1. Missed nursing care, patient
Missed nursing care, patient outcomes and care outcomes in selected hospitals in Southern Nigeria
Mildred E. John1, Mary A. Mgbekem1, Alberta D. Nsemo1, Gloria I. Maxwell2
1Department of Nursing Science, University of Calabar, Calabar, Nigeria
2University of Uyo Teaching Hospital, Uyo, Nigeria

2. Protocols
Outline of presentation
Background
Aim of the study
Methods
Results
Discussion
Conclusion

3. BACKGROUND
It is the right of every patient to receive necessary care appropriately, safely, and at the right time

4. However nurses can only do so much during a shift and tend to leave some of the usually less critical tasks undone at the end of the shift

5. In 2006, Resar reported that patients receive only approximately 55% of the care they should receive
Recent studies (Ball et al, 2013), have revealed lower prevalence of missed nursing care over the years but the problem is still with us
Resar, RK 2006 Making Non-catastrophic Health Care Processes Reliable: Learning to Walk before Running in Creating High-Reliability Organizations. Health Services Research,  41(4):1535–1720.
Ball, J. E., Murrells, T., Rafferty, A. M., et al (2013). ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety doi: /bmjqs

6. Missed nursing care is an error of omission and is increasingly cited as a contributor to adverse patient outcomes (Tubbs-Cooley et al, 2015)
Tubbs-Cooley, H. L., Pickler, R. H., Younger, J. B. & Mark, B. A. (2015) A Descriptive Study of Nurse-Reported Missed Care in Neonatal Intensive Care Units. Journal of Advanced Nursing, 71(4): doi: /jan

7. No matter the reason for these omissions, missed care:
Represents care needed but not provided and therefore constitute a potentially dangerous medical error
Has implications for the quality of care
Negates the right of patients
Compromises the wellbeing and recovery of patients

8. In Nigeria some nursing care activities are sometimes deliberately left undone because of nurse shortages, time pressure and competing demands in most hospitals

9. The policy of task shifting also causes missed nursing care (left for the junior health workers, and sometimes to patients’ relatives “task dumping”)
Missed care by nurses is rarely focused on in Nigeria, therefore little is known about the extent of the problem and its consequences. This was the impetus for this study

10. Aims of the study The Aims of the study were to:
Examine the type, prevalence and frequency of nursing care left undone in selected hospitals in Southern Nigeria
Assess the relationship between missed care and selected patient outcomes/ care outcomes (patient satisfaction, patient wellbeing, improved patient care, quality of care, reduced adverse events, achievement of care goals)

11. Methods Study was done between June and September, 2015
Design: Mixed method (descriptive and intervention).
Descriptive design determined the prevalence, type, and frequency of missed care among nurses in the 7 days preceding the study
The intervention involved nurses’ capacity building on certain care issues to determine influence on prevalence and frequency of missed care

12. SETTING: 4 hospitals in Cross River and Akwa Ibom states in Southern Nigeria

13. Participants and selection
186 nurses providing direct adult care in Medical, Surgical, Orthopaedic and Gynaecology units of 4 hospitals (2 secondary and 2 tertiary), and 120 patients/relatives in those units were purposively selected and enrolled
Ethical clearance was obtained from the HREC of Cross River State

14. Instrument:
Data were collected through researcher- developed and validated questionnaires (for nurses) and interview schedule for patients/relatives (Cronbach 0.81 and 0.79)
The instrument was on 4-point Likert-type scale of:
‘Never’, ‘Rarely’ (1-2 times in 7 days), ‘Frequently’ (3-5 times), ‘‘Most frequently’ (over 5times) (for frequency of missed care)
‘Poor’, ‘Fair’, ‘Good’, ‘Very Good’ (for patient outcomes and care outcomes)

15. Intervention:
Intervention comprised capacity building on certain care issues (time management, timely provision of care, closer surveillance/supervision, cooperative task sharing, and cross-monitoring)
2 wards in each hospital were used for the intervention while 2 served as control wards
Intervention lasted 4 weeks
Post-test data were collected 6 weeks after the intervention

16. Data collection:
Data were collected through self-report by nurses and patients/relatives
Patients and relatives reported:
Their awareness of occurrence of missed care
Perception of influence of missed care on patient wellbeing, patient satisfaction and quality of care

17. Nurses reported:
Care omitted in part or whole, or delayed in the previous seven days (from a list of 15 validated activities), and the frequency & reasons for missed care
Perceived influence of missed care on improved patient care, reduced adverse events, and achievement of care goals

18. Data analysis: Data were analysed on SPSS 18.0.
Descriptive statistics were used for type and frequency of missed care
Inferential statistics
Pearson Chi square for correlation between missed care and outcomes
T-test for significance of difference between scores before intervention and after intervention

19. Prevalence of missed care
Results
Prevalence of missed care
156 (83.9%) nurses reported they had left one or more care activities undone in the 7 days prior to the study. The number in the experimental and control wards were similar (E = 81; C = 75)
Mean number of activities missed per nurse in 7 days = 5.3; range = 5 -7
Mean number of activities missed per shift = 3.8
The pattern of nursing care left undone was similar in all 4 hospitals

20. Care most missed were Routine bed bath (34.9%),
Spiritual support (33.9%),
Patient education (31.2%),
Frequent change of patient’s position (29.6%)
Assessing effectiveness of pain medication (28.0%),
Pain assessment before administering medication (25.8%),
Discharge planning (21.0%),
Routine urine testing (20.4%),

21. Activities delayed but not totally missed were chronic wound care (27
Activities delayed but not totally missed were chronic wound care (27.4%), updating care plans (27.4%), assessment/monitoring of vital signs in long-term rehabilitating patients (24.2%)
Care activities on the validated list that were not missed at all or delayed were assessment of vital signs in patients with acute conditions, and administration of PRN medications

22. Missed care was neither documented nor reported to the head nurse, except for medications, but those delayed were verbally handed over to the next shift
Awareness of missed care by patients/relatives: 73 (60.8%) patients and relatives reported that they were aware that required care was either omitted or delayed

23. Frequency of missed care
42.9% reported missing nursing care activities frequently (3-5 times in 7 days)
Care activities were most missed during the afternoon shift followed by night shift; and mostly in the acute care wards especially medical
Activities were significantly missed by nurses in the secondary health facilities (p = 0.02)

24. At pre-test the means for missed care were similar for both groups
At pre-test the means for missed care were similar for both groups. Experimental (M = 5.4); Control group (M = 5.3)
After intervention both prevalence and frequency of missed care for experimental group reduced significantly (M = 2.1, p = ; once or twice)
There was no significant decrease in the control group over time (M = 5.0; 3-5 times)

25. Table 1: Missed care, care outcomes and patient outcomes before and after intervention
Areas considered
Experimental wards (n = 81)
Before After p
Control wards (n = 75)
Before After p
Mean number of missed care NS
Frequency of missed care
3-5 times times
3-5 times times NS
Patient outcomes
29.2± ±
(t = 3.1)
28.9± ±
(t = 1.2)
Care outcomes
26.9± ±
(t = 3.6)
28.3± ±
(t = 1.5)

26. Patient outcomes and care outcomes
There was an inverse significant relationship between missed care and some patient / care outcomes. The higher the number and frequency of vital care missed, the lower the rating on:
Patients’ satisfaction (p = 0.001),
Patients’ wellbeing (p = 0.001),
Quality of care (p = 0.001),
Improvement of patient care (p = 0.01)
Lake, E. T., Germack, H. D. & Viscardi, M. K. (2016) Missed Nursing Care is Linked to Patient Satisfaction: A Cross- Sectional Study of US Hospitals. BMJ Quality Safety, 25(7),  doi: /bmjqs

27. On one care outcome (adverse events), there was a direct significant relationship (the higher the prevalence and frequency of missed care the higher the rating on occurrence of adverse events; p = 0.01)

28. Reasons for missed care
Staffing factors
Nurses shortage/overwork,
Busy shift,
Inadequate handing over of tasks by previous shift
Involvement of many nurses in non- nursing tasks
Ausserhofer, D., Zander, B., Busse, R. et al (2014) Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multi-country cross-sectional RN4CAST study. BMJ Quality & Safety, 23(2), doi: /bmjqs

29. Materials and supplies factors
Unavailable materials or supplies or medications at time of care
Patient factors
Interruption in care due to unexpected emergencies,
Urgent patient condition leading to delay of routine care,
Refusal of care

30. discussion
Nurses reported frequently leaving some "non- critical" care activities undone at the end of the shift
The results of this study explain in part results from other investigators who have examined missed nursing care in Europe and America (Ausserhofer et al. 2013; Ball et al. 2013; Lake, Germack & Viscardi, 2015)
The present study did not examine the influence of staffing on missed care

31. conclusion
Leaving vital nursing care undone was prevalent across hospitals used for the study
Missed care was significantly related to all patient and care outcomes
Capacity building (on time management, closer surveillance /supervision, and task sharing), significantly reduced prevalence and frequency of missed care among nurses; and influenced patient outcomes and care outcomes

32. IMPLICATIONS FOR POLICY
Findings have implications for healthcare policy
Nurse leaders should put in place strategies for capacity building, task monitoring and cooperative task sharing to reduce the prevalence of missed care
Further study should evaluate specific influence of staffing levels on missed care, patient outcomes and care outcomes in Nigeria

33. REFERENCES
Ausserhofer, D., Zander, B., Busse, R. et al (2014) Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multi-country cross-sectional RN4CAST study. BMJ Quality & Safety, 23(2), doi: /bmjqs
Lake, E. T., Germack, H. D. & Viscardi, M. K. (2016) Missed Nursing Care is Linked to Patient Satisfaction: A Cross-Sectional Study of US Hospitals. BMJ Quality Safety, 25(7),  doi: /bmjqs
Resar, RK (2006) Making Non-catastrophic Health Care Processes Reliable: Learning to Walk before Running in Creating High-Reliability Organizations. Health Services Research,  41(4):1535–1720.
Tubbs-Cooley, H. L., Pickler, R. H., Younger, J. B. & Mark, B. A. (2015) A Descriptive Study of Nurse-Reported Missed Care in Neonatal Intensive Care Units. Journal of Advanced Nursing, 71(4): doi: /jan
Ball, J. E., Murrells, T., Rafferty, A. M., et al (2013). ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety doi: /bmjqs

34. LESSONS LEARNED YOUR VIEWS? LET’S SHARE
Engaging nurses in cooperative task sharing was challenging
Missed care was neither documented nor reported to the head nurse
YOUR VIEWS?
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