Introduction
Nursing care is necessary for the better and quicker recovery of patients [1]. Safe patient care is mostly dependent on the nursing staff [2]. Missed nursing care is the term used to describe situations in which nursing staff members intentionally or inadvertently neglect patient care. “Any aspect of required patient care that is omitted (either in part or in whole) or delayed” is the definition of missed nursing care (MNC) [3]. MNC, sometimes referred to as an error of omission [4, 5], is an inadvertent occurrence that can happen as a result of increased patient demands at the bedside [6] or as a result of significant competing pressure on the nurses to complete multiple tasks in a constrained amount of time [5].
Several terms have been used in the literature to describe MNCs [3‐6]. These terms are frequently used interchangeably [7] and include nursing care left undone [8], unfinished care [4], unmet nursing care needs [9], and implicit rationing of nursing care [10]. These terms have a common feature in which they all recognize any aspects of nursing care omitted (totally or partially) [8]. The terms also indicate prioritizing and decision-making about which care to provide and which care to leave [11].
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Research indicates that the quality of overall healthcare as well as patient safety are significantly impacted by nursing care [12, 13]. Missed nursing care has become a global health concern [14] because of its impact on patient safety [15] and nursing care quality [1, 16]. It is a critical indicator of nursing care quality [17] and adverse patient outcomes [18, 19]. Unfavorable patient outcomes like inpatient mortality [20, 21], medication errors [22], higher occurrences of infections [15, 23], increased pain and discomfort [13, 24], malnourishment [25], patient falls, and pressure ulcers [26] were reported as being the consequences of missed nursing care. In addition, MNC has substantial influence in terms of high cost [27], increased length of stays [28], mortality [23], and other life-threatening complications [29]. MNC also has unfavorable outcomes for nurses, such as low job satisfaction, absenteeism [8], high rates of burnout, and staff turnover [30]. These factors place a heavy load on the healthcare system and jeopardize patient safety [19].
Missed nursing care is affected by many complex factors, such as inadequate hospital resources. Previous studies have identified several factors that can contribute to missed nursing care, including inadequate hospital resources [13, 31], limited labor resources [32], ineffective communication [33], teamwork [34], and financial resources [20]. Increases in unexpected volume of admissions and discharges [35], the inadequacy of staff [33], the unavailability of medicines [36], nurse intention to leave [37], and patient emergency situations [38] have been reported to result in missed care.
Even though research on MNCs has been booming, little is known about MNCs in low- and middle-income nations (LMICs) [39]. Examining nurses’ perspectives on the causes of care neglect is necessary, given the dearth of studies in this area. Specifically, the lack of resources in LMIC contexts makes this study necessary. The institutional frameworks, work environments, and hospital structures are not the same as in industrialized nations [40]. It’s also possible that the reasons for MNCs differ from those in developed environments. Specifically, the healthcare systems in different countries may have different causes of MNC due to environmental variables and the scarcity of resources.
In Ethiopia, where primary healthcare services are covered by nurses, it is important to develop their knowledge and practice of nursing care since the possibility of missing nursing care is high in their day-to-day activities. However, there is limited information in the study area that describes the magnitude and reasons for missed nursing care among nurses. Therefore, this study aimed to determine the magnitude and reasons for missed nursing care.
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Methods
Study design, area, and period
We conducted an institution-based cross-sectional study design among nurses working in South Gondar Zone public hospitals from December 12, 2023, to January 20, 2024. South Gondar is one of the 11 zonal administrations in the Amhara region of northern Ethiopia, with an estimated area of 14095.19 square kilometers. It is located by the South and North Wollo zones in the east, the Bahirdar Liyu zone and Lake Tana in the west, Central Gondar in the north, the Waghimra zone in the northeast, and the East and West Gojjam zones in the south. Based on the information from the South Gondar Zone Administrative Health Bureau, the total population in South Gondar Zone is 2,609,823, of whom 49.9% are male. There are four (404) nurses in 10 public hospitals in the zone, namely Debre Tabor comprehensive specialized hospital, Addis Zemen, Ebnat, MekaneEyesus, Andabet, Wogeda, Woreta, Nefas Mewucha, Dr. Ambachew Makonnen, and Migbaru Kebede primary hospitals.
Study population
All nurses working in all South Gondar Zone public hospitals.
Inclusion and exclusion criteria
All nurses working in all South Gondar zone public hospitals at the time of the data collection period were included in the study, whereas nurses who were on sick leave, nurses with less than 6 months of work experience, and nurses in administrative positions (not directly involved in continuous patient care) were excluded from the study.
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 nurses, increased patient load, working unit, training, working shift, medication availability, equipment availability, and the function of equipment).
Operational definition of key variables
Missed nursing care
nursing care was considered missed if the response of participants for each questionnaire was sometimes missed, frequently missed, or always missed [41]. To conduct logistic regression, if the average of events for an individual was < No>, and if the average was > 2 (i.e., all answered with some times, frequently, and always missed), the occurrence of missed care would be considered < Yes> [42].
Perceived staff adequacy
perception of the respondents toward the adequacy of their nursing staff in their unit to accomplish nursing activities [37].
Reason
reasons for missed nursing care reported as moderate or significant [42].
Sample size determination
The census method was employed because the study population was smaller than the sample size. The study population, or all nurses employed by South Gondar Zone public hospitals (404), served as the sample size for this research.
Data collection tool and procedure
Data was collected using a self-administered MISSCARE survey tool adopted from the development of a psychometric tool to measure missed nursing care [41, 43]. The tool had an overall Cronbach’s alpha value of 0.84 for questions related to types of missed nursing care elements and 0.78 for reasons for missed nursing care questions. Ten Bachelor of Science (BSc) nurses were involved in the data collection under the continuous supervision of the five BSc-trained nurses who were supervisors and each received a full day of training. The overall data collection procedure was being coordinated by the principal investigator. The questionnaires have a total of 63 questions, divided into three parts. Part one contains 20 questions on facility and respondent characteristics. Part two contains five questions to assess the level of satisfaction. Part two includes 22 questions designed to assess various types of missed nursing care. Response is based on a Likert scale: 1 never, 2 rarely, 3 sometimes, 4 frequently, and 5 always missed. For each single question, missed care was defined as “not occurred” (event = 0) if the response would be 1–2 (rarely and never) and as “occurred” (event = 1) if the response would be 3–5 (sometimes, frequently, and always missed). Part three contains 16 questions to assess the reasons for the omission of nursing care. The response range consists of four alternatives: 1 no reason, 2 minor reasons, 3 moderate reasons, and 4 significant reasons.
Data quality control
To ensure data quality, a pretested and validated tool was employed, and continuous supervision was provided during data collection. A pretest was conducted at Woldia Compressive Specialized Hospital from November 23–27, 2023, on 5% of the sample size to check for clarity, understandability, and the total time that it would take to complete the questionnaire prior to the actual data collection. Then, the necessary comments and feedback were incorporated into the final tool to improve its quality. Training was given to the data collectors regarding the objective of the study, data collection tools, ways of collecting data, checking the completeness of the collected data, and how to maintain confidentiality. The collected data were checked for completeness, cleaned, edited, coded manually, and entered into EpiData V.4.2. Double data entry was done for validity and compared with the original data. Outliers were checked, and simple frequencies and cross-tabulation were done for missing values and variables.
Data processing and analysis
The data completeness and consistency were checked manually, coded, filtered, and entered into Epi Data version 4.6, and then it was exported to SPSS version 25 statistical software for analysis. Descriptive analysis was done by computing proportions and summary statistics. The information was presented using simple frequencies, summary measures, tables, and figures. To assess the association between missed nursing care and independent variables, a binary logistic regression model was used at a 95% confidence level. Variables with a p value less than 0.2 in the bivariate analysis were included in the final multivariable analysis model in order to control all the possible confounders, and the variables were selected using the enter method. The assumption of a binary logistic regression model was checked before regression analysis. The goodness of fit was tested by Hosmer-Lemeshow statistics and Omnibus tests. Multicollinearity was also checked using the variance inflation factor (VIF). A multivariable binary logistic regression model was carried out to determine the measure of association (odds ratio). The statistical significance of the association between outcome variables and independent variables was declared at a P-value less than 5% (0.05).
Ethical considerations
Ethics approval was obtained from the College Health Science Ethical Review Board of Debre Tabor University with reference number DTU/1092/24. Informed consent was obtained from all study subjects and health providers. Those who were unwilling to participate in the study were excluded. Names and other identifying information were not included in the study.
Result
Socio-demographic and professional characteristics of participants
Of the total of 404 selected participants, 391 were included in the final analysis, giving a response rate of 96.8%. Most of the participants worked as bachelor degree nurses (n = 353; 90.3%), and the majority of participants had been working for more than five years. Additionally, half (n = 197; 50.4%) of the respondents had received training. Moreover, 218 (58.07%) of them had worked both night and day shifts, and 198 (50.6%) of respondents planned to leave their institution (Table 1).
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Table 1
Socio-demographic characteristics of the respondents working in South Gondar Zone public hospitals, Northcentral Ethiopia, 2024 (n = 391)
Variables | Category | Frequency | Percent |
|---|---|---|---|
Working unit | Medical Surgical Orthopedics Pediatrics Emergency ICU OPD | 75 78 31 59 48 39 61 | 19.2 19.9 7.9 15.1 12.3 10.0 15.6 |
Spend majority of working time in the unit | Yes No | 382 9 | 97.7 2.3 |
Age | < 30 30–39 ≥ 40 | 181 161 27 | 49.1 43.6 7.3 |
Sex | Male Female | 197 194 | 50.4 49.6 |
Marital status | Single Married | 175 216 | 44.8 55.2 |
Education level | Diploma Bachelor degree Master degree | 23 353 15 | 5.9 90.3 3.8 |
Job Title | Staff Nurse Nurse manager | 382 9 | 97.7 2.3 |
Number of hours usually worked per week | < 40 h per week ≥ 40 h per week | 43 348 | 11.0 89.0 |
Work shift | Day Night Day and night | 133 40 218 | 34.0 10.2 55.8 |
Experience in your role | 6 months up 2 years 2 years up to 5 years 5 years up to 10 years More than 10 years | 30 122 181 58 | 7.7 31.2 46.3 14.8 |
Experience on your current care unit | up to 6month 6 month up to 2 years 2years up to 5 years 5 years up to 10 years More than 10 year | 119 187 55 9 21 | 30.4 47.8 14.1 2.3 5.4 |
Training (CPD) in nursing care | Yes No | 197 194 | 50.4 49.6 |
overtime did you work | None 1–12 h > 12 h | 65 37 289 | 16.6 9.5 73.9 |
Number of absent days in the last month | None 1 day or more | 255 136 | 65.2 34.8 |
plan to leave your current position | Yes No | 198 193 | 50.6 49.4 |
Commonly missed nursing care
This study finding showed that the magnitude of missed nursing care among nurses was 51.7% (95% CI: 46.89–55.47%). Patient discharge planning and teaching (n = 273; 69.8%), turning patients every 2 h (n = 272; 69.6%), full documentation of all necessary data (n = 269; 68.8%), patient assessments performed each shift (n = 265; 67.8%), and IV/central line site care and assessments according to hospital policy (n = 259; 66.2%) were among the nursing care elements that were frequently missed (Fig. 1; Table 2).
Fig. 1
magnitude of missed nursing care among nurses in South Gondar zone public hospitals, Northcentral Ethiopia, 2024 (n = 391)
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Table 2
Missed nursing care in South Gondar Zone public hospitals, Northcentral Ethiopia, 2024 (n = 391)
Nursing care item | Performed No (%) | MNC (%) |
|---|---|---|
Initial assessments (physical, social, emotional | 185(47.3) | 206(52.7) |
Physical examination (head-to-toe) | 218(55.8) | 173(44.2) |
Pain assessment and management | 166(42.5) | 225(57.5) |
Ambulation three times per day or as ordered | 200(51.2) | 191(48.8) |
Turning patient every 2 h | 119(30.4) | 272(69.6) |
Medications administered as ordered | 186(47.6) | 205(52.4) |
Vital signs were assessed as ordered and accordingly | 187(47.8) | 204(52.2) |
Monitoring input/output | 198(50.6) | 193(49.4) |
Full documentation of all necessary data | 122(31.2) | 269(68.8) |
Patient teaching about illness, tests, and diagnostic studies | 171(43.7) | 220(56.3) |
Review of collected lab results | 148(37.9) | 243(62.1) |
Emotional support to patient and/or family | 197(50.4) | 196(49.6) |
Patient discharge planning and teaching | 118(30.2) | 273(69.8) |
Bedside glucose monitoring as ordered | 133(34.0) | 258(66.0) |
Patient assessments performed each shift | 126(32.2) | 265(67.8) |
Focused reassessments according to patient condition | 142(36.3) | 249(63.7) |
IV/central line site care and assessments according to hospital policy | 132(33.8) | 259(66.2) |
Administration of PRN medication within 15 min after request | 156(39.9) | 235(60.1) |
Assess the effectiveness of medications | 141(36.1) | 250(63.9) |
Attend interdisciplinary care conferences whenever held | 143(36.6) | 248(63.4) |
Skin/Wound care 118(30.2) 273(69.8) | 201(51.4) | 190(48.6) |
Discussing patients expectation | 210(53.7) | 181(46.3) |
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Reasons for missed nursing care
According to our study, material resources (76.7%), labor resources (65.5%), teamwork (69.1%), and communication (56.3%) were the main reasons for nursing care omissions. In the material resources domain, medications are unavailable when needed (n = 216; 55.2%), supplies and equipment are unavailable when needed (n = 231; 59.1%), and supplies and equipment are not functioning properly when needed (n = 253; 64.7%) are common reasons. From the labor resources domain, unexpected rises in patient volume and/or acuity on the unit (n = 202; 51.7%) and heavy admission and discharge activity (n = 192; 49.1%) are common reasons (Table 3).
Table 3
Reasons for missed nursing care in South Gondar Zone public hospitals, Northcentral Ethiopia, 2024 (n = 391)
Reason category | Reason sub-scale | Reason | No reason |
|---|---|---|---|
Labor Resources | Inadequate number of nursing staff | 176(45.0) | 215(55.0) |
Urgent patient situations (e.g. a patient’s condition worsening) | 187(47.8) | 204(52.2) | |
Unexpected rise in patient volume and/or acuity on the unit | 202(51.7) | 189(48.3) | |
Inadequate number of assistive personnel | 182(46.5) | 209(53.5) | |
Heavy admission and discharge activity | 192(49.1) | 199(50.9) | |
Material Resources | Medications were not available when needed | 216(55.2) | 175(44.8) |
Supplies/equipment not available when needed | 231(59.1) | 160(40.9) | |
Supplies/equipment not functioning properly when needed | 253(64.7) | 138(35.3) | |
Team work | Unbalanced patient assignments | 178(45.5) | 213(54.5) |
Inadequate hand-off from previous shift or sending unit | 176(45.0) | 215(55.0) | |
Other departments did not provide the care needed | 182(46.5) | 209(53.5) | |
Lack of back up support from team members | 186(47.6) | 205(52.4) | |
Caregiver off unit or unavailable | 164(41.9) | 227(58.1) | |
Communication | Tension or communication breakdowns with other department | 174(44.5) | 217(55.5) |
Tension or communication breakdowns within the nursing team | 183(46.8) | 208(53.2) | |
Nursing assistant did not communicate that care was not provided | 174(44.5) | 217(55.5) |
Factors associated with missed nursing care
A binary logistic regression model with multivariate analysis revealed that an inadequate number of staff 2.9 (1.75, 4.75), training (CPD) in nursing care 1.9 (1.16, 3.14), equipment’s not available 3.9 (2.16, 6.89), and medication were not available. 4.4 (2.48, 7.76) were associated with missed nursing care. Nurses who perceived an inadequate number of staff were 2.9 times more likely to miss nursing care (adjusted odds ratio (AOR): 2.9; 95% CI: 1.75 to 4.75). On the other hand, nurses who did not get job training in the last year were 1.9 times more likely (AOR: 1.9; 95% CI: 1.16 to 3.14) to miss nursing care than those who had received training. Additionally, nurses who responded that equipment wasn’t available were 3.9 times more likely to miss nursing care (AOR: 3.9; 95% CI: 2.16 to 6.89), and nurses who responded that medication was unavailable were 4.4 times more likely to miss nursing care (AOR: 4.4; 95% CI: 2.48 to 7.76) (Table 4).
Table 4
Factors associated with missed nursing care among nurses in South Gondar Zone public hospitals, Northcentral Ethiopia, 2024 (n = 391)
Variables | Category | MNC | COR (95%CI) | AOR(95%CI) | P-value | |
|---|---|---|---|---|---|---|
Yes | No | |||||
Inadequate no of staff | Yes No | 120 82 | 56 133 | 3.48(2.28,5.29) | 2.9(1.75,4.75) Ref | 0.000 |
Training (CPD) in nursing care | Yes No | 88 114 | 109 80 | Ref 1.77(1.18,2.64) | Ref 1.9(1.16,3.14) | 0.011 |
Equipment’s not available when needed | Yes No | 167 35 | 64 125 | 9.32(5.81,14.9) Ref | 3.9(2.16,6.89) Ref | 0.000 |
Medication were not available | Yes No | 161 41 | 55 134 | 9.57(6.07,15.2)Ref | 4.4(2.48,7.76) Ref | 0.000 |
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Discussion
It’s common to miss crucial components of nursing care in any setting [23]. Many situations and factors lead to a great deal of nursing care being neglected. This study found that the magnitude of missed nursing care among nurses was 51.7% (95% CI: 46.89 to 55.47). This is consistent with research done in Italy [44]. Comparing this result to research done in the USA [45], Egypt [46], Nigeria [47], Bahir Dar [37], and northern Shewa Ethiopia [43], it was higher. However, less than the research done in Iran [42], Gonder [48], Jimma [49], and Tigray [41]. This discrepancy may be caused by the different study times and study sites, as well as the respondents’ varying degrees of training and understanding regarding nursing care in the various study settings.
The findings showed that the most frequently missed nursing care elements were patient discharge planning and teaching, turning patients every 2 h, full documentation of all necessary data, and patient assessments performed each shift. These most frequent types of missed care are often time-consuming, such as turning patients every two hours and performing patient assessments every shift, which typically call for support that may not be available and may therefore force nurses to prioritize other tasks less. In addition to having to limit their care, nurses frequently find it difficult to complete the most important jobs on the wards and are more likely to skip important work [8]. Prior research has demonstrated that time limits and heavy workloads render patient education ineffective [42]. Improving patient education may benefit from the use of technology-based learning resources. The results of this study also showed that one of the most common components of missed care is inadequate documentation. Systemic problems, including time constraints and an increasing workload for nurses, may be the cause of barriers to nursing care documentation [50]. Documentation may be seen by nurses as an extra task that interferes with the ongoing provision of patient care. Researchers [51] suggested that in order to address the lack of proper documentation in the healthcare system, better system functionality, such as increased skill levels and the availability of efficient IT systems, is required.
The results of this study identified reasons that lead to missed nursing care. These elements are labor resources, material resources, communication, and teamwork. Material resources were the most common element, followed by labor resources, teamwork, and communication aspects in that order. The results of this investigation are in line with previous research by Haftu et al., Diab et al., Andersson et al., and Dutra et al. [41, 46, 52, 53]. In terms of the material resource factor’s significance for missed care, the majority of nurses stated that the most common components were that supplies and equipment malfunctioned when needed and that medications were unavailable when needed, both of which were significant causes of missed care. This result is in line with other research by Chegini et al., Diab et al., and Albsoul et al. [42, 46, 54]. When it comes to the labor resource factor’s components, nurses reported that the most common reasons for missed care were, in that order, an inadequate number of staff, an unexpected rise in patient volume, heavy admission and discharge activity, and urgent patient situations. This outcome is consistent with studies by Chegini et al., Diab et al., and Albsoul et al. [42, 46, 55]. As the researcher noted [55], nurses will overlook providing some nursing care for patients if there are not enough nurses on staff and patient volume or acuity increases. However, this could raise the possibility of unfavorable and insufficient patient outcomes.
The third and fourth reasons for missed nursing care were teamwork and communication domains. Nurses mentioned that lack of backup support from team members, inadequate handover from the previous shift, and unbalanced patient assignments were the most often cited causes in the teamwork sub-scale. This result agrees with [46]. The top communication items for missed cares were that nursing assistants did not communicate that care was not provided and tension and communication breakdown with the medical staff. Chapman [17] reported that effective communication between staff could be beneficial to reduce the length of stay and ensure better patient outcomes.
Another significant finding was the relationship between independent variables and missed nursing care. This study found that nurses who perceive an inadequate number of staff are more likely to miss nursing care, aligning with previous research conducted in the USA [56], Korea [31, 57], Iran [55], and Jordan [54]. It is due to the fact that working in a setting with a sufficient number of nursing personnel can reduce missed nursing care and result in fewer reasons for missed nursing care [58]. There is actually a global nursing shortage, and this issue is becoming worse in low- and middle-income countries as more nurses leave the profession or move abroad to work [40]. As a result, it is critical to determine the staffing levels required to provide safe nursing care. It has been determined that patient safety and lower MNC require an adequate supply of nursing staff. Two strategies that can be used to fill the gap created by the shortage of nurses are implementing overtime and floating regulations. As a result, the likelihood of missed care events has decreased [59].
The results of this study also showed that, in comparison to nurses who received training, those who did not had a higher likelihood of missing nursing care. This outcome is consistent with earlier studies carried out in Ethiopia’s Bahir Dar [37]. It is because receiving training makes it easier to comprehend and carry out nursing care actions, which lowers the possibility of overlooking essential nursing care components. The correlation shown between a higher rate of missed care and a lack of recent job training emphasizes the significance of continuing education for nurses. Nurses receive training that not only keeps them up to date on new technologies and best practices but also emphasizes the value of providing holistic patient care [60]. Thus, improving nursing competency and patient outcomes could be greatly enhanced by in-service training programs.
Similarly, this study also showed that medication unavailability was significantly associated with the occurrence of missed nursing care among nurses, in line with a study conducted in Jordan [54]. It could be explained that the unavailability of medications will lead to a delay in the nursing intervention of patients, thus leading to a lack of continuity in the care of the patients, which causes complications and deterioration in their condition.
Moreover, this study finding also showed that equipment’s unavailability when needed was also significantly associated with the occurrence of missed nursing care among nurses (p < 0.05). Other studies have concluded that the absence of equipment is the primary cause of MNC [16, 61]. In low income countries like Ethiopia, access to material resources is difficult, which leads to increased demand for nursing care. According to the study [62], patients transferred or were referred to another facility due to a lack of equipment for diagnostic and therapeutic purposes.
Limitations of this study
The data was gathered via self-administered surveys. Recall and social desirability biases could affect the study; however, blinding was employed by the authors to reduce these biases. Consequently, underreporting of missing nursing care may arise from self-reporting. Because the study was cross-sectional, the findings did not demonstrate how the patient is affected when nursing care is not provided.
Conclusion
Despite their intention to complete all necessary nursing care tasks, some nurses fail to complete them entirely, partially, or at all. According to the study’s findings, a substantial number of nurses failed to complete nursing care tasks (either completely, partially, or delayed). The most common reasons for missing critical nursing care were labor resources, material resources, communication, and teamwork domains. Lack of job training, insufficient staffing, medication unavailability, and material unavailability all demonstrated significant associations with missed nursing care.
Recommendation
These findings indicate that coordinated efforts are needed to reduce the prevalence of MNCs and improve nursing care. Based on the result of the study, the following recommendation was provided.
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Creating a standard protocol to regularly check for missed nursing care is a crucial step for all hospitals.
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It is necessary to think about ways to support improved organizational resources, increase the number of nurses, and raise their level of professional competency through training.
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Many reasons lead to missed nursing care or omissions, including low staffing, high patient-to-nurse ratios, inadequate training, and scarce resources. Resolving these problems by addressing staffing shortages and guaranteeing the availability of necessary equipment could greatly reduce the number of cases of neglected nursing care.
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Further research is recommended with observational techniques and a qualitative design to see things from the patients’ perspective and separately study items of nursing care. It is also necessary to see other interventional studies to examine the causal relationship between missed nursing care and its factors.
Acknowledgements
First and foremost, we would like to extend our deepest gratitude to Debre Tabor University, College of Health Science, for giving us the opportunity to conduct this study. Second, we would like to thank hospital administrators for their permission and unlimited support. Lastly, we also give our heartfelt thanks to the data collectors and all study participants for their contributions to the study’s success.
Declarations
Competing interests
The authors declare no competing interests.
Ethical approval and consent to participate
Ethics approval was obtained from the College Health Science Ethical Review Board of Debre Tabor University with reference number DTU/1092/24. Informed consent was obtained from all study subjects and health providers. Those who were unwilling to participate in the study were excluded. Names and other identifying information were not included in the study.
Consent for publication
Not applicable.
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