Background
Nursing care is a complex process that involves providing skilled, safe, ethical, holistic, individualized, and interpersonal care to patients based on the best available evidence, with the goal of optimizing health outcomes and achieving positive patient results [1]. However, there may be instances where nurses are unable to provide all aspects of care for a variety of reasons. In this situation, they may miss, reduce, or delay certain aspects of care [2].
The concept of missed nursing care (MNC) refers to any aspect of required care that is omitted either in part or in whole or delayed [3]. This concept was initially explored by Beatrice J. Kalisch in her 2006 study, which eventually led to the development of the MISSCARE survey instrument. This tool evaluates staff members’ perspectives of MNC and the rationale behind such omissions [3, 4].
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MNC is associated with compromised patient safety and quality of care but it commonly occurs worldwide [5, 6]. A systematic review of 42 studies revealed that 55–98% of nurses reported missing required care during the time of assessment [7]. Studies from the United States, Brazil, and Iran showed that the MNC levels were 51.4%,74.1%, and 72.1% respectively [8‐10].
The major impacts of MNC were increased mortality, adverse events, and decreased patient satisfaction [11, 12]. Each 10% increase in MNC is associated with a 16% increase in patient mortality within 30 days of admission [13]. Additionally, MNC leads to a 10% increase in the incidence of adverse patient outcomes, such as medication errors, nosocomial infections, pressure ulcers, and urinary tract infections [14‐16]. Furthermore, MNC is also linked to a higher rate of hospital readmission, with a 10% increase in MNC activity associated with a 2–8% increase in the odds of readmission [17].
In the context of labor and delivery MNC is described as having delayed, unfinished, or completely missed routine care that was expected to be given to childbearing women and newborns during labor and birth as well as the two-hour postpartum period [18]. Most nurses and midwives in the maternity wards frequently fail to provide essential nursing care [19]. Consequently, this results in several adverse maternal and fetal outcomes such as an increased number of cesarean births, depressed newborns at birth, hemorrhage, and negative impacts on patient satisfaction, successful breastfeeding, and the overall patient experience [8, 20].
Missed care is an ethical issue that challenges the professional and moral values of nurses, and is also associated with decreased work satisfaction and work intention [21, 22]. In a study by Cho et al., MNC was associated with increased job dissatisfaction by 7–8% and it also increased the intention to leave the job by 4% [23].
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MNC has been influenced by several factors such as hospital resources, working environment, and nurse-specific factors like age, absenteeism rate, work experience, workload, gender, and qualification [24, 25]. Furthermore, labor resources (staff shortages and high workloads), material resources, and communication contribute to missed nursing care [10].
Missed nursing care is an excellent cost-effective mechanism for determining what care is missed and performed, and it needs to be studied systematically in multiple cultural contexts [3, 26]. Although there is evidence of MNCs from high-income countries, few recent studies have examined this issue in low and middle-income countries [10, 19, 27, 28]. However, low and middle-income countries often face challenges such as limited resources, different hospital structures, and varying organizational environments. Therefore, there is a need for evidence identifying the level and type of nursing care in these countries [29].
Ensuring the prevention of MNC should be considered a fundamental value throughout the entire hospital, rather than solely a nursing concern [30]. Various measures have been implemented to minimize MNC, encompassing both structural interventions, such as increasing the nursing workforce and enhancing teamwork, as well as process interventions, including the utilization of technology or reminders and optimizing relevant care processes [30, 31]. These interventions have significantly reduced instances of MNC. However, there is a need to study the long-term sustainability of the intervention’s impact [31, 32].
Although there are several studies on MNC in Ethiopia, these studies often generalize their findings to all units in hospitals [28, 33]. However, due to the unique structure of maternity wards, it is important to specifically address the issues related to this specific ward [18]. Furthermore, other literature fails to consider factors related to the hospital and staff, such as the level of the hospital and staff’s perception of adequacy, as well as weekly work hours [19]. Therefore, this study aims to address these gaps by focusing on the level of MNC and its associated factors in the maternity wards of public hospitals in the Sidama region.
Method
Study area and period
The study was conducted in randomly selected public hospitals in the Sidama National Regional State from March 28 to April 26, 2022. The Sidama regional state is one of the 11 regional states of Ethiopia, and Hawassa city is the capital city of the region and is located 273 km south of Addis Ababa, the capital city of the country. The estimated total population of the region is 2,966,652. The region has sixteen primary hospitals, four General hospitals, and one comprehensive specialized hospital.
Study design and population
A hospital-based cross-sectional study was conducted among nurses and midwives who worked in the maternity wards of public hospitals in the Sidama region from March 28 to April 26, 2022. Midwives and nurses who worked for more than six months were included in the study, while those who were on maternity, annual, or sick leave during the data collection period were excluded.
Sample size and sampling procedure
The sample size was calculated by using Epi-Info version 7 software [34] by considering the following assumptions: The proportion of MNC was 74.6% [19], with a 95% confidence interval with a 5% margin of error. The sample size for factors associated with MNC was also determined by Epi-Info version 7 software with the assumptions of the two-sided confidence level of 95%, a power of 80%, and the ratio of unexposed to exposed one. The sample size calculated for the shift of the work as a factor (328) [19] was larger than the sample size determined for the proportion of MNC (291). Therefore, by adding a 10% non-response rates the final sample size of this study was 361.
Initially, we stratified the hospitals into three categories: primary, general, and comprehensive specialized. We then utilized simple random sampling to select hospitals from each group. Afterward, the sample size (361) was distributed proportionally among the eleven selected hospitals based on the number of nurses and midwives working in maternity wards, which comprise the antenatal care unit, high-risk unit, delivery unit, post-natal care unit, family planning unit, and gynecology unit. Lastly, the study participants were chosen using a simple random sampling approach.
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Data collection procedure and data quality control
A self-administered MISSCARE survey instrument adapted from a psychometric tool to measure nursing care was used to collect the data [3]. The questionnaire contains twenty-six questions for elements of MNC that assess the amount of time each care was missed and consists of a Likert scale with the answers of never, rarely, sometimes, frequently, and always missed; the reasons for MNC have 18 questions and are asked in four categories; labor resource, material resource, teamwork, and communication, and the responses are not a reason, minor reason, moderate reason, or significant reason.
The reliability of the tool was examined and had a Cronbach’s alpha value of 0.827. Data collectors, along with supervisors, were trained on the objective of the study, the content of the tool, and how to maintain confidentiality and privacy for the study participants. A pre-test of the questionnaire was conducted on 5% of participants (18 participants) before the actual data collection process at Kebado Primary Hospital in the Sidama region. After the pre-test, questions that were confusing or poorly worded and the order of questions were revised. Supervisors and the principal investigator checked all the collected data for completeness and consistency on a daily basis.
Participants were informed about the study’s objectives and the data collection took place in a private room to ensure confidentiality. Each respondent was given the opportunity to complete the questionnaire alone, to create a comfortable environment where they could provide honest and thoughtful responses without any external pressure or influence.
Operational definition
Missed nursing care (MNC)
refers to any aspect of required care that is omitted either in part or in whole or delayed [3]. Responses were measured using 26 items on five-point Likert -type scale responses ranging from 1 (never missed) to 2- (rarely missed), 3- (sometimes missed), 4-( frequently missed), and 5- (always missed). The total MNC score is the sum of the scores of individual items and ranges from 26 to 130. The highest score indicates the highest MNC [35].
Data processing and analysis
The collected data were checked for completeness, cleaned manually, coded, and entered into Epi data version 3.1 and exported to SPSS version 26 for further analysis [36]. Descriptive statistics were used to characterize the variables. Simple linear and multiple linear regression analyses were used to identify the factors associated with MNC. Linear regression analysis assumptions linearity, normality, homogeneity of variance, independent residual, presence of outlier, and presence of Multicollinearity were checked. The linearity assumption was tested and fulfilled using a scatter plot. Normality was checked using the Shapiro-Wilk test, which yielded a value of 0.089, homoscedasticity was tested by plotting a scatter plot of standardized residual against standardized predicted value, and the assumptions were met. The assumption that the values of the residual are independent was met because the Durbin-Watson statistics value was 1.727. The maximum Cook’s distance value was 0.061 suggesting that there were no outliers. The Multicollinearity assumption was checked by examining the tolerance and variance inflation factor (VIF). All tolerance scores were greater than 0.10 and VIF values were below 10 implying Multicollinearity could not exist.
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Variables with a p-value of less than 0.25 and that are biologically plausible were chosen for the multiple linear regression analysis. Factors that had significant association declared at a 95% confidence interval and P-value less than 0.05 and unstandardized β were used for interpretation.
Results
Sociodemographic characteristics of the participants
From a total sample of 361 study participants, 345 participated in the study, giving a response rate of 95.6%. Of the total study participants, 215(62.3%) and 174(50.4%) were female and married respectively. The median age of the participants was 27(IQR: 25–30) years (Table 1).
Table 1
Characteristics of participants in maternity wards of Sidama region public hospitals, Ethiopia 2022 (n = 345)
Variables | category | Frequency | % |
|---|---|---|---|
Marital status | Single | 167 | 48.4 |
Married | 174 | 50.4 | |
Widowed | 4 | 1.2 | |
Educational qualification | Diploma | 98 | 28.4 |
Degree | 238 | 69 | |
Masters | 9 | 2.6 | |
Intention leave institution | Yes | 159 | 46.1 |
No | 186 | 53.9 | |
Absent in the last three months | None | 226 | 65.5 |
1 day | 68 | 19.7 | |
2 days | 36 | 10.4 | |
3 days | 13 | 3.8 | |
4 days | 2 | 0.6 | |
Staff adequacy perception | 100% of the time | 30 | 8.7 |
75% of the time | 119 | 34.5 | |
50% of the time | 119 | 34.5 | |
25% of the time | 62 | 18.0 | |
0% of the time | 15 | 4.3 | |
Working hospital type | Primary | 105 | 30.4 |
General | 146 | 42.3 | |
Comprehensive specialized | 94 | 27.2 | |
Job satisfaction | satisfied | 163 | 47.2 |
dissatisfied | 182 | 52.8 |
Staff and hospital-related characteristics of the participants
Three hundred twenty-five (94.2%) of the respondents were midwives and 222(64.3%) of the respondents had training. One hundred forty-six (42.3%) worked for general hospitals and 235(68.1%) mostly worked during the day shift. The median work experience of the respondents was 3 (IQR: 2–5) years and the mean weekly work hours were 60.5 (Table 1).
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Missed nursing care
The mean MNC score was 67 out of 130 (95% of CI 65.92–68.02) and the average emerged for each nursing intervention was 2.58 out of 5 (95% CI 2.54–2.62). From nursing care activities head-to-toe physical examination, repositioning the client and ongoing monitoring of client status were the most common missed elements. However, monitoring fetal heart rate, medication administration, and reviewing laboratory results were the least common missed activities (Table 2).
Table 2
Missed nursing care in maternity wards of Sidama region public hospitals, Ethiopia 2022 (n = 345)
Elements | Never missed N (%) | Rarely missed N (%) | Sometimes missed N (%) | Frequently missed N (%) | Always missed N (%) | Mean ± SD |
|---|---|---|---|---|---|---|
Head to toe physical examination | 4 (1.2) | 16 (4.6) | 123 (35.7) | 107 (31.0) | 95 (27.5) | 3.79 ± 0.94 |
Ongoing and timely monitoring of client status | 10 (2.9) | 71 (20.6) | 133 (38.6) | 73 (21.2) | 58 (16.8) | 3.28 ± 1.06 |
Intake and output measurement | 8 (2.3) | 75(21.7) | 156 (45.2) | 70 (20.3) | 36 (10.4) | 3.15 ± 0.96 |
Response to rapidly changing condition or deterioration | 25(7.2) | 69 (20.0) | 153 (44.3) | 65 (18.8) | 33(9.6) | 3.03 ± 1.03 |
Reassuring the mother | 59(17.1) | 95(27.5) | 159 (46.1) | 30 (8.7) | 2 (0.6) | 2.48 ± 0.89 |
Documentation | 71(20.6) | 109(31.6) | 148(42.9) | 15(4.3) | 2(0.6) | 2.33 ± 0.87 |
Timely Nurse/ midwives to client communication | 70(20.3) | 137(39.7) | 114(33.0) | 23(6.7) | 1(0.3) | 2.27 ± 0.87 |
Complete review of history | 9(2.6) | 71(20.6) | 165(47.8) | 91(26.4) | 9(2.6) | 3.06 ± 0.82 |
General comfort care based on the client need | 34(9.9) | 86(24.9) | 149(43.2) | 67(19.4) | 9(2.6) | 2.80 ± 0.95 |
Repositioning when client need | 4(1.2) | 53(15.4) | 136(39.4) | 126(36.5) | 26(7.5) | 3.34 ± 0.87 |
Timely cervical examination | 122(35.4) | 164(47.5) | 54(15.7) | 3(0.9) | 2(0.6) | 1.84 ± 0.76 |
Labor support | 87(25.2) | 127(36.8) | 114(33.0) | 17(4.9) | 0(0) | 2.18 ± 0.87 |
Continuous history taking | 17(4.9) | 81(23.5) | 168(48.7) | 71(20.6) | 8(2.3) | 2.92 ± 0.85 |
Giving medications immediately in postpartum | 104(30.1) | 142(41.2) | 81(23.5) | 15(4.3) | 3(0.9) | 2.05 ± 0.89 |
Answering questions raised by the client | 52(15.1) | 103(29.9) | 171(49.6) | 16(4.6) | 3(0.9) | 2.46 ± 0.84 |
Reasons for missed nursing care
This study showed that material resources (92.5%) were the most commonly reported reason for MNC followed by labor resources (68.7%), communication (64.1%), and teamwork (64%). Among the material resource elements not functioning supplies or equipment (97.4%) was the top reason for MNC. Among labor resources, an inadequate number of staff (85.8%) was the most common reason. The teamwork dimension not providing the care needed by other departments (80%) was the main reason and in the communication subscale, communication breakdown within the team (87.2%) was the highest reason for MNC.
Factors associated with missed nursing care
According to simple linear regression analysis age, marital status, educational qualification, work experience, intention to leave the institution, weekly work hours, absenteeism, job satisfaction, and general hospital type were candidate variables for multiple linear regression with a p-value < 0.25. According to multiple linear regression analysis work experience, intention to leave the institution, weekly work hours, and job satisfaction were significantly associated with MNC (p < 0.05).
For every one-year increase in work experience, the MNC score was decreased by 0.963 (β= -0.963, 95% CI: -1.475, -0.452). The Respondents who intended to leave the institution had a 3.8-fold greater MNC score than the respondents who did not intend to leave (β = 3.812, 95% CI: 2.285, 5.340). For every one-hour increase in weekly work hours, the MNC score increased by 0.2 (β = 0.203, 95% CI: 0.134, 0.272). Additionally, respondents who were satisfied with their jobs had decreased MNC scores by a factor of 4.98 times compared to respondents who were dissatisfied with their jobs (β= -4.976, 95% CI: − 6.431, − 3.522) (Table 3).
Table 3
Multiple linear regression analysis of factors associated with missed nursing care in maternity wards of Sidama region, Ethiopia 2022 (n = 345)
Variables | Unstandardized β | 95% CI of β | p-value |
|---|---|---|---|
Age | -0.186 | -0.543, 0.171 | 0.306 |
Marital status | |||
Married | -1.312 | -2.858, 0.234 | 0.096 |
Single | 1 | ||
Educational qualification | |||
Diploma | 1.112 | -0.347, 2.571 | 0.135 |
Masters | 1 | ||
Work experience | -0.963 | -1.475, -0.452 | < 0.001* |
Intention to leave institution | |||
Yes | 3.812 | 2.285, 5.340 | < 0.001* |
No | 1 | ||
Weekly work hour | 0.203 | 0.134, 0.272 | < 0.001* |
Absent in last three month | 0.464 | -0.333, 1.261 | 0.253 |
Job satisfaction | |||
Satisfied | -4.976 | -6.431, -3.522 | < 0.001* |
dissatisfied | 1 | ||
Working hospital type | |||
General | -0.775 | -2.156, 0.606 | 0.271 |
Comprehensive specialized | 1 | ||
Discussion
In this study, the mean MNC score was 67 out of 130 (95% CI 65.92–68.02) and the average score for each nursing intervention was 2.58 out of 5 (95% CI 2.54–2.62). This finding is higher than that of a study conducted in Italy and Saudi Arabia, which reported the average score for MNC of 51.6 and 36.35 out of 120, respectively [35, 37]. Similarly, this result is greater than that of studies from Malaysia, Jordan, and Egypt, which had mean scores of 1.88, 2.16, and 2.26 out of 5 respectively [38‐40]. This variation might be due to the difference in resources, infrastructure, and healthcare systems. Additionally, the greater incidence of MNC in this study might be due to greater patient flow in maternity wards, which could lead to more nursing interventions being missed. Furthermore, the inclusion of private hospitals in these studies might explain their lower MNC; this could be due to private hospitals having less patient flow and are being more concerned about the consequences of MNC [39].
Regarding the reasons for MNC, the current study indicates that the most reported reasons for MNC are material resources followed by labor resources. These findings are supported by the findings of studies conducted in Malaysia and the Amhara region which, indicate that material and labor resources are the main contributing reasons for MNC [28, 38]. This might be the result of a shortage of drugs or equipment, and malfunctioning equipment leads to delay or failure of nursing interventions, which worsens the patient’s condition.
In the labor resource domain, an inadequate number of staff and heavy admissions and discharges were the main reasons. This finding is consistent with the findings of studies from Brazil, Jordan, and Malaysia which indicate that inadequate staff was the top reason in the labor resources domain [38, 39, 41]. The possible reason for this could be a shortage of staff members and a high number of patient admissions, which may force the staff to prioritize or focus more on patients with severe conditions. As a result, the nursing care for other patients may be delayed or omitted.
The current study showed that work experience, intention to leave the institution, weekly work hours, and job satisfaction were factors significantly associated with MNC.
Participants who had more work experience had significantly less MNC. This finding is supported by studies from Egypt and the Amhara region [27, 28]. This might be because staff with greater experience have good relationships with other team members and departments, enabling them to efficiently carry out nursing interventions. Furthermore, they may have the ability to identify and reverse errors which allows them to provide nursing care effectively. Additionally, experienced staff may possess the necessary skills to perform complex nursing procedures, whereas inexperienced staff lack sufficient knowledge about certain procedures and patient requirements [42]. In contrast, studies from Italy and Sydney indicate that staff with more experience are associated with greater MNC [35, 43]. The observed difference may be due to variations in study design and study population, which comprises staff from various units, including medical, surgical, and emergency units as described in previous studies. This implies developing retention strategies for experienced nurses can improve the quality of nursing care, which is critical for ensuring optimal patient care and alleviating the strain on healthcare systems.
Respondents who intended to leave the institution had a higher MNC score than respondents who had no intention to leave. This finding is congruent with those of studies from Taiwan and Tigray Ethiopia [19, 44]. The possible reason for this might be that employees who intended to leave devote much time to searching their next work. Consequently, their focus on providing nursing care may decrease, which leads to a greater likelihood of missing essential nursing care elements.
Regarding weekly work hours, the current study showed that respondents with more working hours per week had more MNC. This finding is consistent with findings from Turkey and the Amhara region, which suggest that an increase in weekly working hours is associated with a higher MNC [25, 28]. This might be because long working hours per week may contribute to increased negligence and fatigue among staff members, ultimately impairing their performance. This has been associated with the omission of nursing care for patients. This indicates Ensuring that staff have adequate rest and recovery periods can help reduce MNC and maintain the quality of care provided [45].
Participants who were satisfied with their jobs had significantly less MNC than their counterparts. These findings are in line with studies from Mexico, Jordan, Egypt, and the Amhara region [28, 39, 40, 46]. This could be because job satisfaction can have a positive impact on overall work performance, and it enhances staff’s ability to provide better necessary nursing care activities to patients [47]. This implies that promoting a supportive work environment can improve patient outcomes by ensuring comprehensive care. Prioritizing job satisfaction among healthcare workers can reduce burnout and turnover, ultimately leading to a more stable workforce and better nursing care services for the community [48, 49].
Strength and limitations
The study used standardized questionnaires to collect participant information. The limitations were that since the study was based on self-reported, social desirability bias may have been introduced. Additionally, the outcomes do not establish definitive cause-and-effect relationships.
Conclusion
The level of MNC in the study area was high. Material and labor resources were the most commonly reported reasons for MNC. Factors that contributed to MNC included the intention to leave the institution and increasing weekly work hours while increasing work experience and job satisfaction served as negative factors.
We recommend that the regional health bureau should regularly assess missed nursing care levels and provide job training to enhance staff skills. Improving the work environment and staff benefits is also crucial for boosting commitment to responsibilities. Hospital managers should focus on enhancing job satisfaction by improving working conditions and investing in professional development. Additionally, increasing staff stability and reducing weekly work hours can significantly improve the provision of nursing care.
Acknowledgements
The authors would like to acknowledge Arba Minch University, College of Medicine and Health Sciences, School of Nursing. We also appreciate the study participants, data collectors, and supervisors for their willingness to provide their time and information for this study.
Declarations
Ethical approval and consent to Participate
Ethical clearance letter was obtained from the ethical review board of Arba Minch University, College of Medicine and Health Sciences (reference no: IRB/1211/2022). Permission letters were obtained from the Sidama Region Health Bureau and the respective hospitals. Furthermore, informed consent was obtained from the participants and they were aware of the study’s purpose, risk and benefit. Study participants were clearly informed about their right to withdraw at any stage of the study. Anonymous data were obtained and the confidentiality of participants information was secured.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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