A descriptive study of nurse-reported missed care in neonatal intensive care units

Missed nursing care and its causes and effects on moral distress in neonatal intensive care nurses

BACKGROUND

Deficiencies emerge in the care provided by nurses because of the complex treatment plans, shortage of labour resources and communication problems in neonatal intensive care units (NICUs). Knowing how to provide quality patient care but being unable to maintain it because of individual or institutional issues can lead to moral distress among nurses.

AIM

This study aimed to examine missed nursing care in NICUs and its relationship with the moral distress experienced by nurses.

STUDY DESIGN

This was a cross-sectional study. This study included a sample of 153 NICU nurses. The data were collected online between January and May 2024 using a descriptive information form, the Missed Care Survey-Paediatric Form, and the Moral Distress Scale-Revised for Paediatric Nurses.

RESULTS

The mean age of the participants was 31.22 years, and on average, they cared for 3.42 ± 0.96 patients per day. The medical condition of the child under care (t = 2.954, p < .001), duration of working in the NICU (F = 15.901, p < .001), inadequate number of nurses (F = 3.626, p = .029) and job satisfaction (F = 3.359, p = .037) were listed as variables affecting the reasons for missed nursing care. Communication (β = .275, p = .018) and labour resources (β = .216, p = .021), subdimensions of the Missed Care survey used in the study, were predictive factors that positively affected moral distress.

CONCLUSIONS

The factors associated with missed care should be explored as strategies to reduce moral distress. Managers should focus on integrating effective communication techniques into nursing care and increasing the labour resources to reduce missed nursing care, thus improving the moral distress levels of NICU nurses.

RELEVANCE TO CLINICAL PRACTICE

Understanding the factors associated with missed care and developing related strategies can complement the efforts of NICU managers, educators and nurses in reducing moral distress.

Job satisfaction, work environment, and burnout as predictors of missed nursing care in pediatric units: A descriptive cross-sectional study

PURPOSE

To examine the frequency and predictors of missed nursing care in pediatric units.

DESIGN AND METHODS

This study with a descriptive cross-sectional design was conducted in the pediatric clinics of two public university hospitals in Türkiye. The convenience sampling method was employed, including all nurses working in pediatric units, with a total of 123 nurses participating. Data were collected face-to-face from May to October 2023 using a sociodemographic and job-related characteristics form, the Practice Environment Scale of the Nursing Work Index (PES-NWI), the Maslach Burnout Inventory (MBI), and missed nursing care activity questions. The data were analyzed using descriptive statistics and logistic regression analysis.

RESULTS

The most frequently missed care activities were found to be skin care (45.5 %), educating patients and families (40.7 %), and preparing patients and families for discharge (37.4 %). Predictors of missed nursing care were nurses' educational level, high nurse-to-patient ratios, low job satisfaction, enough opportunity to discuss patient care issues with other nurses, nursing foundations for quality of care, nurse manager's ability, leadership, and support for nurses, staffing and resource adequacy, and collegial nurse-physician relations, emotional exhaustion and personal accomplishment.

CONCLUSIONS

This study revealed that the most frequently missed care activities among nurses were related to skin care, education, and discharge preparation. Understanding the underlying causes is essential for reducing the rate of missed care.

PRACTICE IMPLICATIONS

To reduce the frequency of missed care, it is necessary to improve the work environment and make institutional investments in nursing, enabling nurses to effectively fulfill their duties.

The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey

AIM

To describe Australian perioperative nurses' reported frequency and reasons for missed nursing care in the operating room.

DESIGN

Cross-sectional online survey conducted in March-April 2022.

METHODS

A census of Australian perioperative nurses who were members of a national professional body were invited to complete a survey that focussed on their reported frequency of missed nursing care and the reasons for missed nursing care in the operating room using the MISSCare Survey OR.

RESULTS

In all, 612 perioperative nurses completed the survey. The perioperative and intraoperative nursing care tasks reported as most frequently missed included time-intensive tasks and communication with multiple surgical team members present. The most frequently reported reasons for missed care were staffing-related (e.g. staff number, skill mix, fatigue and complacency) and affected teamwork. There were no significant differences in the frequency of missed care based on perioperative nurse roles. However, there were statistically significant differences between nurse management, circulating/instrument nurses and recovery room nurses in reasons for missed care.

CONCLUSIONS

Much of the missed care that occurs in the operating room is related to communication practices and processes, which has implications for patient safety.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the types of nursing care tasks being missed and the reasons for this missed care in the operating room may offer nurse managers deeper insights into potential strategies to address this situation.

REPORTING METHOD

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Identifying missed care in pediatric nursing: A scoping review

PROBLEM

Missed nursing care (MNC) refers to required patient care that is omitted or delayed. Commonly missed elements include ambulation, turning, feeding, patient education, discharge planning, emotional support, hygiene, documentation, and patient surveillance. Key reasons for MNC are insufficient staffing, poor resource utilization, time constraints, lack of teamwork, ineffective delegation, habitual practices, and denial. MNC links inadequate work environments and staffing to poor clinical outcomes, especially affecting efficiency in pediatric settings.

OBJECTIVE

To describe missed nursing care in pediatrics and to identify the most frequently missed categories of nursing care and summarize the reasons for this.

ELIGIBILITY CRITERIA

Any quantitative study which reported on any combination of categories, reason and factors associated with missed nursing care within pediatric settings and which was published in English, full-text available and studies that collected variables on the structure and process of missed nursing care in pediatrics.

SAMPLE

The following databases were searched: PubMed, Embase, CINAHL and Scopus with no time limits.

RESULTS

Missed nursing care (MNC) is influenced by workload, work environment, and staffing levels. A higher patient-to-nurse ratios significantly increase MNC. Better work environments correlate with fewer missed care activities, but frequent interruptions and unexpected patient volume spikes remain major issues. Commonly missed activities include oral care, routine bathing, and adherence to infection protocols.

CONCLUSION

Addressing MNC requires strategic staffing, improved work environments, targeted interventions, and continuous education to enhance care quality. The studies collectively highlight the complexity of missed nursing care and its dependence on various factors including workload, work environment, and nurse characteristics.

IMPLICATION

Developing and validating pediatric-specific assessment tools and studying factors like workload, staff training, and work environment are crucial for addressing MNC in these settings. More research is needed to understand MNC in pediatric settings, focusing on specific challenges and needs.

Effect of Routine Nurse Caregiving on the Stress Responses and Behavior State in Preterm Infants: A Systematic Review

BACKGROUND

Although routine nurse caregiving is vital for the overall health of preterm infants, variations in approaches may exert distinct effects on preterm infants' stress responses and behavior state.

PURPOSE

The purpose of this systematic review was to examine routine nurse caregiving in the neonatal intensive care unit and its effect on stress responses and behavior state in preterm infants.

DATA SOURCES

A systematic search was conducted using PubMed, Embase, and CINAHL for studies published between 2013 and 2023.

STUDY SELECTION

Included studies enrolled preterm infants born <37 weeks gestational age and investigated nurse caregiving practices and effects on stress responses and/or behavior state.

DATA EXTRACTION

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, data about study design, methods, findings, and limitations were extracted and summarized. Included studies were evaluated for bias using the National Health, Lung, and Blood Institute quality assessment tools.

RESULTS

All 13 studies included in the review received a fair quality rating. Nurse caregiving activities, including suctioning, diaper changes, bathing, and weighing, were associated with increases in heart and respiratory rates, blood pressure, energy expenditure, and motor responses, lower oxygen saturations, and fewer sleep states.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Adapting nurse caregiving frequency and duration, aligning caregiving with infant state, and integrating developmental care strategies may reduce infant stress responses and support behavioral rest. Further research is needed to understand how caregiving activities affect stress responses and behavior state in preterm infants, aiding in identifying modifiable caregiving stressors to promote optimal development.

Translation and cross-cultural adaptation of the MISSCARE Survey-Ped into Brazilian Portuguese

OBJECTIVES

to translate and cross-culturally adapt the MISSCARE Survey-Ped for use in Brazil.

METHODS

a methodological study proposed by translation, synthesis of translations, back-translation, assessment by a committee of experts and pre-testing with the target population.

RESULTS

two direct translations of the instrument were carried out, followed by a consensual version between them. This synthetic version was back-translated and analyzed by a committee of five experts in pediatric nursing and patient safety, obtaining a Content Validity Index (CVI) of 0.95 and Cronbach's alpha of 0.804. The final version was sent for pre-testing with 254 Brazilian pediatric nurses, with 44 (17.3%) analyzing the instrument for understanding (CVI 0.866; Content Validity Ratio (CVR) 0.773), relevance (CVI 0.931; CVR 0.864) and relevance (CVI 0.977; CVR 0.955).

CONCLUSIONS

the MISSCARE Survey-Ped Brasil was considered suitable for application in pediatric nurses' clinical practice in the country.

Missed nursing care as reported by paediatric nurses: A cross-sectional study

AIMS

Missed nursing care (MNC) significantly affects patient safety and quality of care. It is a widely used concept that has been studied in different settings, but research in paediatric care is quite limited. Therefore, this descriptive cross-sectional study aimed to report the prevalence, patterns, correlates, factors and predictors of MNC in paediatric care units in two central European countries.

DESIGN

A cross-sectional comparative study.

METHODS

Data collection was carried out between June and November 2021 using the MISSCARE Survey-Pediatric. The study included 441 registered nurses working in paediatric care units in the Czech Republic and Slovakia. Data were analysed using descriptive and inferential statistics in the SPSS 25.0 statistical program.

RESULTS

Almost all nurses, 92.7% of nurses missed at least one nursing activity during the last shift. The most missed care activity in both countries was the promotion of neuroevolutionary development, and the most prominent reasons were labour resources. MNC was weakly but significantly correlated with nurse experience in the current position and was predicted by the country, nurse education and overtime hours (p ≤ .05). Differences in prevalence of MNC and reasons for MNC were identified based on several variables (p ≤ .05).

CONCLUSION

The assessment of MNC in paediatric settings is often a neglected area, although the prevalence in this study was moderate.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurse staff shortages, as a global problem, have many impacts on patient outcomes in the delivery of nursing care. However, there are also many factors that can reduce the prevalence of MNC. More research should focus on a closer examination of these factors that involve hospital and nurse variables.

REPORTING METHOD

The study was carried out according to the STROBE checklist and the RANCARE guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Development and validation of the missed intensive nursing care scale

BACKGROUND

Missed nursing care is a pervasive issue in hospitals, nursing homes, and communities, posing a significant threat to patient safety and the quality of nursing care. It has adverse effects on patient satisfaction and the motivation of nursing staff. Understanding the causes and nature of these care omissions in clinical settings is essential for implementing effective interventions. This study aims to develop and validate a tool for assessing missed nursing care in adult intensive care units.

METHODS

Semi-structured interviews, expert consultations conducted via the Delphi method and item analysis were used to develop the initial scale. Our analysis involved data collected from 400 nurses and employed correlation coefficient analysis, critical ratio assessment, Cronbach's α coefficient evaluation, discrete trend analysis, and factor analysis, which were grounded in both classical test theory and item response theory, allowing us to scrutinize and refine the items in the scale. To validate the scale, we conveniently sampled 550 nurses and assessed structural validity, internal reliability, split-half reliability, and test-retest reliability to ensure the scale's robustness and accuracy.

RESULTS

The Missed Intensive Nursing Care Scale (MINCS) comprises three distinct components. Part A serves to collect general information about the participants. In Part B, the missed care elements are categorized into five domains, following the framework of Maslow's hierarchy of needs theory: physiology, safety, belongingness, esteem, and cognition. Part C is dedicated to detailing the reasons behind missed care, which encompass labor resources, material resources, communication factors, and managerial factors. Remarkably, the Cronbach's α coefficient for the MINCS stands at an impressive 0.951, with S-CVI values of 0.988 and 0.977 in Part B and C, respectively, underscoring the scale's exceptional reliability and validity. This demonstrates the scale's effectiveness in measuring missed nursing care while upholding rigorous standards of quality.

CONCLUSIONS

The MINCS emerges as a robust and dependable instrument for quantifying instances of missed care within the ICU. Its efficacy makes it a valuable resource for informing the development of strategies aimed at averting and mitigating the adverse effects associated with missed nursing care.

Factors of Missed Nursing Care in Intensive Care Units: Palestinian Perspective

Maintaining a high standard of nursing care is imperative for ensuring patient safety. Several factors significantly impact the provision of nursing care, including work environment resources, personnel coordination, work systems, and head nurse leadership. In addition, each nurse's clinical and academic career also plays a role in shaping the quality of care provided to patients. This article reports results of a cross-sectional study aimed to identify the different types of missed nursing care and the factors that contribute to them, as perceived by nurses, and second, to investigate how nurses' characteristics may relate to the occurrence of missed nursing care. Data for this study were obtained through a self-administered questionnaire that was distributed to participants working in an intensive care unit. The study included a final sample size of 176 participants, all of whom worked in intensive care unit hospitals located in the north region of Palestine. The study found that handwashing, setting up meals for patients who feed themselves, discharge planning, and response to a call light were the most frequently missed nursing care activities. The primary factors identified as reasons for missed nursing care were inadequate availability of labor and material resources, along with communication issues. Efforts to address these identified issues can potentially lead to improved quality of nursing care in intensive care units.

The Association between Operating Room Nurses' Characteristics, Competence, and Missed Nursing Care: A National Survey

Background

Missed nursing care, which has been explored in various acute care settings, results in adverse patient outcomes and job dissatisfaction in nurses. However, little is known about missed care in the operating room.

Objective

This study tested a hypothesised model to identify relationships between nurses' age, years of experience in the operating room, job satisfaction, and intention to leave which have direct and indirect effects on the frequency of missed care. The frequency of missed care was hypothesised to be mediated by nurses reported perioperative competence and the reasons for missed care.

Design

A cross-sectional design using an online survey of Australian perioperative nurses was undertaken in 2022.

Methods

All Australian College of Perioperative Nurses members were invited to participate. Missed nursing care was measured using the MISSCARE Survey-OR. Age, years of experience, and intention to leave were single-item measures. Satisfaction was a three-item scale. Competence was measured by the 18-item Perceived Perioperative Competence Scale-Short Form. Structural equation modelling was used to test our hypothesised model.

Results

Of the 5,500 nurses invited, 853 (15.5%) responded, but only 602 (10.9%) participant responses were usable for inclusion in the model. The model demonstrates that participants' age directly predicted the frequency of missed care, nurse role satisfaction, perceived perioperative competence, and reasons for missed care. The reasons for missed care and perceived perioperative competence were mediators that were negatively associated with the frequency of missed care.

Conclusions

While the final model explained 22.6% of the frequency of missed care, other variables not identified in this study may influence this outcome.

Qualitative evaluation of missed nursing care in neonatal intensive care units in a teaching hospital in Jordan

PURPOSE

Missed nursing care (MNC) is a worldwide patient safety issue. However, little is known about MNC in neonatal intensive care units (NICU). The aim of this paper is to explore the elements and factors influencing the occurrence of MNC in the NICU in a teaching hospital in Amman, Jordan.

DESIGN AND METHODS

The study used a qualitative descriptive design. Semi-structured interviews were conducted with NICU nurses. Purposeful sampling was used to select the participants and data collection was performed in the period August 2022 to September 2022. Data were analyzed using thematic analysis.

RESULTS

The participants included 15 female nurses. The majority of the participants held a bachelor's degree in nursing. Five themes emerged from the analysis of data namely: (1) Conceptualizations of MNC (2) Missed care elements in the NICU (3) Reasons behind MNC in the NICU (4) Consequences of MNC and (5) Strategies to reduce the occurrence of MNC. Feeding,changing diapers, monitoring vital signs, and medication administrationwere identified as missed care elements in the NICU.

CONCLUSIONS

The findings of this research may inform the development of interventions that may reduce missed care incidents in the NICU.

PRACTICE IMPLICATIONS

Addressing staff shortages and the provision of necessary materials and equipment appear to be the key factors that may reduce the frequency of MNC. Thus, enhancing patient safety and quality healthcare in this challenging healthcare environment.

Exploring Missed Nursing Care in the NICU: Perspectives of NICU Nurses in Saudi Arabia's Eastern Health Cluster

(1) Background: Missed nursing care, an omission error characterized by delayed or omitted nursing interventions, poses significant risks to patients' safety and quality of car.; (2) Methods: This is a quantitative cross-sectional study on 151 nurses who work in NICUs in three main networks in the Eastern Health Province, Saudi Arabia: Dammam (n = 84), Qatif (n = 53), and Jubail (n = 14). The study uses a self-reported questionnaire (MISSCARE) and applies the 5-point Likert Scale. Statistical analysis data were analyzed using SPSS version 23.0. (3) Results: The primary reasons for missed care were shortage of nursing staff and unbalanced patient assignments. Missed nursing care negatively affects job satisfaction and was positively correlated with nurses' intentions to quit their jobs. Inadequate equipment, supplies, and breakdowns in communication between nurses and other healthcare professionals were also significant factors contributing to missed care. (4) Conclusions: Missed nursing care is associated with overwork, nursing shortages, and lower job satisfaction, impacting the quality of care provided in the NICU. Improving working conditions, nurse staffing, and patient assignment planning should be prioritized to address this issue effectively.

Validation and psychometric properties of the Persian version of the MISSCARE survey

AIM

To conduct, translate, and psychometric evaluation of the MISSCARE-Persian Survey.

DESIGN

A cross-sectional study was conducted in Iran in February-June 2021.

METHODS

The translation of the MISSCARE Survey was accomplished according to World Health Organization (WHO) guidelines. Construct validity was performed by (N = 300) exploratory factor analysis and confirmation. To assess the reliability, internal consistency was assessed using Cronbach's alpha coefficient, and relative stability was assessed using the interclass correlation coefficient (ICC). The study adhered to COSMIN guidelines.

RESULTS

The exploratory factor analysis, which resulted in the identification of three factors in the second part of the tool, explained 79.6% of the total variance. Confirmatory factor analysis indicated the model's good fit of information. The reliability of the first and second parts of the tool was 0.912 and 0.901, respectively. Additionally, the ICC was found to be 0.687 for the first and 0.706 for the second part of the tool.

Missed nursing care in pediatric emergency departments in Turkey: A cross-sectional study

OBJECTIVE

A pediatric emergency department deals with a vast number of patients and a high load of emergent/high-priority healthcare practices. Therefore, at times, it is possible to experience missed nursing care in this department. This study aims to ascertain the types of and reasons for missed nursing care cases in pediatric emergency departments in Turkey.

METHOD

This is a cross-sectional survey study. Survey data were collected from 155 nurses using the "Introductory Information Form" and the "MISSCARE-Pediatric Emergency Department Survey."

RESULTS

Gastrostomy care, colostomy care, tracheotomy care, and teaching about hospital discharge were the care practices most often missed. The volume of patients, urgent patient situations, an inadequate number of nurses in charge, too many inexperienced nurses in the department, and assignment of work outside the scope of the job are the main reasons for missed care.

CONCLUSION

Pediatric emergency department patients experience missed nursing care and nurses should be supported more in order for them to provide efficient care to children.

The Association of Missed Nursing Care With Very Low Birthweight Infant Outcomes

The health outcomes of very low birthweight (VLBW) infants in neonatal intensive care units (NICUs) may be jeopardized when required nursing care is missed. This correlational study is the first to look at the association between missed nursing care and mortality, morbidity, and length of stay (LOS) for VLBW infants in a U.S. NICU sample. We used 2016 hospital administrative discharge abstracts for VLBW newborns (n = 7,595) and NICU registered nurse survey responses (n = 6,963) from the National Database of Nursing Quality Indicators. The 190 sample hospitals were from 19 states in all regions. Missed clinical nursing care was significantly associated with higher odds of bloodstream infection and longer LOS, but not mortality or severe intraventricular hemorrhage. With further research, these results may motivate the development of interventions to reduce missed clinical nursing care in the NICU.

Content validity of a Safe Nursing Care Checklist for a neonatal unit

BACKGROUND

Nursing checklists have been shown to improve communication, reduce the occurrence of adverse events, and promote safe, quality care in different care settings. However, to date, there is no validated patient care safety checklist for nurses caring for infants in Neonatal Intensive Care Units (NICU).

AIM

To describe development and content validation of the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit".

STUDY DESIGN

Online Survey.

METHODS

Based upon an integrative literature review, we developed a checklist focused on safe nursing care for infants in the NICU. Nursing experts participated in three rounds of a content validation process where they rated the items online. An agreement level ≥0.90 was required for inclusion in the checklist. Forty- three expert nurses with experience working in the NICU and who were certified in neonatal nursing or had a master's or doctoratal degree in child health provided content validation of the patient care checklist.

RESULTS

The final checklist contained 45 items with content validation index scores greater than 90%. The instrument was structured into six dimensions including patient identification, effective communication, medication safety, infection prevention, fall prevention, and pressure injuries/skin injuries prevention.

CONCLUSION

Content validity was established for the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit" which can identify strengths and weaknesses in safe nursing care for infants in the NICU as well as direct educational interventions to promote nursing care based on scientific evidence.

RELEVANCE TO CLINICAL PRACTICE

This checklist can potentially be used by bedside nurses to promote provision of safe care to infants in the NICU and to guide corrective strategies and encourage evidence-based decision-making. Validation in the clinical setting is needed.

An Overview of Missed Nursing Care and Its Predictors in Saudi Arabia: A Cross-Sectional Study

Background

Nursing care is holistic, and missing any aspect of care can be critical to patients' health. However, due to the complex and intense nature of the nursing practice, nurses have to unintentionally prioritize some activities, forcing them to omit some aspects of nursing care.

Aim

To explore the dimensions of missed nursing care and its predictors within the Saudi Arabian healthcare system.

Methods

Quantitative, cross-sectional study used the MISSCARE survey by utilizing nonprobability convenience sampling to collect the data of 604 staff nurses working in inpatient wards in Jazan, Saudi Arabia.

Results

The overall mean of missed nursing care is (m = 1.37, SD = 0.45). Missed nursing care activities were mostly failure to attend interdisciplinary care conferences (m = 1.66, SD = 0.96) and patient ambulation thrice a day (m = 1.63, SD = 0.97). Missed nursing care was mainly caused by human resource shortage (m = 3.53, SD = 0.88). Missed nursing care is predicted by the turnover intention (B = 2.380, t = 3.829, p < 001) and job satisfaction (B = −0.864, t = −4.788, p < 001).

Conclusion

Although missed nursing care is evident in Saudi Arabia, it is significantly lower than the international rates, and it is mainly caused by labor resource shortage which directly influences nurses' job satisfaction and intention to leave. Optimizing the recruitment process, resource allocation and effective nurses' retention programs are proposed solutions that may be beneficial to mitigate missed nursing care.

Exploring Care Left Undone in Pediatric Nursing

OBJECTIVES

This study aimed to investigate the association between nursing care left undone in pediatrics and factors related to nursing staff characteristics and work environment.

METHODS

The data of the present study were extracted from our RN4CAST@IT-Ped database, a cross-sectional observational study, which included 13 hospitals belonging to the Italian Association of Paediatric Hospitals. Through convenience sampling, nurses and pediatric nurses providing direct care in routine pediatric wards were enrolled in the study. Data aggregated by clinical care area were analyzed, through descriptive and inferential statistics methods using IBM SPSS 22.0 software.

RESULTS

We collected data from 399 pediatric nurses working in surgical wards, 1208 in medical wards, and 631 in critical care units. Some of the investigated factors have shown an association with the risk of omitting essential nursing activities, like health care judged of poor quality, patient safety judged as poor, and nurses' intention-to-leave the job. For every nursing activity under investigation, we found some significant statistical associations.

CONCLUSIONS

Our results are consistent with the international literature showing that nurses miss some activities more frequently. Understanding the associations underpinning care left undone could be a starting point for the implementation of patient-centered care and the improvement of the quality and safety of care in pediatric settings, as well as the work environment.

Data-Driven Nurse Staffing in the Neonatal Intensive Care Unit

ABSTRACT

The challenge of nurse staffing is amplified in the acute care neonatal intensive care unit (NICU) setting, where a wide range of highly variable factors affect staffing. A comprehensive overview of infant factors (severity, intensity), nurse factors (education, experience, preferences, team dynamics), and unit factors (structure, layout, shift length, care model) influencing pre-shift NICU staffing is presented, along with how intra-shift variability of these and other factors must be accounted for to maintain effective and efficient assignments. There is opportunity to improve workload estimations and acuity measures for pre-shift staffing using technology and predictive analytics. Nurse staffing decisions affected by intra-shift factor variability can be enhanced using novel care models that decentralize decision-making. Improving NICU staffing requires a deliberate, systematic, data-driven approach, with commitment from nurses, resources from the management team, and an institutional culture prioritizing patient safety.

Missed nursing care and its influencing factors among neonatal intensive care unit nurses in South Korea: a descriptive study

Purpose

Preventing missed care is important in neonatal intensive care units (NICUs) due to neonates’ vulnerabilities. This study examined missed care and its influencing factors among NICU nurses.

Methods

Missed care among 120 Korean NICU nurses was measured using a cross-culturally adapted online questionnaire. The frequency of missed care for 32 nursing activities and the significance of 23 reasons for missed care were collected.

Results

All participants had missed at least 1 activity, missing on average 19.35 activities during a typical work-day. The most common missed item was “provide developmental care for the baby”. The most common reason for missed care was “emergency within the unit or deterioration of one of the assigned patients”. The final regression model explained 9.6% of variance in missed care. The average daily number of assigned patients receiving inotropes or sedation over the last month influenced the total number of missed care items.

Conclusion

Missed care was affected by nurses’ workload related to the number of patients taking medication. Frequently missed activities, especially those related to developmental care, require patience and time, conflicting with safety prioritization and inadequate working conditions. NICU nurses’ working conditions should be improved to ensure adequate time for nursing activities.

Psychometric properties of the perinatal missed care survey and missed care during labor and birth

Aim:

To evaluate the psychometric characteristics of the Perinatal Missed Care Survey and assess the prevalence of nurse-reported missed care during labor and birth.

Background:

Nursing care during labor and birth differs from other nursing care. Empirical evidence is scant regarding nursing quality and missed nursing care during labor and birth, which are important aspects of quality in maternity care.

Methods:

We conducted exploratory and confirmatory factor analysis on a previously developed perinatal missed nursing care instrument using data from 3,466 registered nurses. Measures included missed nursing care, reasons for missed nursing care, and demographic characteristics. All birth hospitals in each of 37 states were invited to distribute surveys electronically via email to their labor and delivery RN staff. The overall response rate from 277 hospitals that facilitated the survey was 35%.

Results:

Some missed care was reported for each of 25 missed care items. Labor support, intake and output, patient teaching, timely documentation, timely medication administration, and thorough review of prenatal records were missed at least occasionally by >50% respondents. Labor resources (83%), material resources (77%), and communication (60%) were reported reasons for missed nursing care. Exploratory factor analysis aligned with previous testing. Confirmatory factor analysis demonstrated good model fit.

Conclusions:

The Perinatal Missed Care Survey demonstrates good validity and reliability as a measure of missed nursing care during labor and birth. Our findings suggest missed nursing care during labor and birth is prevalent and occurs in aspects of care that could contribute to patient harm when missed.

Missed nursing care and its relationship with perceived ethical leadership

BACKGROUND

Determination of the factors affecting missed nursing care and the impact of ethical leadership is important in improving the quality of care.

AIM

This study aims to determine the missed nursing care and its relationship with perceived ethical leadership.

RESEARCH DESIGN

A cross-sectional study.

PARTICIPANTS AND RESEARCH CONTEXT

The sample consisted of 233 nurses, of whom 92.7% were staff nurses and 7.3% were charge nurses, who work in three different hospitals in Turkey. The study data were collected using a personal and professional characteristics data form, the Missed Nursing Care Survey, and the Ethical Leadership Scale.

ETHICAL CONSIDERATIONS

The study was approved by the non-interventional ethics committee of Dokuz Eylül University Ethics Committee for Noninvasive Clinical Studies. All participants' written and verbal consents were obtained.

FINDINGS

The most missed nursing care practices were ambulation, attending interdisciplinary care conferences, and discharge planning. According to the logistic regression analysis, sex, the number of patients that the nurse is in charge of giving care, the number of patients discharged in the last shift, and satisfaction with the team were determined as factors affecting missed care. No significant relationship was found between ethical leadership and missed nursing care (p > 0.05), and a weak but significant relationship was found between the clarification of duties/roles subscale and missed nursing care (r = -0.136, p < 0.05).

DISCUSSION

Ethical leaders should collaborate with policy-makers at an institutional level to particularly achieve teamwork that is effective in the provision of care, to control missed basic nursing care, and to organize working hours and at the country level to determine roles and to increase the workforce.

CONCLUSION

The results of this study contribute to the international literature on the most common type of missed nursing care, its reasons, and the relationship between the missed care and ethical leadership in a different cultural context.

A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care

BACKGROUND

Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas.

OBJECTIVE

This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs).

METHODS

We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents.

RESULTS

In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols.

CONCLUSIONS

Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

Measures of Stress Exposure for Hospitalized Preterm Infants

BACKGROUND

Extended hospitalization in neonatal intensive care units subjects preterm infants to multiple stress exposures that affect long-term cognitive functioning, motor development, and stress reactivity. Measurement of stress exposure is challenging with multiple measures of stress exposure in use, including counts of skin-breaking or invasive procedures or counts of noxious sensory exposures.

OBJECTIVES

The purpose of this analysis was to compare measures of stress exposure commonly used by researchers and to determine the predictive validity of these measures for early neurobehavior. We accomplished this objective through the following specific aims: (a) describe the stress exposures of preterm infants in the first 2 weeks of life, (b) determine the correlations among measures of stress exposure, and (c) compare the predictive validity of measures of stress exposure for early neurobehavior.

METHODS

Very preterm infants born between 28 and 31 weeks postmenstrual age were enrolled from four neonatal intensive care units in a large Midwest city. We measured stress exposure over the first 14 days of life for each infant as a count of skin-breaking procedures, a count of invasive procedures, and cumulative scores derived from the Neonatal Infant Stressor Scale. Neurobehavior was assessed at 35 weeks postmenstrual age using the motor development and vigor and alertness/orientation subscales from the Neurobehavioral Assessment of the Preterm Infant. We used Spearman's rho to determine correlations among the measures of stress exposure and multiple linear regression to determine the predictive validity of each stress exposure measure for neurobehavioral outcomes.

RESULTS

Seventy-one preterm infants were included in the analysis. We found marked variance across individuals in all measures of stress exposure. There were moderate-high correlations among the measures of stress exposure. No measure of stress exposure was associated with early neurobehavior.

DISCUSSION

The stress experiences of hospitalized preterm infants vary. This variance is reflected in all measures of stress exposure. Because measures of stress exposure are highly correlated, the most objective measure requiring the least interpretation should be used. However, the currently available measures of stress exposure used in this analysis may not reflect the infant's physiological stress responses and fail to associate with early neurobehavior.

Missed, rationed or unfinished nursing care: A scoping review of patient outcomes

AIMS

To collate evidence about patient outcomes resulting from the phenomenon of incomplete nursing care described in the literature variously as missed, rationed, or unfinished nursing care.

BACKGROUND

Nursing care which is not completed is known to have a negative impact on patients. However, to date, there has been no thorough exploration of the extent and potential seriousness of patient outcomes.

METHODS

The search was performed in four scientific databases; 44 studies were included in the final content analysis.

RESULTS

Missed, rationed and unfinished care negatively influence the patient outcomes in the context of patient safety and quality of nursing care. Despite the differences among concepts, the negative association with patient outcomes was significant and common for all concepts.

CONCLUSION

Awareness of potential harm of the phenomena to patient outcomes may help the management to develop preventive strategies to reduce or eliminate its actual occurrence.

IMPLICATIONS FOR NURSING MANAGEMENT

Hospital management should consider the phenomenon as an indicator of the quality of nursing care as well as establish the routine monitoring of the phenomena in the assessment of patient safety in healthcare facilities.

Association of Patient Acuity and Missed Nursing Care in U.S. Neonatal Intensive Care Units

The health outcomes of infants in neonatal intensive care units (NICUs) may be jeopardized when required nursing care is missed. This correlational study of missed care in a U.S. NICU sample adds national scope and an important explanatory variable, patient acuity. Using 2016 NICU registered nurse survey responses (N = 5,861) from the National Database of Nursing Quality Indicators, we found that 36% of nurses missed one or more care activities on the past shift. Missed care prevalence varied widely across units. Nurses with higher workloads, higher acuity assignments, or in poor work environments were more likely to miss care. The most common activities missed involved patient comfort and counseling and parent education. Workloads have increased and work environments have deteriorated compared with 8 years ago. Nurses' assignments should account for patient acuity. NICU nurse staffing and work environments warrant attention to reduce missed care and promote optimal infant and family outcomes.

Turkish Validation of the MISSCARE Survey - Pediatric Version

PURPOSE

To conduct Turkish validity and reliability study of the MISSCARE Survey-Pediatric version identifying the missed nursing care in pediatric units and its reasons.

DESIGN AND METHODS

The sample of this methodological study consisted of 222 nurses working in pediatric units. The study was conducted in three training and research hospitals and one university hospital. In the Turkish adaptation of the survey, confirmatory and explanatory factor analyses were performed within the context of language validity, content validity, and construct validity. In the reliability analyses of the survey, Cronbach's alpha for internal consistency analysis and intraclass correlation analysis for test re-test were used.

RESULTS

The language validity of the survey was conducted by expert linguists. Content validity index was calculated as 0.88 for section A and 0.90 for section B. Turkish version consisting of three factors and 16 items for section B of the survey met the construct validity. In reliability analyses it was determined that Cronbach's alpha values were between 0.82 and 0.88 in subscales of the survey and Intraclass Correlation Coefficient values were between 0.52 and 0.65 in subscales of the survey and 0.64 in overall survey.

CONCLUSION

In the Turkish version of MISSCARE Survey-Pediatric version, the section A with 29 items and the section B with 16 items were valid and reliable.

PRACTICE IMPLICATIONS

The survey is a valid and reliable tool for intercultural studies revealing the nursing care activities missed by nurses working in pediatric clinics and the reasons for such activities.

Parent Satisfaction With Care and Treatment Relates to Missed Nursing Care in Neonatal Intensive Care Units

Background: The satisfaction of parents of infants in neonatal intensive care is important to parent-infant bonding and parents' ability to care for their baby, including after discharge. Given the principal caregiver role of nurses in this setting, parent satisfaction is influenced by high quality nursing care. Nursing care that is required but missed, such as counseling and support, might influence parent satisfaction. How missed nursing care relates to parent satisfaction is unknown. Objective: To describe the satisfaction of parents of infants in neonatal intensive care and to determine how satisfaction relates to missed nursing care in a sample of USA nursing units. Methods: The design was cross-sectional and correlational. Thirty neonatal intensive care units that participate in the National Database of Nursing Quality Indicators were recruited. To maximize sample variation in missed care, the highest and lowest quartile hospitals on missed nursing care, measured by nurse survey, were eligible. Ten parents of infants who were to be discharged were recruited from each site to complete a survey. Parent satisfaction was measured by the EMPATHIC-38 instrument, comprising five subscales: information, care and treatment, organization, parental participation, and professional attitude, and a total satisfaction score. Multivariate regression models were estimated. Results: Parent satisfaction was high (5.70 out of 6.00). The prevalence of missed care was 25 and 51% for low and high missed care units, respectively, and 40% for all units. On average, nurses missed 1.06 care activities; in the low and high missed care units the averages were 0.46 and 1.32. Over 10% of nurses missed activities that involved the parent, e.g., teaching, helping breastfeeding mothers, and preparing families for discharge. One standard deviation decrease in missed care activities at the unit level was associated with a 0.08-point increase in parent satisfaction with care and treatment (p = 0.01). Conclusion: Parents in USA neonatal intensive care units are highly satisfied. Neonatal intensive care nurses routinely miss care. Parent satisfaction with care and treatment is related to missed nursing care. Nursing care that is missed relates primarily to the care of the baby by the parents, which could have long term health and developmental consequences.

Missed care relates to nurse job enjoyment and intention to leave in neonatal intensive care

AIM(S)

To determine relationships among missed nursing care, job enjoyment and intention to leave for neonatal nurses.

BACKGROUND

Being unable to provide required nursing care to infants could contribute to poorer neonatal nurse job outcomes, which may exacerbate staffing challenges. Little evidence exists about how missed nursing care relates to neonatal nurse job outcomes.

METHOD(S)

The design was cross-sectional. Secondary data from the 2016 National Database of Nursing Quality Indicators Registered Nurse Survey were used, which included nurse ratings of job enjoyment, intention to leave and missed nursing care. American Hospital Association data from 2016 were used to describe hospitals. Linear and logistic regressions were calculated.

RESULTS

There were 5,824 neonatal nurses. Mean nurse job enjoyment was 4.26 out of 6 (SD = 0.97). On average, 15% of nurses intended to leave their position. Each one unit increase in missed nursing care was associated with a 0.26 decrease in job enjoyment and a 29% increased odds of intention to leave after controlling for nursing and hospital characteristics.

CONCLUSIONS

Missed nursing care can influence nurse job enjoyment and intention to leave in neonatal care units.

IMPLICATIONS FOR NURSING MANAGEMENT

Neonatal nurse managers should address missed nursing care to improve neonatal nurse job outcomes.

A qualitative descriptive inquiry of the influences on nurses' missed care decision-making processes in acute hospital paediatric care

AIM

To explore influences on nurses' missed care decision-making processes in acute hospital paediatric care.

BACKGROUND

Many contemporary studies describe the phenomenon of missed care. It is clear that environment and organizational culture influence the nursing activities; however, what influences their decision-making processes has not been investigated.

METHOD

A descriptive qualitative inquiry was performed using semi-structured interviews with paediatric nurses (n = 20) from one Italian paediatric hospital.

FINDINGS

Thematic analysis revealed four themes: nurses' value system; hospital logistics, structures and resources; prioritization processes; and the informal caregiver's role.

CONCLUSION

This paper offers insights into the various factors involved in nurses' decision-making process when contemplating missed care that will be of use to managers when planning care or addressing missed care in the paediatric clinical setting.

IMPLICATIONS FOR NURSING MANAGEMENT

Knowledge and awareness of missed care in children's nursing needs greater exploration, especially in relation to what influences nurses' decision-making choices around missed care. Overall, a greater understanding of this will help managers to manage situations effectively and ethically so that missed care does not impact on outcomes for children in health care.

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

AIM

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR NURSING MANAGEMENT

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

A revised MISSCARE survey: Results from pilot testing

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adaptation of the MISSCARE Survey to the Maternity Care Setting

Missed nursing care is an important measure of nursing care quality that is sensitive to nurse staffing and is associated with patient outcomes in medical-surgical and pediatric inpatient settings. Missed nursing care during labor and birth has not been studied, yet childbirth represents the most common reason for hospitalization in the United States. The Missed Nursing Care (MISSCARE) Survey, a measure of medical-surgical nursing quality with substantial evidence for validity and reliability, was adapted to maternity nursing care using data from focus groups of labor nurses, physicians, and new mothers and an online survey of labor nurses. Content validity was evaluated via participant feedback, and exploratory factor analysis was performed to identify the factor structure of the instrument. The modified version, the Perinatal Missed Care Survey, appears to be a feasible and promising instrument with which to evaluate missed nursing care of women during labor and birth in hospitals.

Missed nursing care in newborn units: a cross-sectional direct observational study

BACKGROUND

Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identify missed care using direct observational methods.

METHODS

A cross-sectional study using direct-observational methods for 216 newborns admitted in six health facilities in Nairobi, Kenya, was used to determine which tasks were completed. We report the frequency of tasks done and develop a nursing care index (NCI), an unweighted summary score of nursing tasks done for each baby, to explore how task completion is related to organisational and newborn characteristics.

RESULTS

Nursing tasks most commonly completed were handing over between shifts (97%), checking and where necessary changing diapers (96%). Tasks with lowest completion rates included nursing review of newborns (38%) and assessment of babies on phototherapy (15%). Overall the mean NCI was 60% (95% CI 58% to 62%), at least 80% of tasks were completed for only 14% of babies. Private sector facilities had a median ratio of babies to nurses of 3, with a maximum of 7 babies per nurse. In the public sector, the median ratio was 19 babies and a maximum exceeding 25 babies per nurse. In exploratory multivariable analyses, ratios of ≥12 babies per nurse were associated with a 24-point reduction in the mean NCI compared with ratios of ≤3 babies per nurse.

CONCLUSION

A significant proportion of nursing care is missed with potentially serious effects on patient safety and outcomes in this LMIC setting. Given that nurses caring for fewer babies on average performed more of the expected tasks, addressing nursing is key to ensuring delivery of essential aspects of care as part of improving quality and safety.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Implications of a Decentralized Postpartum Unit Design and Clinical Operations

OBJECTIVES

This postoccupancy study sought to understand whether a decentralized unit design supported a postpartum care delivery model by evaluating nurses' efficiency, staff perception, acoustical conditions, and patient satisfaction.

BACKGROUND

Today, standardization and decentralization design concepts are being applied to all types of inpatient unit. There have been many studies that investigated how these concepts influence care delivery on medical-surgical units, but no study has evaluated a postpartum unit.

METHODS

This study utilized a mixed-method approach that involved unobtrusive shadowing (roughly 25 hr) and surveying (n = 19) of nursing staff, physical acoustic readings (eight, 24-hr readings), and comparison of patient satisfaction pre- and postmove.

RESULTS

On average, nurses spent roughly 36.90% of their time at charting stations. Nurses were observed mostly using the central charting station located at the entry of the unit and adjacent to the well-baby nursery rather than the five decentralized chart stations. This was due to nurses operating with old workflow habits, not fully integrating electronic medical records, and needing to be near the nursery and other nurses. Nurses were satisfied with their ability to interact and their proximity to supplies, patients, and team members while in the central charting station. Additionally, patient satisfaction significantly increased postmove, particularly with the overall hospital's quietness and cleanliness.

CONCLUSION

This study highlights the importance of aligning administrative operations of the unit with the design intent. Although standardization and decentralization design concepts aimed to improve nurses' workflow, misalignment with the operations may not deliver the most optimal outcomes.

Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit

IMPORTANCE

Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen.

OBJECTIVE

To evaluate the association of NICU nurse workload with missed nursing care.

DESIGN, SETTING, AND PARTICIPANTS

A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018.

EXPOSURES

Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjective measure (the National Aeronautics and Space Administration Task Load Index [NASA-TLX]).

MAIN OUTCOMES AND MEASURES

Missed nursing care was measured by self-report of omission of 11 essential care practices. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care.

RESULTS

A total of 136 nurses provided reports of shift-level workload and missed nursing care for 418 infants during 332 shifts of 12 hours each. When workload variables were modeled independently, 7 of 12 models demonstrated a significant worsening association of increased infant-to-nurse ratio with odds of missed care (eg, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift [95% credible interval, 1.81-3.47]), and all 12 models demonstrated a significant worsening association of increased NASA-TLX subjective workload ratings with odds of missed care (eg, each 5-point increase in a nurse's NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment for his or her assigned infant[s] during the same shift [95% credible interval, 1.30-1.39]). When modeling all workload variables jointly, only 4 of 12 models demonstrated significant association of staffing ratios with odds of missed care, whereas the association with NASA-TLX ratings remained significant in all models. Few associations of acuity scores were observed across modeling strategies.

CONCLUSIONS AND RELEVANCE

The workload of NICU nurses is significantly associated with missed nursing care, and subjective workload ratings are particularly important. Subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.

Neonatal nasogastric tube feeding in a low-resource African setting - using ergonomics methods to explore quality and safety issues in task sharing

BACKGROUND

Sharing tasks with lower cadre workers may help ease the burden of work on the constrained nursing workforce in low- and middle-income countries but the quality and safety issues associated with shifting tasks are rarely critically evaluated. This research explored this gap using a Human Factors and Ergonomics (HFE) method as a novel approach to address this gap and inform task sharing policies in neonatal care settings in Kenya.

METHODS

We used Hierarchical Task Analysis (HTA) and the Systematic Human Error Reduction and Prediction Approach (SHERPA) to analyse and identify the nature and significance of potential errors of nasogastric tube (NGT) feeding in a neonatal setting and to gain a preliminary understanding of informal task sharing.

RESULTS

A total of 47 end tasks were identified from the HTA. Sharing, supervision and risk levels of these tasks reported by subject matter experts (SMEs) varied broadly. More than half of the tasks (58.3%) were shared with mothers, of these, 31.7% (13/41) and 68.3% were assigned a medium and low level of risk by the majority (≥4) of SMEs respectively. Few tasks were reported as 'often missed' by the majority of SMEs. SHERPA analysis suggested omission was the commonest type of error, however, due to the low risk nature, omission would potentially result in minor consequences. Training and provision of checklists for NGT feeding were the key approaches for remedying most errors. By extension these strategies could support safer task shifting.

CONCLUSION

Inclusion of mothers and casual workers in care provided to sick infants is reported by SMEs in the Kenyan neonatal settings. Ergonomics methods proved useful in working with Kenyan SMEs to identify possible errors and the training and supervision needs for safer task-sharing.

Practices and Perceptions of Family Centered Care among Healthcare Providers: A Cross-sectional Study in a Pediatric Hospital

PURPOSE

This study aimed to: (1) investigate the extent to which Family Centered Care (FCC) principles are currently applied in clinical practice by healthcare providers working in inpatient units; (2) evaluate the extent to which FCC principles are perceived as necessary; and (3) examine the associations between FCC principles and socio-demographic and job characteristics of participants. Design and Methods A cross-sectional study was conducted at a large pediatric hospital using the Italian version of the FCC Questionnaire Revised (FCCQ-R). Univariate and multivariate analyses were performed.

RESULTS

Data from 469 healthcare providers were used for analysis. Scores for the FCC daily practices (Current activities) were significantly lower than those for their perceived necessity (Necessary activities) (p < .001). Participants who were male, younger, with work experience >20 years and working in rehabilitation reported a significantly higher perception of Current activities of FCC than others. The older and the more educated the participants, the greater was the perceived necessity of FCC activities. Female, older, and less experienced participants employed by the hospital but not working in the rehabilitation setting perceived a greater gap between Necessary and Current activities of FCC.

CONCLUSIONS

Scores for the Current and Necessary activities of FCC were lower than those reported in other studies. The lower scores in the Current activities and the significant gap can be due to organizational barriers or lack of skills, but the lower scores in the Necessary activities should be interpreted as a deficit of knowledge about FCC.

PRACTICE IMPLICATIONS

There is a need for further education about FCC in order to increase its perceived relevance in clinical practice.

Monthly variation of unfinished nursing care at the US Army Burn Center

OBJECTIVE

To describe the monthly variation in the prevalence and patterns of unfinished nursing care and to determine the relationships between the system of nursing care and unfinished nursing care at the US Army Burn Center.

METHODS

This was a repeated measures, descriptive study. For one week per month for six months, all nurses providing direct patient care on two inpatient burn units (intensive care and progressive care) were asked to complete an anonymous paper survey, which contained the Perceived Implicit Rationing of Nursing Care instrument, to estimate the prevalence of unfinished nursing care on their unit. Unit administrative data also were collected from the unit nursing leaders each month. Descriptive statistics and multilevel modeling were used in the analysis.

RESULTS

Most (80.5%) eligible nurses participated at least once; 46.6% participated three or more times. A high proportion (85.7-100%) of nurses left at least one element of care unfinished; the mean number of activities left unfinished over each 7 shift period per nurse was 16.2. Only nursing care hours provided by float staff significantly predicted nurse estimates of unfinished nursing care, β=.008, SE=.001, p<.05.

CONCLUSIONS

The prevalence of unfinished nursing care at the US Army Burn Center was high and generally consistent with other studies of unfinished nursing care in non-burn settings. The inability to meet the demand for nursing care, as evidenced by the presence of unfinished nursing care, may be the result of a limited surge capacity. Implications for research, policy, and practice were discussed.

Quantifying nursing care delivered in Kenyan newborn units: protocol for a cross-sectional direct observational study

INTRODUCTION

In many African countries, including Kenya, a major barrier to achieving child survival goals is the slow decline in neonatal mortality that now represents 45% of the under-5 mortality. In newborn care, nurses are the primary caregivers in newborn settings and are essential in the delivery of safe and effective care. However, due to high patient workloads and limited resources, nurses may often consciously or unconsciously prioritise the care they provide resulting in some tasks being left undone or partially done (missed care). Missed care has been associated with poor patient outcomes in high-income countries. However, missed care, examined by direct observation, has not previously been the subject of research in low/middle-income countries.

METHODS AND ANALYSIS

The aim of this study is to quantify essential neonatal nursing care provided to newborns within newborn units. We will undertake a cross-sectional study using direct observational methods within newborn units in six health facilities in Nairobi City County across the public, private-for-profit and private-not-for-profit sectors. A total of 216 newborns will be observed between 1 September 2017 and 30 May 2018. Stratified random sampling will be used to select random 12-hour observation periods while purposive sampling will be used to identify newborns for direct observation. We will report the overall prevalence of care left undone, the common tasks that are left undone and describe any sharing of tasks with people not formally qualified to provide care.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the Kenya Medical Research Institute Scientific and Ethics Review Unit. Written informed consent will be sought from mothers and nurses. Findings from this work will be shared with the participating hospitals, an expert advisory group that comprises members involved in policy-making and more widely to the international community through conferences and peer-reviewed journals.

Missed nursing care and its relationship with confidence in delegation among hospital nurses

AIMS AND OBJECTIVES

To (i) identify the types and reasons for missed nursing care among Jordanian hospital nurses; (ii) identify predictors of missed nursing care based on study variables; and (iii) examine the relationship between nurses' confidence in delegation and missed nursing care.

BACKGROUND

Missed nursing care is a global concern for nurses and nurse administrators. Investigating the relation between the confidence in delegation and missed nursing care might help in designing strategies that enable nurses to minimise missed care and enhance quality of services.

METHODS

A correlational research design was used for this study. A convenience sample of 362 hospital nurses completed the missed nursing care survey, and confidence and intent to delegate scale.

RESULTS

The results of the study revealed that ambulating and feeding patients on time, doing mouth care and attending interdisciplinary care conferences were the most frequent types of missed care. The mean score for missed nursing care was (2.78) on a scale from 1-5. The most prevalent reasons for missed care were "labour resources, followed by material resources, and then communication". Around 45% of the variation in the perceived level of "missed nursing care" was explained by background variables and perceived reasons for missed nursing. However, the relationship between confidence in delegation and missed care was insignificant.

CONCLUSION

The results of this study add to the body of international literature on most prevalent types and reasons for missed nursing care in a different cultural context.

RELEVANCE TO CLINICAL PRACTICE

Highlighting most prevalent reasons for missed nursing care could help nurse administrators in designing responsive strategies to eliminate or reduces such reasons.