point scale of very dissatisfied, dissatisfied, satisfied, and very satisfied (scored as 1, 2, 3, and 4, respectively). The The overall mean score for the MNC was 2.26 with items for satisfaction were the following: work schedule highest mean score attributed to “Planning” and lowest flexibility, opportunities for advancement, independence mean score attributed to “Assessment and Vital Signs” at work, professional status, salary, educational oppor- (2.64 and 1.96, respectively). Item with the highest mean tunities, and annual sick and study leaves. scores was attending “conferences” (2.84), whereas items The study tools were translated to Arabic by the re- with the least mean score was “IV site care,”“Vital signs search team and then reviewed by a professional transla- assessed as ordered(1.74 ± 1.32),” and “Full documenta- tor. The tool was assessed for face validity by a panel of tion of all necessary data” ) (1.76±1.36) (Table 1). experts. The questionnaire was piloted on 20 nurses to MNC was not significantly associated with any of the assure understandability and relevance of items. There work and demographic characteristics except the unit were no changes in the tool and the 20 questionnaires where the ICU was the unit with the lowest mean score were included in the sample. as compared to the medical and surgical units (1.91 ver- sus 2.48 and 2.30, respectively) (Table 2). MNC was significantly associated with number of pa- 2.4 Statistical analysis tients admitted and cared for in the last shift and per- Data was entered and analyzed using SPSS (Statistical ceived staffing adequacy. The higher the patients Package for Social Sciences) version 21. Descriptive sta- admitted and cared for the last shift, and the lower the tistics (frequencies, percentages, and means) were per- perceived staff adequacy, the higher the overall MNC formed. T test was used for comparison of means score (Table 3). between two groups and one-way ANOVA for compari- Unexpectedly, almost all non-nursing care tasks son of means of more than two groups. The 5% level showed negative weak correlation with overall MNC. was used as a cut-off point value for statistical signifi- This means that the more the non-nursing tasks, the cance. Spearman rank-order correlation was used to as- lower the overall MNC score (Table 4). sess the correlation between MNC and non-nursing Most of satisfaction elements showed negative weak tasks and nurses’ job satisfaction. Spearman rank-order correlation with the overall MNC. This means that the correlation was selected as the data was not normally higher the satisfaction, the lower the overall MNC score distributed. (Table 5). 2.5 Ethical considerations 4 Discussion Approvals of Ethics Committee of High Institute of Pub- The overall MNC in the current study is much higher lic Health and the Director of Central Administration of than a study comparing the MNC in the USA and Alexandria Hospitals were obtained. Verbal consent was Lebanon (2.26 for the current study versus 1.71 and obtained from participants in the study, who were as- 1.31 in the USA and Lebanon, respectively) [14]. sured of confidentiality and anonymity of information Similarly, in another study conducted in a public Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 4 of 9 Table 1 Mean scores of missed nursing care among inpatient nurses in a teaching hospital in Alexandria, Egypt Elements of MISSCARE survey Total (n = 553) Assessment and vital signs (overall) 1.96 ± 1.07 Full documentation of all necessary data 1.76 ± 1.36 IV site care and assessment according to hospital policy 1.70 ± 1.31 Monitoring intake/output 1.90 ± 1.30 Vital signs assessed as ordered 1.74 ± 1.32 Focused reassessment according to patient condition 2.47 ± 1.54 Hand washing 1.99 ± 1.43 Bedside glucose monitoring as ordered 1.88 ± 1.38 Patient assessments performed each shift 2.26 ± 1.55 Interventions and individual needs (overall) 2.19 ± 0.98 Assessing effectiveness of medications 2.30 ± 1.44 PRN medication requests acted up on within 15 min 2.06 ± 1.41 Medications administered within 30 min before or after scheduled time 1.96 ± 1.28 Assist with toileting needs within 5 min of request 2.44 ± 1.40 Response to call is provided within 5 min 2.0 ± 1.34 Emotional support to patient and/or family 2.41 ± 1.47 Intervention /basic needs (overall) 2.48 ± 1.17 Ambulation three times per day or as ordered 2.72 ± 1.48 Turning patient every 2 h 2.44 ± 1.49 Mouth care 2.64 ± 1.56 Feeding patient when the food is still warm 2.58 ± 1.53 Patient bathing 2.65 ± 1.62 Setting up meals for patients who feed themselves 2.29 ± 1.58 Skin/wound care 2.01 ± 1.37 Planning (overall) 2.64 ± 1.08 Patient teaching 2.59 ± 1.36 Attending interdisciplinary care conferences whenever held 2.84 ± 1.42 Ensuring discharge planning 2.50 ± 1.52 Overall missed care 2.26 ± 0.96 Score (1–5) with higher score indicating higher MNC level hospital in South Korea, the overall MNC was 1.39 and which did not require teamwork were less fre- for high staffing units (7 patients per RN) versus 1.51 quently missed. On the other hand, care items, for low staffing units (17 patients per RN) [6]. How- which may be perceived as less serious, although ever, the results were comparable to the overall mean linked to patients’ outcomes, for example, mouth scores in four public hospitals in Australia where the care and those that often require teamwork (such as mean scores ranged from 2.02 in ICU units to 2.40 in ambulation) were more likely to be missed [7]. An- the medical units [26]. other possible explanation is that least frequently re- The overall dimensions “assessment and vital ported elements of MNC as vital signs, monitoring signs” and “interventions and individual needs” had intake/output, and glucose monitoring are routinely less missed opportunities when compared to the recorded in nursing documentation and hence recog- overall dimensions “basic needs” and “planning.” nized by others if the medical file was audited. Con- This result is consistent with the results of other versely, ambulation of patients, patients’ bathing, studies [4, 7, 27]. Possible explanations for the MNC mouth care, and turning patients are nursing duties items is that those tasks that respondents perceived not routinely recorded in nursing documentation, as important (e.g., vital sign and glucose monitoring) and there is less opportunity for others to perceive Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 5 of 9 Table 2 Association between overall missed nursing care and demographic and work characteristics Characteristic Overall MNC Test of Sig. p Mean ± SD Sex 1.15 0.24 Male 2.45 ± 0.84 Female 2.24 ± 0.84 Age group (years) 1.70 0.14 < 20 2.30 ± 0.88 20 to < 30 2.25 ± 0.88 30 to < 40 2.12 ± 0.86 40 to < 50 2.27 ± 0.99 ≥ 50 2.43 ± 1.11 Unit 14.31 0.000 Medical unit 2.48 ± 0.77 Surgical unit 2.30 ± 0.87 ICU 1.91 ± 1.06 Professional qualification (highest degree) 1.42 0.22 Nursing diploma (high school equivalent) 2.29 ± 0.94 Nursing technician diploma 2.29 ± 1.19 BSN (bachelor’s degree) 2.04 ± 0.75 Postgraduate diploma 1.94 ± 0.78 Master’s degree or more 2.70 Job title 1.22 0.30 Head nurse (head of unit) 1.98 ± 0.90 Nurse supervisor (BSN) 2.14 ± 0.78 Nurse technician 2.29 ± 1.19 Practical nurse (high school equivalent) 2.28 ±0.93 Shift worked 1.80 0.14 Morning 2.32 ± 1.05 Evenings 2.26 ± 0.92 Nights 1.94 ± 0.65 Rotates 2.20 ± 0.87 P value < 0.05 (T test was used for comparison of means between two groups and one-way ANOVA for comparison of means of more than two groups) this care as missed. Increased attention to these ele- degree in nursing. In addition, the nurse to patient ments, including a refocus of existing documentation ratio is usually 1:1 or 1:2 in ICU which reduce the systems, is a necessity [27]. workload on nurses and hence reduce the missed Hospital unit was significantly associated with the care. overall MNC score where the ICU had a lower over- Higher mean scores of MNC were significantly as- all MNC score when compared to the medical and sociated with increasing number of patients cared surgical units (1.91 versus 2.48 and 2.30, respect- for and admitted in the last shift and nurses’ per- ively) (P < 0.000). This result is consistent with the ceived inadequacy of staffing. Several studies con- results of a study conducted in eight hospitals in ducted in the USA and South Korea, demonstrated Iceland and another study conducted in four hospi- the association between nurses’ workload and staff- tals in Australia and among ICU units in two teach- ing adequacy and MNC [11, 12, 26, 28]. In other ing hospitals in Egypt [7, 12, 20]. The better scores studies, staffing adequacy had a positive impact on in the ICU can be explained by the fact that ICU reducing instances of failure to rescue, inpatient has skilled nursing staff who hold at least bachelor mortality, postoperative mortality, and length of Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 6 of 9 Table 3 Association between overall missed nursing care and staffing adequacy, workload, and intention to leave Characteristic Total (n = 553) Overall Test p MNC of No. % Mean ± Sig. SD No. of working hours/week 0.69 0.48 ≥ 30 h 492 89.0 2.17 ± 0.99 < 30 h 61 11.0 2.26 ± 0.96 No. of patients cared for/last shift 17.49 0.00 0-5 213 38.5 1.97 6-10 100 18.1 2.26 > 10 240 43.4 2.49 Mean ± SD 11.94 ± 11.30 No. of patient admissions/last shift 4.32 0.01 0-5 468 84.6 2.20 6-10 78 14.1 2.54 > 10 7 1.3 2.45 Mean ± SD 3.17 ± 2.74 No. of patient discharges/last shift 2.27 0.10 0-5 495 89.5 2.27 6-10 49 8.9 2.23 > 10 9 1.6 1.58 Mean ± SD 2.50 ± 2.81 Perceived staffing adequacy 7.88 0.00 100% of the time 47 8.5 2.27 ± 1.00 75% of the time 130 23.5 2.04 ± 0.81 50% of the time 158 28.6 2.07 ± 0.80 25% of the time 129 23.3 2.41 ± 1.10 0% of the time 89 16.1 2.64 ± 1.03 Work retention plan 1.65 0.09 Plan to leave work within 6 months 137 24.8 2.38 ± 1.15 No plan to leave work within 6 months 416 75.2 2.21 ± 0.88 P value < 0.05 (T test was used for comparison of means between two groups and one-way ANOVA for comparison of means of more than two groups) Table 4 Spearman rank-order correlations between overall missed nursing care and non-nursing tasks Non-nursing task Total (n = 553) Overall MNC Mean (SD) Delivering and retrieving food trays 0.79 (0.81) −0.133 Performing non-nursing care 1.14 (0.70) −0.017 Arranging discharge referrals and transportation (including long-term care) 1.43 (0.68) −0.077 Routine phlebotomy/blood draw for tests 1.72 (0.53) −0.041 Transporting patients within hospital 1.36 (0.65) −0.085 ** Cleaning patient rooms and equipment 1.45 (0.68) −0.259 Filling in for non-nursing services and available on off hours 0.96 (0.78) 0.027 Obtaining supplies or equipment 1.53 (0.63) −0.085 Answering phones, clerical duties 0.79 (0.81) 0.056 Spearman correlation coefficient P value < 0.05 ** Spearman Correlation Coefficient P value < 0.01 Scores (0-2) Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 7 of 9 Table 5 Spearman rank-order correlations between missed nursing care and satisfaction Satisfaction dimension Total (n = 553) Overall MNC Mean (SD) ** Work schedule flexibility 2.49 ± 0.90 −0.136 ** Opportunity for advancement 2.47 ± 0.92 −0.110 ** Professional status 2.49 ± 0.96 −0.186 Salary 1.82 ± 0.88 −0.103 Educational opportunities 2.25 ± 0.91 0.015 Annual leave 2.26 ± 0.90 0.054 ** Sick leave 1.99 ± 0.92 −0.119 Study leave 2.05 ± 0.91 −0.001 Current job 2.87 ± 0.85 −0.066 Independence at work, be a nurse or technician 2.83 ± 0.88 −0.095 Team work and co-operation within department/unit 2.89 ± 0.88 −0.079 ** Overall 2.40 ± 0.56 −0.170 Spearman correlation coefficient P value < 0.05 ** Spearman Correlation Coefficient P value < 0.01 Scores (1–4) hospital stay [29–31]. Thus, adequacy of staffing is the fact that people respond positively and with more of paramount importance in ensuring patient safety motivation to do a good job when they witness their and reducing missed nursing care. Thus, it is recom- constituents benefiting from their efforts. In the case of mended to use a staffing approach which accounts nursing, unlike some other occupations, the providers for individual patient variation in need as alterna- have direct and many times immediate knowledge about tives to, or in conjunction with, minimum staffing the effect of the quality of their work on their patients. levels based entirely on patient volumes which is Thus, nurses are fully cognizant of the impact of missing used in public hospitals in Egypt [32]. care for their patients, and when the effect is negative In the current study, only two non-nursing tasks [19, 35]. This was supported by a study conducted in the correlated positively with missed nursing care: clean- USA where each one unit increase in missed nursing ing patients’ rooms and filling in for non-nursing ser- care was associated with a 0.26 decrease in job enjoy- vices and available on off hours. Both correlations ment [36]. The second possible explanation is that the were weak and non-significant. This unexpected find- dissatisfied nurse is more prone to miss elements of ing could be explained by the fact that nurses may nursing care. Further research should explore the causa- consider all the other non-nursing tasks to be part of tive relation between MNC and nurses’ satisfaction. their workload. Studies pointed out that nurses accept performing non-nursing duties, because these roles 4.1 Limitations are founded on organizational as well as individual The current study addresses the concept of MNC in one patient relationships [33]. of the largest teaching hospitals in Egypt. It sets a basis The current study showed transporting patients in for further assessments and suggestions for improve- hospital correlated negatively and significantly with cer- ment. Further research studying the link between MNC tain missed nursing care elements. The rationale for this and adverse events is recommended. might be that when patients are transferred outside of The current study used subjective measures of missed the unit, it is crucial that all procedures are done before care, with most relying on retrospective reports by leaving the unit [17]. nurses. Further studies using objective measures as dir- Overall satisfaction showed a negative weak significant ect observation of nursing care are recommended to correlation with overall MNC. This is consistent with evaluate the current study findings. The study was con- the results of two studies conducted in the USA where ducted in a teaching hospital which limits the nurses who perceived less MNC on the patient care unit generalization of the results to other settings as private, where they work are more satisfied in their current pos- Ministry of Health and Insurance settings. ition and occupation [19, 34]. This can have two possible explanations in the present study. First, is that when 5 Conclusions nurses see that the elements of nursing care are missed, The missed nursing care is relatively higher when com- they become more dissatisfied. This can be explained by pared to other settings. The dimensions which are Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 8 of 9 frequently missed are “basic needs” and “planning.” The 2. Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509–17. mean missed care was lower in the ICU as compared to 3. Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and the medical and surgical units. Nursing staffing adequacy implicitly rationed care: state of the science review. Int J Nurs Stud. 2015; and number of patients cared by nurse were factors as- 52(6):1121–37. 4. Kalisch BJ, Tschannen D, Lee H, Friese CR. Hospital variation in missed sociated significantly with higher score of missed nursing nursing care. Am J Med Qual. 2011;26(4):291–9. care. Non-nursing tasks and nurses’ job satisfaction 5. Kalisch BJ, Lee KH. Missed nursing care: magnet versus non-magnet showed negative weak correlation with the overall MNC. hospitals. Nurs Outlook. 2012;60:e32–9. 6. Palese A, Ambrosi E, Prosperi L, Guarnier A, Barelli P, Zambiasi P, et al. Missed nursing care and predicting factors in the Italian medical care Abbreviation setting. Intern Emerg Med. 2015;10(6):693–702. MNC: Missed nursing care 7. Chapman R, Rahman A, Courtney M, Chalmers C. Impact of teamwork on missed care in four Australian hospitals. J Clin Nurs. 2017;26(1-2):170–81. Acknowledgements 8. Moreno-Monsiváis MG, Moreno-Rodríguez C, Interial-Guzmán MG. Missed The authors would like to express their gratitude for the nurses who agreed nursing care in hospitalized patients. Aquichan. 2015;15(3):318–28. to conduct the interview and the hospital administration who facilitated the 9. Kalisch BJ, Tschannen D, Lee KH. Do staffing levels predict missed nursing conduction of the research. care? Int J Qual Health Care. 2011;23(3):302–8. 10. Dabney BW, Kalisch BJ. Nurse staffing levels and patient-reported missed Authors’ contributions nursing care. J Nurs Care Qual. 2015;30(4):306–12. MH has made substantial contributions to or acquisition and interpretation 11. Kim YS, Yeon KN, You SJ, Lee ID. Effects of increasing nurse staffing on of data. WG has made substantial contributions to conception and design, missed nursing care. Int Nurs Rev. 2015;62:267–74. analysis, and interpretation of data. RM has contributed to analysis and 12. Bragadóttir H, Kalisch BJ, Tryggvadóttir GB. Correlates and predictors of interpretation of data and drafted the manuscript. The authors read and missed nursing care in hospitals. J Clin Nurs. 2017;26(11-12):1524–34. approved the final manuscript. 13. Ausserhofer D, Zander B, Busse R, Schubert M, De Geest S, Rafferty AM, et al. Prevalence, patterns and predictors of nursing care left undone in European Funding hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ There was not any funding agency for this research. Qual Saf. 2014;23(2):126–35. 14. Kalisch BJ, Doumit M, Lee KH, Zein JE. Missed nursing care, level of staffing, Availability of data and materials and job satisfaction: Lebanon versus the United States. J Nurs Adm. 2013; The data are available from the corresponding author on reasonable request. 43(5):274–9. 15. Al-Kandari F, Thomas D. Perceived adverse patient outcomes correlated to Declarations nurses’ workload in medical and surgical wards of selected hospitals in Kuwait. J Clin Nurs. 2008;18:581–90. Ethics approval and consent to participate 16. Aiken LH, Clarke SP, Sloane DM, Sochalski JA, Busse R, Clarke H, et al. Nurses’ The manuscript was approved by the ethics committee of the High Institute reports on hospital care in five countries. Health Aff (Millwood). 2001;20(3): of Public Health, Alexandria University and the Director of Central 43–53. Administration of Alexandria Hospitals (The Ethics Committee does not 17. Bekker M, Coetzee SK, Klopper HC, Ellis SM. Non-nursing tasks, nursing tasks provide a reference number). Verbal consent was obtained from nurses. The left undone and job satisfaction among professional nurses in South African ethics committee approved this type of consent. The purpose of the study hospitals. J Nurs Manag. 2015;23(8):1115–25. was explained to the nurses and they were assured of confidentiality and 18. Tschannen D, Kalisch BJ, Lee KH. Missed nursing care: the impact on anonymity of information and that it will be used for research purposes only. intention to leave and turnover. Can J Nurs Res. 2010;42(4):22–39. Verbal consent was approved by the ethics committee. Following this verbal 19. Kalisch B, Tschannen D, Lee H. Does missed nursing care predict job explanation, a study information sheet was given to the nurses and they satisfaction? J Healthc Manag. 2011;56:117–31. were allowed enough time to consider whether or not to participate in the 20. Abd Elrehem MAE, Abd El Fatah MA, Seloma YA. Correlates of missed study. nursing care in selected medical intensive care units, Egypt. J Biol Agric Procedures for the ensuring nurses confidentiality were taken. Identification Healthc. 2014;4:88–105. code numbers were used on the questionnaires instead of personal 21. Attia NM, Abdeen MA, El Sayed SH. Impact of nursing teamwork on missed identifiers. Access to research data was limited to the research team. nursing care in intensive care units at Zagazig University Hospitals. Zagazig Nurs J. 2014;10(2):201–17. Consent for publication 22. Mohamed SA, Abed F. Perception of teamwork and missed nursing care Not applicable. among nurses in intensive care units at South Valley University Hospitals. IOSR J Nurs Health Sci. 2016;5:89–97. Competing interests 23. El Rehem MAE, Elhamid MA, Elsalam YA. Missed nursing care: observation Dr. Rasha Mosallam is a co-author of this study and editorial board member versus perception in selected medical intensive care units, Egypt. Int J of the journal. She declares a competing interest for this submission. She has Health Wellness Soc. 2017;7(1):31–47. not handled this manuscript. The rest of the authors have no conflict of 24. Kalisch BJ, Williams RA. Development and psychometric testing of a tool to interest to declare. measure missed nursing care. J Nurs Adm. 2009;39(5):211–9. 25. Report of the Irish RN4CAST study 2009-2011. [Cited 2017 Nov 8]. Available Author details from: http://doras.dcu.ie/19344/1/RN4CAST_FINAL_report_18_April_2013_ Ministry of Health, 97 El-Horeya Road, Qism Bab Sharqi, Wabour Al Meyah, DORAS.pdf Alexandria Governorate, Egypt. High Institute of Public Health, Alexandria 26. Orique SB, Patty CM, Woods E. MNC and unit-level nurse workload in the University, 165 El-Horeya Road, Al Ibrahimeyah Qebli WA Al Hadrah Bahri, acute and post-acute settings. J Nurs Care Qual. 2016;31(1):84–9. Qism Bab Sharqi, Alexandria Governorate, Egypt. 27. Kalisch BJ, Xie B. Errors of omission: missed nursing care. West J Nurs Res. 2014;36(7):875–90. Received: 22 July 2020 Accepted: 22 June 2021 28. Tubbs-Cooley HL, Mara CA, Carle AC, Mark BA, Pickler RH. Association of nurse workload with missed nursing care in the neonatal intensive care unit. JAMA Pediatr. 2019;173(1):44–51. References 29. Ball JE, Bruyneel L, Aiken LH, Sermeus W, Sloane DM, Rafferty AM, et al. 1. Kalisch BJ. Missed nursing care: a qualitative study. J Nurs Care Qual. 2006; RN4Cast Consortium. Post-operative mortality, missed care and nurse 21(4):306–13. Hammad et al. Journal of the Egyptian Public Health Association (2021) 96:22 Page 9 of 9 staffing in nine countries: a cross-sectional study. Int J Nurs Stud. 2018;78: 10–5. 30. Clarke SP, Aiken LH. Failure to rescue: needless deaths are prime examples of the need for more nurses at the bedside. Am J Nurs. 2003;103(1):42–7. 31. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195–204. 32. Griffiths P, Saville C, Ball J, Jones J, Pattison N, MonksT, et al. Safer Nursing Care Study Group. Nursing workload, nurse staffing methodologies and tools: a systematic scoping review and discussion. Int J Nurs Stud. 2019;103: 33. Allen D. Re-conceptualising holism in the contemporary nursing mandate: from individual to organisational relationships. Soc Sci Med. 2014;119:131–8. 34. Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care community hospital. J Nurs Adm. 2018;48(7-8): 361–7. 35. Grant AM. Relational job design and the motivation to make a prosocial difference. Acad Manag Rev. 2007;32(1):393–417. 36. Smith JG, Rogowski JA, Lake ET. Missed care relates to nurse job enjoyment and intention to leave in neonatal intensive care. J Nurs Manag. 2020;00:1–8. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Journal

Journal of the Egyptian Public Health AssociationSpringer Journals

Published: Jul 20, 2021

Keywords: Missed nursing care; Staffing adequacy; Non-nursing tasks; Egypt

References