Missed Nursing Care And Associated Factors Among Nurses At University Of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022. A cross sectional study

doi:10.21203/rs.3.rs-2362996/v1

Introduction: The lack of nursing care is the most common cause of quality problems in health care that results in adverse outcomes for patients, nurses, and organizations. Although there is a lot of evidence regarding nursing care practices, there is limited evidence about missed nursing care and its factors in Ethiopia and no evidence at all in the study area. Therefore, this study was designed to assess missed nursing care and related factors among nurses.

Methods: An institutional-based cross-sectional study was conducted among 485 nurses at the University of Gondar Comprehensive Specialized Hospital from May 15 to June 15, 2022. The data were collected through a self-reported questionnaire. A simple random sampling technique was used to select study participants. The data was then added to EPI DATA version 4.6 and exported to SPSS version 23 for analysis. Descriptive statistics were computed, and a summative score of missed nursing care was calculated. Then, multiple linear regression analysis was used to identify the factors of missed nursing care. A P-value of 0.05 was used to identify significant factors.

Results: In this study, missed nursing care was 62.5% (95% CI 60.98-64.02). Documentation of all necessary data, assessment of vital signs, intravenous care, and assessment as per hospital policy and patient education were the most frequently lacking nursing care. Being single in marital status (B=-4.609, P =0.004), adequacy of nursing staff (B=-2.458, P=0.003), satisfaction with income (B=-8.753, P=0.007), working in the medical unit (B=-5.708, P=0.002) and working in both day and night shift (B=1.731, P=0.027) were statistically associated with missed nursing care.

Conclusion recommendation: In this study, more than half of the participants missed basic nursing care. Efforts should be considered to enhance communication between health team members, assign a manageable number of patients per nurse, and adjust shifts and units.

missed nursing care

nurses

factors

Gondar

Ethiopia

Nursing care in the hospital is a very critical component of patient care to decrease morbidity and hasten recovery from a disease. These include medication administration, patient ambulation, position changes, patient bathing, oral care, recording vital signs, documenting intakes and outputs, nutrition, education for discharge from hospital, and so forth. When these essential elements of care are not offered to the patient, it is known as missed nursing care [1]. It can also be defined as care that is delayed, partially completed, or not completed at all [2–6].

Missed nursing care is a worldwide problem in the healthcare arena of nurses and nurse managers which varies from 10 to 50% [7, 8]. Some of the most common types of missed nursing care include lack of oral care, failure to observe proper medication time, lack of skin care, and lack of attention to the patient's religious needs [8–10].

In a cross-sectional studies in US, Malaysia and Iran showed that the misses nursing care was 36% [26], 28.6% and 23% [27, 28] respectively. In another Mixed and descriptive studies conducted in Nigeria and Egypt reported that 42.5% [29] and 41.1%)[24] respectively. Findings in Ethiopia showed that the average score for missed nursing care is 63.24%, in Jimma [21], and 74.6% in Tigray [31]. The level of missed nursing care was high in a cross-sectional observational and medical record review study in Bahir Dar [32].

The burden of missed nursing care needs to be emphasized not only because of the large number of patients affected every day, but also for its substantial innocence in terms of high cost, increased length of stays, leads to mortality, and other life-threatening complications [11, 12]. It can also bring many consequences for patients, nurses and the organizations such as nosocomial infection, medication error, increase health care costs, pressure ulcers, nurses and patient dissatisfaction, reduced organizational creditability and even patient death are some of them [13]. These consequences were also seen in Ethiopia in the form of pressure ulcers, increase health care costs, nosocomial infection due to lack of positioning and others [14, 15].

In addition missed nursing care leads to higher occurrences of infections and falls, new onset delirium, increased pain and discomfort, malnourishment, and unfavorable outcomes for nurses, such as increased levels of burnout and low job satisfaction, reduced overall quality of care levels, poor staff retention and high staff turnover in the institution [7, 16]. Currently, patient outcomes like inpatient mortality, medication errors, patient falls, pressure ulcers and were reported as being the consequences of missed nursing care [17, 18].

Missed nursing care has been affected by many complex factors such as inadequate hospital resources [7, 34 ] working environment [6], nurse-patient ratios, increase in a nurse's workload (35), and the number of hours a nurse works per shift [19], lack of effective communication, nurses' satisfaction with their current job and their intention to remain working [20, 21, 24, 34, 38]. In more recent years, the working environment of nurses has been identified as a major contributing factor to missed nursing care [22].

There are also other factors like heavy admission/discharge activity, fewer assistive personnel, and unbalanced patient assignments [33], perception of patient safety culture within a unit (31, 34), severe clinical conditions, perceived lack of time to care [32, 36], working unit type, nurses' age and perceptions of staffing adequacy [37, 24], sex, number of days absent, satisfaction towards teamwork) [21], educational level, working shift and having an intention to leave the institution [31] are associated with missed nursing care.

There are many challenges that may influence the quality of nursing care in Ethiopia [23]. The issue of missed nursing care is the most common cause of quality problem and is becoming public health challenge. Investigating such kind of challenges and factors helps to generate evidence that help nurses to minimize the missed nursing care [24]. However, in Ethiopia, there is limited evidence on missed care and its factors [17, 25]. Therefore, this study aims to determine missed nursing care and identify the factors that influence missed nursing care.

The results of this study will help nurses use the evidence that enables them to minimize missed nursing care and increase the continuity of patient care. It also helps patients access better nursing services, improve the quality of care, decrease anxiety, and shorten hospital stays. Thus, the findings of this study would also increase the body of knowledge of hospital managers to act on missed nursing care and its consequences and help design appropriate nursing care strategies to minimize or avoid missed nursing care. Evidence could also serve as a resource for future studies dealing with this issue.

Study period and area

This study was carried out in the comprehensive specialized hospital of the University of Gondar from May 15 to June 15, 2022. The hospital is a university referral hospital located in Gondar and serves as a referral center for over 5 million populations. It provides specialty and subspecialty services, including pediatrics, surgery, gynecology and obstetrics; internal medicine, psychiatry, and ophthalmology in its inpatient and outpatient services. Based on the University of Gondar compressive specialized hospital's matron office report, there were around 679 nurses who were working in the hospital during the study period. The average nurse's patient ratio in this study area was 1:8. The hospital has more than 1,000 beds and provides services to over 200,000 patients each year [39, 40].

Study design

An institutional-based cross-sectional study design was conducted at the University of Gondar Comprehensive Specialized Hospital.

Source and study population

Source population

All nurses working at the University of Gondar Comprehensive Specialized Hospital.

Study population

All nurses working at the University of Gondar Comprehensive Specialized Hospital are available during the data collection period.

Inclusion and exclusion criteria

Inclusion criteria

All nurses who were working in the university of Gondar comprehensive specialized hospital.

Exclusion criteria

Nurses who were not available during the data collection period, nurses who deliver free services, nurse managers and guests were excluded.

Sample size determination

The maximum sample size was calculated from the factors of missed nursing care using stat calc Epi info software version 7 with the assumption of power 80%, confidence level 95%, and ratio 1:1 with 3 statically significant variables such as sex, working shift and educational status (31) and non-response rate 5%. Then the final maximum sample size was 485.

Sampling technique and procedure

The total sample size was obtained from the University of Gondar comprehensive specialized hospital. Study participants were selected by using a simple random sampling method.

Study Variables

The dependent variable of the study was Missed Nursing Care while the independent variables were socio-demographic variables (age, sex, marital status, educational level, income status), profession-related factors (work experience, satisfaction, hand-over from the previous shift, communication within the nursing team, support from team members (nursing)) and organizational factors (an inadequate number of nurse, increased patient load, working unit, training, working shift, medication availability, equipment availability, the function of equipment).

Operational Definitions

Missed nursing care is any aspect of required patient care that is omitted either in part or in whole (31).

An inadequate number of nurses: Can be defined as the number of nurses that is not sufficient to provide high-quality care or is lower than the standard nurse-patient ratio. A study conducted in Ethiopia showed that the nurse-to-patient ratio ranges from 1:6 to1:12 based on the individual institution's patient load and nurse availability, if the ratio is more than 1:12, it is inadequate [41].

Medication availability

medications are the most common therapeutic intervention and a crucial component of medical care for any health care system. WHO recommends at least 80% availability of essential medicines in healthcare facilities[42]. But in low/middle-income countries this is still a major challenge [43].

Hand-over

is proper communication when one nurse transitions patient care to another nurse (previous shift or sending unit). It was categorized as a significant reason, moderate reason, minor reason and not a reason for missed care [44].

Communication breakdown

Breakdown in communication impedes workflow and creates tension between the nursing team. It was categorized as a significant reason, moderate reason, minor reason and not a reason for missed care [44].

Other departments

Defined as any departments like physiotherapy, psychiatry, laboratory, pharmacy and others rather than nursing departments.

Data collection tool and procedure

A customized and self-administered "modified MISSCARE" survey tool was used to collect the data[45]. The missed nursing care tool is a 24 five-point Likert-type scale. Participants were asked to answer from 5 to 1 (5-always, 4-often, 3-occasionally, 2-rarely, and 1-never). The reliability of this tool in this study was Cronbach's alpha of 0.84, and it has four dimensions (basic care interventions, interventions to attend to individual needs; discharge planning and patient education, and care interventions with continuous assessment). In addition, demographic, professional, and factors of missed nursing care data were also collected. The study participant list was extracted from the head nurse's office and then the lottery method was used to select participants. Participants were grouped into their own units and the number of participants in each unit was determined. Questionnaires were distributed to each unit by data collectors during work periods.

The missed nursing care score was calculated with a minimum potential score of 24 and a maximum score of 120. Then, the mean score with its SD (84 ± 16.38) was calculated.

The mean percentage score of the missed nursing care was calculated using the following formula:

\(\mathbf{P}\mathbf{e}\mathbf{r}\mathbf{c}\mathbf{e}\mathbf{n}\mathbf{t}\mathbf{a}\mathbf{g}\mathbf{e} \mathbf{m}\mathbf{i}\mathbf{s}\mathbf{s}\mathbf{e}\mathbf{d} \mathbf{n}\mathbf{u}\mathbf{r}\mathbf{s}\mathbf{i}\mathbf{n}\mathbf{g} \mathbf{c}\mathbf{a}\mathbf{r}\mathbf{e}=\frac{\text{A}\text{c}\text{t}\text{u}\text{a}\text{l} \text{m}\text{e}\text{a}\text{n} \text{m}\text{i}\text{s}\text{s}\text{e}\text{d} \text{n}\text{u}\text{r}\text{s}\text{i}\text{n}\text{g} \text{c}\text{a}\text{r}\text{e}-\text{S}\text{c}\text{a}\text{l}\text{e} \text{m}\text{i}\text{n}\text{i}\text{m}\text{u}\text{m} \text{s}\text{c}\text{o}\text{r}\text{e} }{\text{S}\text{c}\text{a}\text{l}\text{e} \text{m}\text{a}\text{x}\text{i}\text{m}\text{u}\text{m} \text{s}\text{c}\text{a}\text{l}\text{e}-\text{s}\text{c}\text{a}\text{l}\text{e} \text{m}\text{i}\text{n}\text{i}\text{m}\text{u}\text{m} \text{s}\text{c}\text{o}\text{r}\text{e} }\) X100 [46]

The highest score implied the highest missed nursing care.

Data processing and analysis

Data were entered into Epi DATA version 4.6 and exported to SPSS version 23 for analysis. Descriptive statistics were done for socio-demographics, job-related characteristics, and items of missed nursing care. The overall missed nursing care scores was calculated for each of the sub-scales.

Multiple linear regression analysis was used to identify the most significant predictor of missed nursing care. The assumption of multiple linear regressions; linearity, normality, and constant variance were checked. The variance inflation factor was used to see whether there is a correlation among the independent factors. Significant independent predictors were declared at a 95% confidence interval with a P-value of ≤ 0.05, and unstandardized β was used for interpretation.

Data quality assurance

To ensure data quality, a pretested and validated tool was employed. Training was given to the data collectors and supervisors on the research objectives, participant selection process, data collection tools and procedures. Data collected were checked for completeness on a daily basis. And appropriate data coding and categorization were used before analysis.

Socio-demographic and professional characteristics of participants

The response rate of the study was 100%. The age of the participants ranged from 23-51 years. Around 277 (57.1%) were female, and 410 (84.5%) were Bachelor's degree holders. More than half of the participants, 312 (64.3%) were ever married. Two hundred-six (42.5 %) of participants had 1-5 years of work experience. In terms of working shift, the majority, 303 (62.5%) of participants worked day and night in the last month. Around 123 (25.4%) had planned to leave the nursing profession, and 461 (95.1%) participants were not satisfied with their income (Table 1).

Table 1: - Socio-demographic and professional characteristics of participants at University of Gondar comprehensive specialized hospital, 2022(n=485).

Variable	Category	Frequency	Percentage (%)
Age in years	<30	261	53.8
	30-34	126	26.0
	35-39	69	14.2
	>39	29	6.0
Sex	Male	208	42.9
Sex	Female	277	57.1
Marital status	Single	173	35.7
Marital status	Ever married	312	64.3
Educational level	Diploma	20	4.1
	Bachelor degree	410	84.5
	Masters	55	11.3
Work experience (years)	1-5	206	42.5
	6-10	189	39.0
	11-15	59	12.2
	16-26	31	6.4
Working shift	Day	151	31.1
	Night	31	6.4
	Both	303	62.5
On job training	Yes	189	39.0
On job training	No	296	61.0
Average hours of overtime work (hrs)	0	27	5.6
	1-12	5	1.0
	>12	453	93.4
Number of absent days	Not absent	433	89.3
	1-3 days absent	17	3.5
	≥4 days absent	35	7.2
Plan to leave the current working area	Yes	166	34.2
Plan to leave the current working area	No	319	65.8
Plan to leave the nursing profession	Yes	123	25.4
Plan to leave the nursing profession	No	362	74.6
Satisfied with your income	Yes	24	4.9
Satisfied with your income	No	461	95.1
Working unit	Emergency	46	9.5
	Medical	96	19.8
	OPD	59	12.2
	Opta & Fistula	66	13.6
	Pediatrics	94	19.4
	Surgical	124	25.5

Work related satisfaction and Perceived staff adequacy of nurses

Around 306 (63.1%) were satisfied with their current position, and 351 (72.4%) were satisfied with being a nurse. Almost 425 (87.6%) of respondents reported that they were satisfied with the level of teamwork. Regarding the adequacy of staff, 280 (57.7%) participants felt that the staff is not adequate (Table -2).

Table 2:-Work-related satisfaction and perceived staff adequacy of nurses at the university of Gondar comprehensive specialized hospital, 2022(n=485).

Variable	Category	Frequency	Percentage (%)
Satisfaction with the current position	Not satisfied	179	36.9
Satisfaction with the current position	Satisfied	306	63.1
Satisfaction with Being a nurse	Not satisfied	134	27.6
Satisfaction with Being a nurse	Satisfied	351	72.4
Satisfaction with the level of teamwork	Not satisfied	60	12.4
Satisfaction with the level of teamwork	Satisfied	425	87.6
Numbers of staff in your unit/ward	<6	9	1.9
	6-12	216	44.5
	>12	260	53.6
Number of patients	<14	344	70.9
Number of patients	>14	141	29.1
Do you think the unit staffing is adequate	Yes	205	42.3
Do you think the unit staffing is adequate	No	280	57.7

Missed nursing care among nurses

The overall missed nursing care was 62.5% (95% CI 60.98-64.02). The majority of participants reported that documentation of all necessary data (81.25%), vital sign assessment (75.5%), performing IV catheter care and assessments according to hospital policy (71.25) and patient teaching (70%) as the most frequently missed nursing care. Others like patient bathing, mouth care and attending interdisciplinary conferences are less frequently missed nursing care (Table-3).

Regarding the dimension of missed nursing care, continuous assessment dimension was the most frequently missed nursing care with a mean of 30.63(SD ± 6.17). Whereas, the planning and teaching dimension were reported as less frequently missed nursing care with a mean of 10.39 (SD± 2.58) (Table-4).

Table 3:- Item description to assess the missed nursing care among nurses at the university of Gondar comprehensive specialized hospital, 2022(n=485)

Item	Never No (%)	Rarely No (%)	Occasionally No (%)	Frequently No (%)	Always No (%)	Missed Care (%)
Basic care intervention dimension
Ambulation of a patient	54(11.1)	87(17.9)	130(26.8)	114(23.5)	100(20.6)	56.25
Turning patient as needed	60(12.4)	112(23.1)	127(26.2)	93(1 9.2)	93(19.2)	52.5
Feeding patient when food is warm	114(23.5)	56(11.5)	120 (24.7)	86(17.7)	109(22.5)	51
Dietary advice & communication to meal providers	14(2.9)	48(9.9)	152(31.3)	149(30.7)	122(25.2)	66.25
Wound or skincare	37(7.6)	67(13.8)	122(25.2)	10 5(21.6)	154(31.8)	66
Patient bathing	136(28. 0)	120 (24.7)	117(24.1)	69(14.2)	43(8.9)	37.75
Mouth care	130 (26.8)	116(23.9)	103(21.2)	79(16.3)	57(11.8)	40.55
Care with continuous assessment dimension
Vital sign assessment as needed/ordered	14(2.9)	38(7.8)	73(15.1)	159(32.8)	201(41.4)	75.5
Monitoring input and output	20(4.1)	71(14.6)	121(24.9)	118(24.3)	155(32. 0)	66.3
Documentation of all necessary data	8(1.6)	28(5.8)	62(2.8)	123(25.4)	264(54.4)	81.25
Hand washing	38(7.8)	23(4.7)	90(18.6)	139(28.7)	195(40.2)	72.25
Bedside glucose monitoring	41(8.5)	61(12.6)	128(26.4)	129(26.6)	126(26. 0)	62
Patient assessment in each shift	18(3.7)	46(9.5)	116(23.9)	172(35.5)	133(27.4)	67.9
Focused reassessment as patient condition	18(3.7)	41(8.5)	119(24.5)	180(37.1)	127(26.2)	68.5
IV, catheter/central line care	33(6.8)	38(37.8)	90(18.6)	132(27.2)	192(39.6)	71.25
Individual need intervention dimension
Medication administration within 30 minute	28(5.8)	60(12.4)	112(s23.1)	139(28.7)	146(30.1)	64
Assisting patient with the toilet within 5 minutes of request	62(12.8)	100(20.6)	130(26.8)	116(23.9)	77(15.9)	52.25
Emotional support for patient/family	18(3.7)	55(11.3)	119(24.5)	148(30.5)	145(29.9)	68
Assessing the effectiveness of medication	22(4.5)	56(11.5)	133(27.4)	155(32. 0)	119(24.5)	65
PRN medication requests reacted within 15 minutes	26(5.4)	50(10.3)	147(30.3)	144(29.7)	118(24.3)	64
response to patient call or alarm within 5 minutes	24(4.9)	41(8.5)	131(27. 0)	186(38.4)	103(21.2)	65.5
Planning and teaching
patient discharge planning	24(4.9)	34(7. 0)	130(26.8)	170(35.1)	127(26.2)	67.75
Patient teaching	13(2.7)	52(10.7)	108(22.3)	157(32.4)	155(32. 0)	70
Attending interdisciplinary conferences	101(20.8)	92(19.0)	126(26. 0)	98(20.2)	68(14. 0)	47

Table 4: Mean score of missed nursing care dimensions (n=485)

Dimension of nursing care	N	Mean	% mean score	SD
Basic care intervention dimension	485	21.73	55.8	5.92
Care with continuous assessment dimension	485	30.63	73.21	6.17
Individual need intervention dimension	485	21.27	65.05	4.48
Planning and teaching	485	10.39	53.9	2.58

Descriptive analysis of items of factors affecting missed nursing care

Among factors of missed nursing care, urgent patient situations (73%), unexpected rise in patient volume and/or acuity on the unit (72.6 %), medications not available when needed (72.3%), inadequate number of staff (71.7%), supplies/ equipment not available when needed (71.3%), Supplies/ equipment not functioning properly when needed (71%) had taken the highest percentage. (Table-5).

Table 5:-Descriptive analysis for factors of missed nursing care among nurses at university of Gondar comprehensive specialized hospital, 2022(n=485).

Item	Not a reason No (%)	Minor reason No (%)	Moderate reason No (%)	Significant reason No (%)	%
Labor resource-related factors
The inadequate number of nursing staff	40(8.2)	72(14.8)	150(30.9)	223(46.0)	71.7
Urgent patient situations	26(5.4)	69(14.2)	177(36.5)	213(43.9)	73
Unexpected rise in patient volume and/or acuity on the unit	26(5.4)	71(14.6)	176(36.3)	212(43.7)	72.6
Inadequate number of assistive and/or clerical personnel	30(6.2)	129(26.6)	197(40.6)	129(26.6)	62.6
Unbalanced patient assignments	39(8.0)	137(28.2)	171(35.3)	138(28.5)	61.3
Materials and supplies-related factors
Medications were not available when needed	24(4.9)	76(15.7)	180(37.1)	205(42.3)	72.3
Equipment not functioning properly when needed	29(6.0)	85(17.5)	167(34.4)	204(42.1)	71
Equipment not available when needed	21(4.3)	92(19.0)	171(35.3)	201(41.4)	71.3
Communication-Related factors
Inadequate hand-over from previous shift or sending unit	62(12.8)	136(2.0)	161(33.2)	126(26.0)	57.3
Other departments working in the unit who did not provide the care needed	57(11.8)	154(31.8)	179(36.9)	95(19.6)	54.6
Lack of backup support from team members (nursing)	47(9.7)	146(30.1)	169(34.8)	123(25.4)	58.7
Communication breakdowns with supportive departments	49(10.1)	147(30.3)	147(30.3)	142(29.3)	59.6
Communication breakdowns within the nursing team	63(13.0)	137(28.2)	164(33.8)	121(24.9)	57
Communication breakdowns with the medical staff	61(12.6)	121(24.9)	173(35.7)	130(26.8)	59
Heavy admission and discharge activity	48(9.9)	93(19.2)	189(39.0)	155(32.0)	64.3
Caregiver off unit/unavailable	90(18.6)	143(29.5)	148(30.5)	104(21.4)	51.7
Assistants did not communicate care was not done	82(16.9)	161(33.2)	131(27.0)	111(22.9)	52

Factors associated with missed nursing care

In this study, nineteen variables were statistically associated with missed nursing care in the simple linear regression analysis, but in the multiple linear regressions being single in marital status (B=-4.609, P =0.004), adequacy of nursing staff (B=-2.458, P=0.003) satisfaction with income (B=-8.753, P=0.007), other departments working in the unit who did not provide the care needed (B= 2.178, P=0.009), working in the medical unit (B=-5.708, P=0.002) and working in both shift (B=1.731, P=0.027) were statistically significant predictors of missed nursing care. (Table-6).

Table 6: Multiple linear regressions to assess factors of missed nursing care among nurses at the university of Gondar comprehensive specialized hospital, 2022(n=485)

	Unstandardized Coefficients B	Std. Error	P value	95.0% Confidence Interval for B Lower Bound Upper Bound
Single	-4.609	1.582	.004	-7.718	-1.501
Adequacy of nursing staffing	-2.458	.825	.003	-4.079	-.838
Satisfaction with income	-8.753	3.226	.007	-15.092	-2.414
Other departments working in the unit who did not provide the care needed	2.178	.830	.009	.547	3.809
Working shift/both	1.731	.779	.027	.200	3.263
Working in medical ward	-5.708	1.871	.002	-9.385	-2.030

In this study, missed nursing care and associated factors among nurses at the University of Gondar Comprehensive Specialized Hospital were assessed. Therefore, it was reported that nearly 63% of nursing care was missed. Documentation of all necessary data, vital sign assessment, performing intravenous catheter (central line site) care and assessments according to hospital policy, and patient teaching as the most frequently missed nursing care. Being single in marital status, adequacy of nursing staff, satisfaction with income, other departments working in the unit did not provide the care needed, working shifts and working units were statistically significant predictors of missed nursing care.

In the current study, more than half (62.5%) of nursing care was missed. This implies that the nursing care provided by the majority of the study participants had been delayed, partially completed, or not completed at all. This finding is consistent with studies conducted in Jimma and Kenya, where the missed nursing care was reported to be 63.24% and 60% respectively [21, 47]. The reason may be due to the similarity in age and sex distribution of the study participants.

However, the result of this study is much higher than the studies conducted in Nigeria, Malaysia, the US, Egypt and Iran where the missed nursing care was 42.5% [48],28.6% [49],36% [26],41.1% [50] and 23% [51] respectively. This difference might be due to differences in the age where the majority of the participants in this study were under 30 years old, but they were between 30–40 years old in a study done in Nigeria. Three fourths of the participants were females (70.4% in Nigeria), the difference in educational status, where only one-fifth (18.3%) of the participants have a bachelor's degree in nursing, whereas in this study the majority of the participants have a bachelor's degree and some of the participants mastered in nursing. Whereas the difference between studies done in Malaysia and this study might be due to the difference in human resources, where 2157 registered nurses work in three shifts in Malaysia but only 679 registered nurses work in two shifts in this study area. And, samples were taken only from the medical and surgical ward in Malaysia, and most study participants were female and diploma holders in the US. They were only on NICU and almost all of the study participants were females (98.4%), and it was done in 2016, in hospitals in three teaching hospital only in ICU unit, in Iran participants were taken from eight public hospitals and medical and surgical wards in private hospitals.

But, this finding is lower than a study conducted in Tigray where the missed nursing care was reported to be 74.6% [52]. This difference might be because the study in Tigray was conducted only in the gynecology and obstetrics unit and multi-setting and more than half of the participants were midwives (58.4%). But, in this study all participants were nurses.

In the current study, documentation of all necessary data, vital sign assessment, IV catheter care and following assessments as per the hospital policy and patient teaching were the most frequently missed nursing care. This finding is supported by studies conducted in Iran and Egypt where patient teaching was missed [50, 51], and also supported by a study conducted in Nigeria where study participants missed IV catheter care [48]. This similarity might be due to similarity in study design (cross-sectional study design), sex distribution (the majority were female) and level of experience (< 5 years).

The basic care intervention dimension and planning and teaching intervention dimension were relatively the least frequently reported missed nursing care in this study. This finding is not in line with a study conducted in Jimma where the basic care intervention dimension was reported as the most frequently missed nursing care [21]. This difference might be due to multiple study settings and a higher number of diploma levels of education in a study done in Jimma.

A unit increase in marital status being single decreased missed nursing care by 4.6 units. In this study, being single was almost five times less likely to have missed nursing care as compared with being ever married. This implies delayed, partially completed or not completed at all nursing care is five times more common in those ever married than single. This result is inconsistent with the result of a study conducted in Egypt where being single was almost two times (63.4%) more likely to have missed nursing care as compared to ever married[50]. This difference might be due to only one-fifth of the participants being single (21.3%) in a study done in Egypt as compared to this study where one third is single (35.7%) and that might be due to a difference in the level of education, where about 95% of the participants, in this study have BSC and master degree in nursing but only 40% of the participants in a study done in Egypt have BSC and master degree.

Other departments working in the unit that did not provide the care needed to be increased missed nursing care by 2.2 units. This implies that other departments, like physiotherapy, working in the unit which did not provide their duties properly, increased missed nursing care by almost 2 times. Whereas units increase in working in medical units decrease missed nursing care by 5.7 units, which means missed nursing care decreased by nearly 6 times in the medical work unit as compared with working in other units.

A unit increase in satisfaction with income decreased missed nursing care by 8.8 units. This implies delayed, partially completed, or not completed at all nursing care is 9 times more common in nursing care of those who are not satisfied with their income as compared with those satisfied with their income. A unit increase in working in both shifts (i.e. day and night) increases missed nursing care by 1.7 units. Missed nursing care is almost 2 times more common among nurses working on both shifts than working on one shift.

Limitations Of The Study

Due to the cross-sectional nature of the study, establishing the cause-and-effect relationship between missed nursing care and associated factors would be impossible.

Despite the high response rate in this study, recall bias and social desirability bias could be potential limitations for this study. As the data was participants' perceived self-report, it might be under/over-reported.

In this study, more than half of basic nursing care was missed. Being single in marital status, adequacy of nursing staff, satisfaction with income, and working in a medical unit are protective factors of missed nursing care. As per the findings, the Minister of Health had better improve nurses’ salary so as to increase nurses’ level of satisfaction to avoid missed nursing care. The hospital ought to decrease the workload of nurses to prevent missed nursing care. The hospital should better consider the balanced distribution of nurses’ to-patient ratio. Further research is recommended with observational techniques and qualitative design to see from the patients’ perspective. It is also needed to see other interventional studies to examine the causal relationship between missed nursing care and its factors.

CD/RW: Compact Disk-Rewritable, CI: Confidence Interval, ERC: Ethical Review Committee, HLS: Hospital Length of Stay, ICU: Intensive Care Unit, IV: Intravenous, MNC: Missed Nursing Care, NCI: Nursing Care Intervention, NICU: Neonatal Intensive Care Unit, PI: Principal Investigator, PRN: Pro re nata /as needed, RN: Register Nurse, SD: Standard Deviation, SPSS: Statistical Package for Social Science, SRS: Simple Random Sampling, US: United States

Acknowledgments

The authors would like to express their deep gratitude to the medical directors and head nurses of each hospital for their special contribution by helping to have the necessary information.

Authors’ contributions

HK: Involved in analysis, interpretation, report, and manuscript writing. KE: Conceptualized the study and was involved in design, analysis, interpretation, report and manuscript writing. CWK: Involved in supervision, analysis, interpretation, report, and manuscript writing.

Funding

Not applicable.

Availability of data and materials

The data set generated in this study will be available upon reasonable request from the corresponding author. As the data set is from human beings, there are ethical restrictions in the data set.

Ethical consideration

The study was conducted in accordance with relevant guidelines and regulations. The proposal/protocol was approved by Ethical Review Committee (ERC) of the school of nursing, college of medicine, and health sciences University of Gondar (Ref No: S/N/246/2014). Study participants were informed about the purpose and objectives of the study through written informed consent. Participants were told to quit their participation at any stage without any restrictions. Participants’ identifiers were not used.

Consent to publication

Not applicable.

Competing interest

The authors declared that there is no competing interest.

Authors’ detail

¹Department of nursing, school of nursing, University of Gondar, Gondar, Ethiopia, ²Department of comprehensive nursing, school of nursing, University of Gondar, Gondar, Ethiopia, ³Department of medical nursing, school of nursing, University of Gondar, Gondar, Ethiopia.

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No competing interests reported.

Missed Nursing Care And Associated Factors Among Nurses At University Of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022. A cross sectional study

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Abstract

Introduction

Methods