Determinants of Missed Nursing Care by Nurses at University Teaching and Referral Hospital (Chuk) of Kigali in Rwanda

doi:10.21203/rs.3.rs-1545346/v1

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Research Article

Determinants of Missed Nursing Care by Nurses at University Teaching and Referral Hospital (Chuk) of Kigali in Rwanda

https://doi.org/10.21203/rs.3.rs-1545346/v1

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Objective

The aim of this study was to determine the levels, types and the factors that influence Missed Nursing Care activities by nurses at the University Teaching and Referral Hospital of Kigali in Rwanda.

Material and Methods

This study was cross-sectional descriptive correlation design. The researchers used complete coverage method of sampling technique to obtain participants. The researchers used MISSCARE survey questionnaires for data collection with. The data was analysed using SPSS version 26.0. Frequencies, crosstabulation, chi-square and multinomial logistic regression were computed to find the percentage, associations and effects between independent and dependent variables at 95% confidence interval and significance level of 5%.

Results

Two hundred and one (201) nurses took part in the study, 56.7% were female and 46.3% were male. The majority were aged 31–40 years, 54.2% had Diploma, 42.3% had bachelor while 3.5% had master’s degree, and 75.6% were married. The mean experience in nursing and in current unit were 13years and 7years respectively. Missed nursing care was regarded as moderate as perceived by 46.73% of respondents. The study showed that replying to call alarms within 5 minutes, joining interdisplinary whenever held, documentation of necessary information, monitoring intake and output, and patient health education were always being missed by nurses. Institutional unit type (χ² (6, N = 201) = 63.31, p = 0.001), gender (χ² (2, N = 201) = 10.35, p = 0.006), orientation (χ² (2, N = 201) = 9.51, p = 0.009), satisfaction with salary (χ² (2, N = 201) = 8.25, p = 0.016), level of education (χ² (2, N = 201) = 10.34, p = 0.006), and ward size were the most statistically significant factors associated with level of missed nursing care activities.

Discussion

Majority, 46.73% of nurses viewed the level of missed nursing care at the hospital as moderate. The top five nursing activities that have always been missed were replying to call alarms within 5 minutes, joining interdisplinary whenever held, documentation of necessary information, monitoring intake and output, and patient health education. The study findings revealed that gender, level of education, and the department in which the nurses work were the most statistically significant factors contributing to missed nursing care at the hospital.

Conclusions

The study findings showed that level of missed nursing care was moderate and it was different across the hospital. The findings also showed that there was top five missing nursing care that are aways missing affected by various factors.

Nursing

Nursing care

missed nursing

Nursing activities

Patient safety and care outcomes determine the excellence of healthcare services given in hospital settings. Nursing personnel primarily and positively impacts this safety and outcomes through their nursing care provision. Nursing care is any activity needed by the patient prescribed or implemented by a nurse. It includes assessing admitted patient and their progress, timely drug administration, patient teaching, changing their position, ambulation, convenient feeding, mouth care, conversing with both patient and his family comfortably, documenting nursing activities in the patient record, and actively joining interdisciplinary meetings(1). Nursing care services or activity that is not implemented reflects the healthcare underuse or wastage. It is referred to as Missed Nursing Care (MNC) and affects the quality of nursing care delivered to hospitalised patients is negatively affected(2). MNC is described as any nursing care essential to the patient that is left undone, uncompleted, rationed, omitted, or forgotten. Furthermore, this has contributed to poor patient outcomes(1); (2). The incidence of MNC reflects underusing or wasting healthcare services, and it is due to different factors. These factors primarily include communication, staffing, working environment, material resources, and some staff characteristics. It was proven to be associated with frequent hospital readmissions in the USA(1).

According to different studies done in United States America, females, older Registered Nurses (RN), day shifts nurses, experienced nurses, nurses who perceive that the Unit's staffing is not enough, nurses who nurse a large number of patients during their shift reported more missed nursing care (2);(1); (3).Furthermore, when this care is not implemented, significantly delayed, or unfinished, it adversely impacts patients' outcomes. These adverse outcomes include healthcare-related infections, inadequate discharge planning, falls, and delayed ambulation, resulting in delayed wound healing, surgical site infections, respiratory system infections, poor coping, and adherence to treatment regimens(3);(4). Similarly, USA research reported that MNC was associated with nursing unit type, workload, and staffing or skill mix (5). According to a Brazilian study, among 58 nurses who participated in a survey assessing Missed Nursing Care and their reasons, 74.1% reported at least one nursing activity missed on their shift. This MNC was associated with inadequate staffing, material resources (drugs, equipment, and consumables), and emergencies (6). The findings from a study done in Mexico emphasized that the most common MNC were to ambulate the patients at least three times a day, feeding the patient, patient's foot and wound care, and patient teaching while still in hospital (7). A study conducted across twelve different countries studying the prevalence and predictors of MNC in Europe revealed that most nursing activities (care) were left undone. The results included comforting patients, nursing care planning and revising, giving psycho-emotional support, evaluating recently admitted patients and documenting, evaluating medication efficiency, and mouth hygiene or care and client position change (8).

Moreover, research from the United Kingdom, which included 2,917 nurses from general medical-surgical wards in 46 England hospitals, agreed with the studies mentioned above(9). The survey conducted in nine European countries intended to explore whether MNC intervened in the detected association between the ratio of staff and mortality and included 26,516 registered nurses. It found a significant relationship among MNC, staffing level, and patient's death within 30 days from admission. When the data was adjusted, the finding showed that increasing workload for nurses by a single patient and reported MCN by 10% increase the odds of admitted patient's death by 7% and 16%, respectively, within 30 days. Furthermore, this mediation analysis found an association of staffing with MNC and MNC with mortality(10).

In addition, the findings from different studies conducted in Egypt were congruent with other researches. They reported that patient feeding, patient assessment, and patient health education were missing and associated with inadequate staffing, material resources, ineffective teamwork, and communication factors(11); (12). Another similar study conducted in Tigray, northern Ethiopia, which included 422 nurses from 16 general hospitals, found at least one Missed Nursing Care at each shift and was associated with Communication, labor, material resources(13). This concept has been found in East Africa. However, literature is scarce in East Africa. An observational study in neonatology (Kenya) found that the least completed nursing activities included a reassessment of newborns, cleaning their eyes and assessing infection, turning or positioning the babies at 38%, and monitoring oxygenation 3,4% and skin assessment 15% in neonatology. These were associated with the baby per nurse ratio (14).

A similar study conducted in three Egyptian university teaching hospitals with 240 nurses found that 63.3%, 61.3%, and 57.2% of the respondents ranked inadequate nursing staffing as a significant reason for omitted nursing care. The same researcher reported that communication and material resources, and assistive personnel were among the factors leading to missed nursing care (11). Despite the adverse effects of this omission on patient outcomes, sketchy literature was found from the African context except in Egypt, Ethiopia, and South Africa. However, there is a single observational study found in Kenya; no literature was found in Rwanda on this concept. Therefore, there was a need to understand and describe the magnitude of Missed Nursing Care in Rwanda.

Study setting and data collection

This research was conducted at the University Teaching and Referral Hospital of Kigali in Rwanda, also known on its French name as "Centre Hospitalier Universitaire de Kigali" (CHUK). It is offering healthcare services through the following units: accident and emergency, general surgery, internal medicine, dermatology, paediatrics, obstetrics & gynaecology, Ear Nose and Throat (ENT), dental, ophthalmology, orthopaedics, Intensive care unit (ICU), clinical psychology, oncology, nephrology, dermatology, Urology, cardiology, radiology, neonatology. In addition, they also provide mental healthcare services and other specialised outpatient clinics. This study adopted MISSCARE survey to gather the data from the sample population. Kalisch & Williams(16) developed the MISSCARE survey. The MISSCARE survey was comprised of three parts; the first section was for nurse related factors (gender, age, marital status, education, and job experience, work schedules (Shift mostly worked (day or night), and hours work per shift), staffing (absenteeism, perceived staffing adequacy, and patients' workloads, Intent to leave the institution, and satisfaction with the payment and incentives) and personal satisfaction and section two with institutional related factors (level of ward staffing, bed capacity, size of the ward when admitting patients and when performing procedures, workload and call for additional shifts, material resources with three items, and huma resources with seven items. Section three had 24 questions regarding Missed Nursing Care grouped into nine (9) areas: 1) assessment with five (5) subjects, 2) drug administration with four(4) subjects, 3) patient health education with three (3) elements 4) patient feeding with three (3) items, 5) hygiene with three elements, 6) patient mobility with two (2) subjects, 7) responding to patient inquiries with two (2) elements 8) attending interdisciplinary meetings one (1) element and 9) documenting all necessary data with one(1) element.

The rating was on 5 points Likert scales as 1= never missed, 2=rarely missed, and 3 = sometimes missed, 4= frequently missed and 5= always missed (17). Therefore 1 and 2 were regarded as nursing care provided, three as neutral, and 4,5 was considered as nursing care missed (11,18). Section three of the MISSCARE survey has 17 independent variable questions on factors associated with missed nursing care grouped into two domains: 1) material resources with three elements, and 2) staff (labor) resources with seven elements. The rating was on three points Likert scale as (3) significant factors or reasons, (2) moderate reasons, and (1) not a factor, then means and percent scores was computed (11). The items of the questionnaire were rearranged to suit the study objectives.

Specific objectives

1. To determine the level of Missed Nursing Care activities by nurses working at University Teaching and Referral Hospital of Kigali.

2. To assess the type of Missed Nursing Care activities by nurses working at University Teaching and Referral Hospital of Kigali.

3. To determine the nurse related factors that contributing to Missed Nursing Care activities by nurses working at University Teaching and Referral Hospital of Kigali.

4. To determine the institutional related factors that contribute to Missed Nursing Care activities by nurses working at University Teaching and Referral Hospital of Kigali.

Inclusion and exclusion criteria

The study included nurses who were six months and above working experience in the clinical setting in the selected hospital units. Nurses providing direct care to inpatients in selected hospital units and it excluded nurses in administrative positions and nurses who were on their leave in the period of data collection. During data collection, the researcher utilized a self-report method of data collection using a self- administered MISSCARE survey. First, the departments were visited in different shifts to maximize accessibility to participants; then, the researcher invited the participants and explained the study's objectives. After this explanation, each participant signed informed consent for participation. Then researcher distributed envelope containing MISSCARE survey with the instructions on how to filling it.

Statistical analysis

The data were analysed using SPSS version 26.0. The analysis was comprised of descriptive and inferential statistics. Descriptive statistics were frequency distributions, mean, and mode and crosstabulation/ percentages. Inferential statistics included Pearson chi-square test for independence (X²) and multinomial logistic regression was computed to describe and explain the effects of independent variables on the dependent variable at the significance level of (P≤0.05).

Two hundred and one (201) nurses working in different departments at the hospital took part in this study in response to various metric variables being examined. The nurses who took part in this study work in different hospital ward departments with majority of them (39.8%,80) working in the surgical ward, 24.9% (50) of them work in the medical ward whereas 21.9% (44) work in accident and emergency ward. A relatively small percentage of nurses 13.4% (27) work in intensive care unit Table1.

In this study, female nurse respondents working at the hospital were the majority accounting to 56.7%. The percentage of male respondents who took part in this study was 46.3%. Majority of the nurses working at the hospital were aged between 31–40 years which represents 47.3%. It is followed by those aged between 21–30 years which represents 26.9%. Those aged between 41–50 years account for 25.9% of the entire study population. The level of education among respondents was assessed. 54.2% had a Diploma, 42.3% had a Bachelor degree and 3.5% have a master’s degree. From the study, a vast majority of nurses were married accounting for 75.6%. Those who are single represent 18.9%. The respondents who were not married (Divorced, Widowed) were the minority representing only 5.5% Table 2.

Levels Of Missed Nursing Care At The Hospital

At the University Teaching and Referral Hospital (CHUK) of Kigali, the level of missed nursing was regarded as moderate. It was concluded that a vast majority of nurses 46.73% perceive the level of missed nursing care as moderate. 29.65% of them perceive the level of missed nursing care activities to be high whereas 23.62% perceive that there is low level of missed nursing care activities by nurses working at the hospital Fig. 1.

Types of Missed Nursing Care activities by nurses working at the hospital

The study assessed the types of nursing care activities at the hospital. The goal was to establish which nursing care activities have been missed by the studied nurses. The results were as shown in Table1.The frequency of missed nursing care activities was recoded into three categories, that is nursing activities that have never been missed, sometimes been missed and always been missed. From the table it is apparent that over 50% of the studied nurses have never missed the various types of nursing activities. Despite majority of the nurses responding not to have missed any nursing care activities there was some who sometimes missed and always missed certain nursing care activities. The top 10 nursing care activities that are sometimes missed by the nurses were: responding to drug request within 15 minutes (27.4%), reassessment of patients (26.4%), reply to call alarms within 5 minutes (26.4%), providing skin care for patients (26.4%), monitoring blood glucose level (25.9%), changing patient position after every 3 hours (25.4%), joining interdisplinary whenever held (24.9%), setting food for patients who cannot feed oneself (24.4%), supporting patient reach latrine within 5 minutes (23.9%), providing patient health education 23.4% and assessing vital signs. The frequency of nursing activities that have always been missed at the hospital was quite low. However, ranking the top five nursing activities that have always been missed, the following results: replying to call alarms within 5 minutes (29.9%), joining interdisplinary whenever held (25.4%), documentation of necessary information (24.9%), monitoring intake and output (21.9%) and patient health education (18.4%), Table 1.

Nurse related factors that contributing to Missed Nursing Care activities by nurses working at the Hospital of Kigali.

Different variables were examined to determine their relationship with levels of MNC. From the analysis nurses aged between 31–40 years had the highest levels of missed nursing care (35.1%) as compared to

the rest of the age groups, gender was examined and the findings revealed that female (32.1%) of females reported low level of missed nursing care compared to 12.6% of males who reported low level of missed nursing care. Regarding those who had high level of missed nursing care, males ranked the highest with 33.3% whereas females with high level of missed nursing care levels accounted for 26.8%. Those who were oriented had a low level of missed nursing activities at 28.0% compared to those who were not oriented at 5.3%. 42.9% of nurses who were not oriented had high level of missed nursing care compared to 26.7% of nurses who were oriented, it was noted that nurses who were satisfied with orientation had low levels of missed nursing care (27.1%) compared to those who were dissatisfied (14.5%). The nurses who were dissatisfied had high levels of missed nursing care accounting to a percentage of 38.2%. It was also noted that 29.7% of nurses who are planning to leave had low level of missed nursing care compared to 22.2% who had no intention of leaving. 21.6% of nurses who were planning to leave had high level of missed nursing care compared to those who had no intention of leaving. The disparity in percentages could be due to very low numbers of nurses who were planning to leave the institution Table 2.

Table 1

Frequency distribution of types of missed nursing care activities
Missed Nursing Care Variable	Never Missed		Sometimes Missed		Always Missed
Missed Nursing Care Variable	No	%	No	%	No	%
Vital Signs Assessed	133	66.2	47	23.4	21	10.4
Monitoring Intake &Output	120	59.7	37	18.4	44	21.9
Monitoring blood glucose level	138	68.7	52	25.9	11	5.5
Patient Assessment	137	68.2	37	18.4	27	13.4
Reassess of Patients	121	60.2	53	26.4	27	13.4
Drug Administration within 30Minute	151	75.1	21	10.4	29	14.4
Care Per standard hospital procedure	126	62.7	40	19.9	35	17.4
Drug Request responded within 15 Minutes	128	63.7	55	27.4	18	9.0
Assessment of effectiveness of medication	127	63.2	48	23.9	26	12.9
Health Education of Patient’s family	141	70.1	41	20.4	19	9.5
Patient Health Education	117	58.2	47	23.4	37	18.4
Information to Patients	129	64.2	40	19.9	32	15.9
Setting food for patient who cannot feed oneself	136	67.7	49	24.4	16	8.0
Feeding Patient who cannot feed oneself	139	69.2	34	16.9	28	13.9
Feeding Patient warm food	158	78.6	28	13.9	15	7.5
Provide skin care for patients	125	62.2	53	26.4	23	11.4
Patient mouth care	128	63.7	36	17.9	37	18.4
Hand Washing for Nurses	138	68.7	39	19.4	24	11.9
Ambulating Patients as prescribed	127	63.2	51	21.4	23	11.4
Change patient position every 3hours	127	63.7	51	25.4	23	11.4
Support patient reach latrine within 5 minutes	127	63.7	48	23.9	26	12.9
Reply to call alarm within 5 Minutes	88	43.8	53	26.4	60	29.9
Documentation of necessary information	110	54.7	41	20.4	50	24.9
Join interdisplinary whenever held	100	49.8	50	24.9	51	25.4

However, more research needs to be done to determine the cause of this disparity. Nurses were asked whether they were satisfied with their current position at the hospitals. From their responses it was apparent that majority (89.45%) were satisfied with their position while 10.55% were dissatisfied with their position. 25.8% of nurses who were satisfied with position had low level of missed nursing care activities compared to those who are dissatisfied with their position. Salary is a motivating factor when it comes to employee performance. From the nurses who took part in this research, it was apparent that majority of them were satisfied with their salaries. 25.5% of nurses who were satisfied with their salaries reported low level of missed nursing care compared to those who were dissatisfied with their salaries. 50% of nurses who were dissatisfied with their salaries reported high level of missed nursing care activities. Regarding the satisfaction with incentives, 38.9% of nurses who were dissatisfied with incentives had high level of missed nursing care compared to 21.2% of nurses who were satisfied with incentives. Moreover, 36.5% of nurses who were satisfied with incentives had low level of missed nursing care compared to 9.5% of nurses who are dissatisfied with incentives. From the cross-tabulation, 25.9% who were satisfied with in-service training had low level of missed nursing care compared to 18.3% of those who were dissatisfied with in-service training. Moreover, 31.7% of nurses who were dissatisfied with in-service training had high level of missed nursing care compared 28.8% of nurses who were satisfied with in service training. The nurses who had a Diploma degree (30.8%) reported low level of missed nursing care compared to 15.2% of nurses who had a Bachelor’s Degree. Nurses with a Bachelor’s degree (39.1%) reported high level of missed nursing care compared to 21.5% of the nurses with a Diploma Degree. The studied nurses were asked whether they are satisfied with their career. Majority of the nurses (94%) were satisfied with their career and 6% were not satisfied. Among those who were satisfied, a large proportion (46.5%) had moderate level of missed nursing care activities. 28.9% of them had high levels of missed nursing care activities whereas 24.6% had low level of missed nursing care. The nurses who were dissatisfied with their career, 41.7% had high levels of missed nursing care.

Institutional related factors that contribute to Missed Nursing Care activities by nurses working at the Hospital of Kigali.

The most significant variable that was always inadequate was the size of ward when performing procedures accounting for 53.2%. It was followed by level of bed capacity at 49.8% and size of the ward when admitting patients at 48.3%. 41.3% of the respondents said that the level of ward staffing was always inadequate. Respondents were asked whether the workload was heavy and how often additional shift was called. Majority (55.2%) of the nurses responded call for additional shift has never occurred whenever the workload was heavy. Circumstances when the workload was presumed to be heavy, has always occurred as reported by 57.2% of the nurses. Generally, the studied nurses were of the view that material resources were a moderate factor contributing to missed nursing care activities. The rank of material resources factors that were presumed to be moderate by the nurses were absence of drugs when needed 51.2%, equipment not operating when needed 49.3% and unavailability of medical equipment when needed 45.3%. Human resource factors were examined. From the responses of the studied nurses, it was apparent that insufficient staff members were the most significant factor at 40.3%. It was followed by unpredictable upsurge in patient numbers (32.3%), huge massive admissions and few discharge-ins (31.8%) and emergency patient situation (29.9%). 61.7% of the studied nurses said that insufficient clerical personnel were a moderate factor. It was followed by emergency patient situation at 49.3%, imbalanced patient assignment 48.3%, insufficient staff members 45.8%, care giver unavailable in the unit when needed (43.8%) and huge massive admission and few discharge-ins (43.3%), table 3 (additional documents).

Relationship between nurse related factors and levels of missed nursing care.

The chi-square was computed to assess the relationship between nurse related factors and levels of missed nursing care and the statistically significant were department where nurses work, χ² (6, N = 201) = 63.31, p = 0.001, gender, χ² (2, N = 201) = 10.35, p = 0.006, orientation, χ² (2, N = 201) = 9.51, p = 0.009, Satisfaction with salary, χ² (2, N = 201) = 8.25, p = 0. 016, Satisfaction with incentives,χ² (2, N = 201) = 21.61, p = 0.001, level of education, χ² (2, N = 201) = 10.34, p = 0.006.However, age p = 0.461; marital status, p = 0.137; experience in the nursing profession, p = 0.447; experience in the current unit, p = 0.514; satisfaction with being a nurse, p = 0384; satisfaction with orientation, p = 0.104; satisfaction with current position, p = 0.98; satisfaction with in service trainings, p = 0.514 and plan for leaving the institution, p = 0.419 were not statistically significant in Table 2.

6. Relationship between institutional related factors and missed nursing care.

The researcher further sought to find whether there was any relationship between institutional related factors and levels of missed nursing care activities and chi square was computed. The findings revealed that level of ward staffing and ward size when performing procedures, how often additional shift is called, Absence of drugs when needed and unavailability of medical equipment, unpredictable upsurge in patient numbers, caregiver unavailability in the unit when needed, emergency patient situation, and imbalanced patient assignment were statistically significant table 3 and 4 ( additional documents).

The nurses were asked how often certain types of nursing activities have been missed at the hospital. The data collected from their responses was computed and recoded into three levels, that is low, moderate and high. Frequency analysis was done and the results revealed that majority, 46.73% of nurses viewed the level of missed nursing care at the hospital as moderate, these findings were consistent with that of(11). Since majority of the studied nurses had a view that the level of missed nursing care activities was moderate, it can be generalized that the level of missed nursing care activities at the hospital was moderate. Moreover, this can be explained by noting that from the analysis of nurse related factors specifically on their satisfaction level, majority of the nurses were satisfied with orientation, trainings offered at the hospital to nurses, they were satisfied with their job position, salary and had no intention of leaving. It should also be noted that 79.1% of nurses had not missed any shift. This also helps to explain why the level of missed nursing care was moderate at the hospital.

Types Of Missed Nursing Care

Nurses working at the hospital were asked questions on five-point Likert scale on how often various nursing care activities have been missed. The data from their responses were recoded into three levels of frequency that was, whether the types of nursing activities have never been missed, sometimes missed and always missed. From frequency analysis of their responses the study found out that majority of the nurses responded that most of the nursing activities at the hospital that were being assessed have never been missed. The frequency of nursing activities that have always been missed at the hospital was quite low. This can be seen from their lower percentages in frequency analysis Table 1. However, ranking the top five nursing activities that have always been missed, the following were the results: replying to call alarms within 5 minutes (29.9%), joining interdisplinary whenever held (25.4%), documentation of necessary information (24.9%), monitoring intake and output (21.9%) and patient health education (18.4%)(19).Despite majority of the nurses responding not to have missed any nursing care activities there are some who sometimes missed certain nursing care activities. The top 10 nursing care activities that are sometimes missed by the nurses are: responding to drug request within 15minutes (27.4%),reassessment of patients (26.4%), reply to call alarms within 5 minutes (26.4%), providing skin care for patients (26.4%), monitoring blood glucose level (25.9%) ,changing patient position after every 3hours (25.4%), joining interdisplinary whenever held (24.9%), setting food for patients who cannot feed oneself (24.4%), supporting patient reach latrine within 5 minutes (23.9%) and providing patient health education( 23.4%)(11, 16, 17, 18).

Nurse Related Factors Contributing To Missed Nursing Care Activities

The analysis of nurse related factors was done in two-fold, that was, nurse demographic factors and level of satisfaction of the studied nurses. The demographic factors that were examined in the study included: age, gender, marital status, level of education, plan of leaving, orientation, experience in the current unit and experience in the nursing profession. The ward departments in which the nurses work was also analysed. The study findings revealed that gender, level of education, orientation and the department in which the nurses work to be the most significant demographic factors contributing to missed nursing care at the hospital. The chi-square statistics computed for these factors were statistically significant. The analysis of the gender show that female nurses were more diligent in their duties compared to their male counterparts. This follows from the fact that 32.1% of female nurses had low level of missed nursing care compared to 12.6% of males who had low level of missed nursing care. Regarding those who had high level of missed nursing care, males rank the highest with a percentage of 33.3% whereas females with high level of missed nursing care levels accounted for only 26.8%.

Nurses with a Diploma degree were diligent in delivering their duties compared to those with a Bachelor’s Degree. The study findings showed that the nurses who had a Diploma degree (30.8%) reported low level of missed nursing care compared to 15.2% of nurses who had a Bachelor’s Degree. Nurses with a Bachelor’s degree (39.1%) reported high level of missed nursing care compared to 21.5% of the nurses with a Diploma. The result of level of education can be explained by the fact that Diploma training normally focus mainly on skills and focuses on practical approach compared to Bachelor’s Degree training which is too theoretical which neither emphasizes on critical thinking skills approach. Majority of the studied nurses who were oriented in their current unit (28.0%) had low level of missed nursing care activities compared to those who were not oriented. 42.9% of nurses who were not oriented had high level of missed nursing care compared to 26.7% of nurses who were oriented. Departmental wards in which the nurses work also had an influence on missed nursing care activities at the hospital. Nurses working in the accident and emergency wards had the highest level of missed nursing care activities compared to nurses working in other departments. Nurses working in the intensive care units had the lowest level of missed nursing care compared to nurses working in other departmental wards. Nurses working in the medical and surgical wards had moderate level of missed nursing care activities these findings are similar to that of (22). The satisfaction level of nurses was assessed and the findings revealed that salary and incentives were the most significant factors contributing to missed nursing care at the hospital. From the nurses who took part in this research, it is apparent that majority of them were satisfied with their salaries. 25.5% of nurses who were satisfied with their salaries had low level of missed nursing care compared to those who were dissatisfied with their salaries. 50% of nurses who were dissatisfied with their salaries had high level of missed nursing care activities compared to those who are satisfied with their salaries. 38.9% of nurses who were dissatisfied with incentives had high level of missed nursing care compared to 21.2% of nurses who are satisfied with incentives. Moreover, 36.5% of nurses who were satisfied with incentives had low level of missed nursing care compared to 9.5% of nurses who were dissatisfied with incentives as it was also reported by (19).

Institutional Related Factors Contributing To Missed Nursing Care Activities

The institutional related factors were analysed separately to find out whether they contribute to missed nursing care at the hospital. From the analysis, the level of ward staffing and ward size when performing procedures were statistically significant. This signifies that there was association between level of ward staffing, ward size when performing procedures and missed nursing care activities at the hospital. Workload was also among the institutional related factors that were assessed, how often additional shifts were called when the workload was heavy had an influence on the level of missed nursing care at the hospital. 37.3% of nurses who reported that additional shifts have always been called had low level of missed nursing care never been called. These findings are consistent with(11).

Table 2

Relationship between nurse related factors and level of Missed Nursing Care.
Sample characteristic and nurse related factors	Missed nursing care levels						χ²	P-value
Sample characteristic and nurse related factors	Low No = 24		Moderate No = 132		High No = 38		χ²	P-value
	No	%	No	%	No	%
Hospital department	Values were omitted for confidentiality.						63.31	0.001*
Age
21–30 years	14	25.9	29	53.7	11	20.4	3.61	0.461
31–40 years	21	22.3	40	42.6	33	35.1
41–50 years	12	23.5	24	47.1	15	29.4
Gender
Male	11	12.6	47	54.0	29	33.3	10.34	0.006*
Female	36	32.1	46	41.1	30	26.8	10.34	0.006*
Marital status
Married	42	28.0	66	44.0	42	28.0	6.98	0.137
Single	4	10.5	20	52.6	14	36.8
Not married (widow, divorced)	1	9.1	7	63.6	3	27.3
Education level
Diploma, A1	33	30.8	51	47.7	23	21.5	10.34	0.006*
Bachelor’s degree	14	15.2	42	45.7	36	39.1	10.34	0.006*
Experience in nursing profession
0–5 years	4	18.2	14	63.6	4	18.2	3.71	0.447
5–10 years	16	25.4	30	47.6	17	27.0
> 10 years	27	23.7	49	43.0	38	33.3
Experience in the current unit
0–5 years	15	20.5	38	52.1	20	27.4	3.27	0.514
5–10 years	22	26.8	38	46.3	22	26.8
10–20 years	10	22.7	17	38.6	17	38.6
Plan of leaving							1.74	0.419
Yes	11	29.7	18	48.6	8	21.6
No	36	22.2	75	46.3	51	31.5
Satisfaction with being a nurse
Yes	46	24.6	87	46.5	54	28.9	1.91	0.384
No	1	8.3	6	50.0	5	41.7	1.91	0.384
Orientation
Yes	45	28.0	73	45.3	43	26.7	9.51	0.009*
No	2	5.3	20	52.6	16	42.1	9.51	0.009*
Satisfaction with orientation
Yes	39	27.1	67	46.5	38	26.4	4.52	0,104
No	8	14.5	26	47.3	21	38.2	4.52	0,104
Satisfaction with current position
Yes	46	25.8	81	45.5	51	28.1	4.64	0.098
No	1	4.8	12	57.1	8	38.1	4.64	0.098
Satisfaction with salary
Yes	42	25.5	81	49.1	42	25.5	8.25	0.016*
No	5	14.7	12	35.3	17	50.0	8.25	0.016*
Satisfaction with incentives
Yes	38	36.5	44	42.3	22	21.2	21.61	0.001*
No	9	9.5	49	51.6	37	38.9	21.61	0.001*
Satisfaction with in-service training
Yes	36	25.9	63	45.3	40	28.8	1.33	0.514
No	11	18.3	30	50.0	19	31.7	1.33	0.514

24.7% of nurses who were of the view that additional shifts have never been called had high level of missed nursing care compared to 21.6% of nurses who were of the opinion that additional shifts have always been called. Material resource factors that were assessed are: Absence of drugs when needed, unavailability of medical equipment and equipment not operating when needed as it can be seen in table 3, and table 4 (additional documents). The study findings revealed that absence of drugs when needed and unavailability of medical equipment were significant factors contributing to missed nursing care activities. Similar findings were reported by (20, 6, 21, 22, 7, 23). Additionally, the study sought to find out whether human resource contribute to missed nursing care activities by the nurses working at the hospital. The findings revealed that, unpredictable upsurge in patient numbers, caregiver unavailability in the unit when needed, emergency patient situation and imbalanced patient assignment were statistically significant factors contributing to missed nursing care at the hospital and this is similar to findings reported by(6, 24, 25, 26),27).Insufficient staff members, insufficient assistive or clerical personnel, huge massive admission and few discharge-ins were not statistically significant factors contributing to missed nursing care at the hospital.

Multinomial Logistic Regression Analysis

Multinomial logistic model was used to predict dependent variable given independent variables studied. The findings shows the percentage of the dependent variable explained by a set of independent variables. The Nagelkerke Pseudo-Square is 36.5%. This implies that 36.5% on the variation of the dependent variable is being explained by the independent variables in the model.

Parameter estimates provide information comparing each level of missed nursing care against the reference category (High). The analysis compares the likelihood of falling in a certain level of missed nursing care against the reference category. In this case the “low” and “moderate” levels of missed nursing care are compared against high level of missed nursing care. The institutional related factors were not significant. For every one unit increase in unit related factors there is an increase in likelihood by 0.174 of nurses having moderate levels of missed nursing care. The log odds of nurses falling into moderate level of missed care category increases by 1.190 for ever one unit increase in institutional related factors. For human resource factors there was a decrease in likelihood by -1.054 of nurses having low level of missed nursing care compared to the reference category. For every one unit increase in human resource factors there is a decrease of 0.349 in log odds of nurses to have moderate levels of missed nursing care. The human resource factors here was statistically significant (p-value = 0.005).

Material resource factors were not significant. For every one unit increase in material resources there is an increase of 0.643 in likelihood of nurses to have low levels of missed nursing care. For every one unit increase in material resource factors there is 1.903 increase in the log odds of nurses to have moderate levels of missed nursing care compared to the reference category. The nurse related factors are not statistically significant. For every one unit increase in nurse related factors there is a decrease in likelihood by -0.306 of nurses to have moderate levels of missed nursing care. The log odds for nurses falling into category of moderate levels of missed nursing care decrease by 0.737 for every unit increase in nurse related factors table 5 (additional documents).

\(Y=0.378-0.355Nc+0.174It-1.054Hr+0.643Mr-0.306Nr\) \(Y\) -Dependent Variable-Level of missed nursing care, \(Nc\)-Nursing communication, \(It\)-Institutional related factors

\(Hr\) -Human resource factors, \(Mr\)-Material resource factors, \(Nr\)-Nurse related factors

On the basis of study findings, the following conclusions were arrived at regarding the types, factors and level of missed nursing care activities at the University Teaching and Referral Hospital of Kigali. The results indicated the level of missed nursing care activities was moderate. The rank of factors contributing to missed nursing care activities according to their level of significance was nurse related factors and institutional related factors. Nurse related factors that were significantly impacting level of missed nursing care activities were gender, level of education, departmental wards where the nurses work, orientation, and nursing communication. On the level of satisfaction of the nurses, salary and incentives were the most significant factors influencing the level of missed nursing care at the hospital.

Material resources factors that were associated with missed nursing care activities were: absence of drugs and unavailability of medical equipment when needed. The level of ward staffing, size of ward when performing procedures and how often additional shift is called when the workload is heavy were the main significant factors influencing level of missed nursing care at the hospital. Unpredictable upsurge in patient numbers, caregiver unavailability in the unit when needed, emergency patient situation and imbalanced patient assignment were the human resource factors that are significantly contributing to missed nursing care at the hospital. On analysis of types of missed nursing care activities at the hospital majority of the studied nurses responded that they have never missed the various nursing activities that were being assessed. However, there were some nurses who sometimes missed and always missed certain nursing activities. In the study the nursing activities that were sometimes missed and always missed were ranked in descending order based on the percentages.

The institution should make sure that all new staff being hired are oriented well and making sure that they are well acquainted with what is expected of them about their duties and responsibilities. Allocating nurses to departmental wards where they are well suited. Ensure that there is adequate level of ward staffing at the hospital. Ensure that there is expansion in hospital infrastructure in regard to ward size when performing procedures. Make sure there is availability of drugs and medical equipment at the hospital. Make sure that there is a plan to deal with unexpected upsurge in patient numbers and emergency patient situation at the hospital.

Further studies should examine if there is relationship between missed nursing care and quality of patient care. How to control or mitigated various factors that contribute to missed nursing care to make sure that there is sufficient and efficiency service delivery to patients. This was a cross sectional study, thus only associations between missed care and factors leading to missed nursing care have been established. Longitudinal and experimental research that does not rely on nurse or patient self-report is required to better clarify if these relationships between missed care and patient outcome are likely cause and effect.

Ethical approval and consent to participate.

Before starting data collection, the researcher sought clearance from the Institution Ethical Review board at Mount Kenya University (MKU-IERB). The researcher submitted this copy from MKU ethical clearance to CHUK -ethical review committees and was granted the permission to conduct the research. Therefore, the research acquired an informed consent from the participants. The researcher followed all guidelines and protocols as stipulated in the ethical approvals.

Availability of data and materials

The datasets used and analyzed during the current study are available from

the principal or corresponding author on reasonable request through Mount Kenya University. This article is a part of the whole thesis.

Competing interests

Not applicable.

Funding

Not applicable.

Authors’ contributions

Mr. Faustin Ntezimana designed and implemented the study.

Dr. Nilufa Jivraj, PhD and Dr. Dominic Mogere, PhD were supervisors and responsible for efficiency and effective implementation of the study. All authors critically and scientifically reviewed the manuscript and approved its final copy for publication.

Author details

¹Principal author and a master student in medical surgical nursing at Mount Kenya University.

^1*The first corresponding author, Senior Lecturer, school of Nursing at Mount Kenya University.

^2*The second corresponding author, Senior Lecturer, school of Public Health at Mount Kenya University.

Acknowledgements

We thank everyone who directly and indirectly played the role in this research to be successful. Our gratitude is addressed to all institutions, members and leaders who enabled the execution of this project through granting permissions. Finally, we thank all participants who gave their precious tin to prove the data for this research.

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No competing interests reported.

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Determinants of Missed Nursing Care by Nurses at University Teaching and Referral Hospital (Chuk) of Kigali in Rwanda

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Abstract

Objective

Material and Methods

Results

Discussion

Conclusions

Figures

Background

Methods

Inclusion and exclusion criteria

Results

Levels Of Missed Nursing Care At The Hospital

Types of Missed Nursing Care activities by nurses working at the hospital

Discussions

Types Of Missed Nursing Care

Nurse Related Factors Contributing To Missed Nursing Care Activities

Institutional Related Factors Contributing To Missed Nursing Care Activities

Multinomial Logistic Regression Analysis

Conclusions

Recommendations

Declarations

References

Competing Interests

Supplementary Files

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