INVESTIGATING MISSED NURSING CARE IN AUSTRALIAN ACUTE … · This research aims to explore the...
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INVESTIGATING MISSED NURSING CARE IN AN AUSTRALIAN ACUTE CARE HOSPITAL: AN EXPLORATORY STUDY RANIA ALI MOHAMMAD ALBSOUL Doctor of Dental Surgery, Jordan University of Science and Technology, 2010 Master of Health Services Management/Advanced, Griffith University, 2015 Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy (Research). School of Public Health and Social Work Faculty of Health Queensland University of Technology 2019
Transcript of INVESTIGATING MISSED NURSING CARE IN AUSTRALIAN ACUTE … · This research aims to explore the...
INVESTIGATING MISSED NURSING CARE IN
AN AUSTRALIAN ACUTE CARE HOSPITAL:
AN EXPLORATORY STUDY
RANIA ALI MOHAMMAD ALBSOUL
Doctor of Dental Surgery, Jordan University of Science and Technology, 2010
Master of Health Services Management/Advanced, Griffith University, 2015
Submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy (Research).
School of Public Health and Social Work
Faculty of Health
Queensland University of Technology
2019
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Keywords
Missed care, missed nursing care, mandated staffing ratios, nursing care left undone, practice environment, patient safety, patients report, quality nursing care, rationing of nursing care, staffing, unfinished nursing care.
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Table of contents Keywords .................................................................................................................................. i
List of Figures ......................................................................................................................... v
List of Tables .......................................................................................................................... vi
Statement of Original Authorship ..................................................................................... viii
Acknowledgements ................................................................................................................ ix
Chapter 1: Introduction ............................................................................................. 1
1.1 Background to the Study ................................................................................................ 4
1.2 Australian Nursing Context ......................................................................................... 10
1.3 Justification for the PhD study ..................................................................................... 14
1.4 Significance of the PhD study ...................................................................................... 15
1.5 Research Questions ...................................................................................................... 15
1.6 Research Aim, Objectives and Methods ...................................................................... 16
1.7 Conceptual Frameworks .............................................................................................. 17
1.8 The Outline of the Thesis ............................................................................................. 24
1.9 Chapter Summary ........................................................................................................ 25
Chapter 2: Literature Review ................................................................................. 26
2.1 Introduction .................................................................................................................. 26
2.2 Review Methods and Procedures ................................................................................. 27 2.2.1 Problem Identification ............................................................................. 27 2.2.2 Inclusion and Exclusion criteria ................................................................ 30 2.2.3 Studies Selection and evaluation ............................................................... 31 2.2.4 Search Results ........................................................................................... 31
2.3 MNC Definitions and Measurement ............................................................................ 33 2.3.1 MNC Defined ............................................................................................ 33 2.3.2 Measurement of MNC............................................................................... 35
2.4 Perceptions of MNC ..................................................................................................... 39 2.4.1 MNC as perceived by healthcare providers (nursing staff) ....................... 40 2.4.2 MNC as perceived by patients .................................................................. 42 2.4.3 MNC as perceived by both patients and nurses ........................................ 43
2.5 Factors influencing MNC ............................................................................................. 44 2.5.1 Nursing Practice Environment .................................................................. 44 2.5.2 Individual Nursing Staff Features and Work-Related Conditions ............ 55
2.6 Research Gaps .............................................................................................................. 59
2.7 Chapter Summary ........................................................................................................ 61
Chapter 3: Methodology and Methods ................................................................... 62
3.1 Introduction .................................................................................................................. 62
3.2 Research Paradigms ..................................................................................................... 63
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3.2.1 Theoretical underpinning .......................................................................... 63
3.3 Institutional background of research setting ................................................................. 70
3.4 Research Design ........................................................................................................... 72
3.5 REsearch Strategy ......................................................................................................... 75 3.5.1 Study 1: Secondary Data Analysis to provide context information about
the study hospital ..................................................................................... 76 3.5.2 Study 2: Nurses’ Attitudes toward missed nursing care ........................... 85 3.5.3 Study 3: Descriptive Case Study .............................................................. 95
3.6 Methodological Limitations ........................................................................................ 105
3.7 Gatekeeping ................................................................................................................ 105
3.8 Ethical Considerations ................................................................................................ 106
3.9 Chapter Summary ....................................................................................................... 110
Chapter 4: Findings of Study One (Secondary Data Analysis) ......................... 111
4.1 Introduction ................................................................................................................ 111
4.2 Findings of Patient Satisfaction Survey Data ............................................................. 112
4.3 Findings of Nursing Employee Engagement Survey .................................................. 117
4.4 Findings from Clinical Incidents Data ........................................................................ 119 4.4.1 Patient Falls ............................................................................................ 120 4.4.2 Medication Incidents .............................................................................. 129 4.4.3 Pressure Injuries (PIs) ............................................................................. 135
4.5 Chapter Summary ....................................................................................................... 137
Chapter 5: Findings of Study Two (MISSCARE Survey) .................................. 139
5.1 Introduction ................................................................................................................ 139
5.2 Survey Results ............................................................................................................ 139 5.2.1 Response Rate and Respondents’ Demographic Profile ......................... 139 5.2.2 Working conditions and nurse perceived staffing adequacy .................. 142 5.2.3 Missed care elements .............................................................................. 144 5.2.4 Categories of MNC ................................................................................. 145 5.2.5 Reasons for MNC ................................................................................... 149
5.3 Individual Nursing Characteristics and Work Conditions and MNC ......................... 150
5.4 Chapter Summary ....................................................................................................... 151
Chapter 6: Findings of Study Three (Descriptive Case Study) ......................... 153
6.1 Introduction ................................................................................................................ 153
6.2 Case study Findings .................................................................................................... 154 6.2.1 Ward Profile............................................................................................ 154 6.2.2 Patients’ Profile (Demographic and Clinical) ......................................... 159 6.2.3 Nurse Rostering Information .................................................................. 161 6.2.4 Patients related Incidents Data ................................................................ 163 6.2.5 Patients Survey Results ........................................................................... 164 6.2.6 Nurses Survey Results ............................................................................ 168
6.3 Chapter Summary ....................................................................................................... 174
Chapter 7: Discussion, Recommendations and Conclusion ............................... 176
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7.1 Introduction ................................................................................................................ 176
7.2 Missed Nursing Care .................................................................................................. 177
7.3 Complexity Theory View ........................................................................................... 194
7.4 Limitations ................................................................................................................. 203
7.5 Implications for Nursing Practice, Leadership and Management .............................. 206
7.6 Recommendations for Future Research ..................................................................... 213
7.7 Conclusion ................................................................................................................. 214
References ............................................................................................................... 219
Appendices .............................................................................................................. 262
Appendix 1: Quantitative studies about elements and reasons of MNC .............................. 262
Appendix 2: Quantitative studies investigating the relationship between MNC and staffing levels 269
Appendix 3: MISSCARE survey (study 2 and 3) (Modified) .............................................. 271
Appendix 4: Permission letter to use MISSCARE survey ................................................... 278
Appendix 5: invitation email (Study 2) ................................................................................ 279
Appendix 6: Participant information sheet for nurses (study 2) ........................................... 280
Appendix 7: MISSCARE survey- Patient ............................................................................ 282
Appendix 8: Permission letter to use MISSCARE survey-Patient in study 3 from Professor Beatrice Kalisch ................................................................................................................... 286
Appendix 9: Participant information sheet for patient (study 3) .......................................... 287
Appendix 10: Consent form for patient (study 3) ................................................................ 290
Appendix 11: Participant information sheet for nurses (study 3) ......................................... 291
Appendix 12: Consent form for nurses (study 3) ................................................................. 295
Appendix 13: Ethical approval ............................................................................................. 296
Appendix 14: PHA approval ................................................................................................ 300
Appendix 15: QUT approval ................................................................................................ 303
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List of Figures
Figure 1.1. Missed Nursing Care Model. ......................................................... 17
Figure 1.2. Complex Systems. ......................................................................... 21
Figure 2.1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow. .................................................................. 29
Figure 2.2. Literature map ................................................................................ 33
Figure 3.1. Convergent Parallel Mixed Methods Design ................................. 75
Figure 3.2. Falls incidents report format ......................................................... 83
Figure 4.1. Patient satisfaction with the hospital (trend by year) ................... 113
Figure 4.2. Patient satisfaction (trend by year)-Medical Divisions................ 114
Figure 4.3. Patient satisfaction (trend by year)-Surgical Divisions ............... 116
Figure 4.4. Organisational Culture in the Study Hospital–Medical Divisions ........................................................................................... 117
Figure 4.5. Number of falls incidents in the study hospital (July 2014–July 2017) ................................................................................................. 122
Figure 5.1. Interventions–basic care .............................................................. 146
Figure 5.2. Interventions–individual needs .................................................... 147
Figure 5.3. Assessment nursing procedures ................................................... 148
Figure 5.4. Planning ....................................................................................... 149
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List of Tables
Table 4.1 Nursing Employees Engagement Data (2015) ................................ 118
Table 5.1 Demographic profile of the respondents ......................................... 140
Table 5.2 Working conditions and nursing perceived staffing adequacy ....... 143
Table 5.3 Nurses perceived MNC ................................................................... 144
Table 5.4 Reasons for missed care .................................................................. 149
Table 5.5 The relationship between individual nursing characteristics and MNC (ANOVA results) ...................................................................... 151
Table 5.6 The relationship between work related conditions and MNC (ANOVA results) ............................................................................................... 151
Table 6.1 Case study ward profile (during two-week case study period). ...... 154
Table 6.2 DRGs for patients who were in the case study ward during the two weeks case study period (clinical profile) ......................................... 160
Table 6.3 Essential care elements reported by patients .................................. 165
Table 6.4 Timeliness care elements missed by the patients ............................ 166
Table 6.5 Communication care elements missed by the patients .................... 167
Table 6.6 Care elements most frequently missed by the nurses ...................... 170
Table 6.7 Care elements least frequently missed by the nurses ...................... 170
Table 6.8 Comparing nurses and patient perceptions of missed nursing care .................................................................................................... 172
Table 6.9 Reasons for missed care as perceived by the nurses ....................... 173
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List of Abbreviations
CN Clinical Nurse CSCF Clinical Services Capability Framework CT Complexity Theory DON Director of Nursing DRGs Diagnosis Related Groups EN Enrolled Nurse ENAPs Enrolled Nurse Advanced Practitioners MNC Missed Nursing Care MS Minimum Specifications NCLU Nursing Care Left Undone NHPPD Nursing Hours Per Patient Day NPM New Public Management NUM Nurse Unit Manager RN Registered Nurse UNC Unfinished Nursing Care
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Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the best
of my knowledge and belief, the thesis contains no material previously published or
written by another person except where due reference is made.
QUT Verified Signature
Signature: ________________________
Date: 9th August 2019_______________
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Acknowledgements
I would like to thank Allah, the Lord of the Worlds, who made everything
possible. I would like to express my sincere appreciation to my supervisors,
Professor Gerard Fitzgerald, Dr Erika Borkoles, and Ms Paula Bowman for their
exceptional guidance, patience, and caring. and for providing me with a superb
atmosphere for doing my research project.
I would like to thank the Director of Nursing in the study hospital for her
support and cooperation during this research. I also thank all who participated in this
research and who were giving of their time. I am grateful for their input, as it served
as a basis for my research results.
I would like to thank the editor of the thesis, Judith Lydeamore, for her
valuable suggestions/notes.
I would like to thank my husband, Dr. Muhammad Alshyyab, and my sweets
kids, Rayyan and Ahmad. They were always there cheering me up and settled me
through the good times and bad.
Last, but not least, I would also like to thank my mother, Fandiah Albsoul, for
her exceptional encouragement, my lovely father, Dr. Ali Albsoul, and my husband’s
great family, uncle Ahmad Alshyyab and mother in law Aminah Alshyyab. They
were always encouraging me and supporting me with their best wishes.
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Executive summary Hospitals are determined to provide quality and safe healthcare to patients.
However, there is concern that the growth in demand for hospital care, increased
complexity of modern healthcare, and the restrained resourcing level available
(particularly human resources) are potentially compromising patient safety and
quality.
Nurses are the most common and thus the most important care providers in
healthcare organizations particularly in developed countries. Thus, their actions will
most commonly influence the overall quality of healthcare. Missed Nursing Care
(MNC) is an important indicator for quality healthcare that impacts patient outcomes
as well as nursing staff outcomes. In this context, MNC is the nursing care required
by the patients but missed or delayed by the nurses. While it is obvious that MNC
could be related to resources issues, whether workforce or material resources, there
might be some contextual conditions that impact nursing care provision on the
ground that may lead to MNC.
From this perspective, several questions arise, including: What are the most
common elements of MNC? What factors contribute to MNC and what could be
done to minimize MNC? Is MNC related to nurses’ perspectives or actions? Is MNC
related to patients’ preference? Further, is MNC caused by system wide issues that
lie outside the control of individuals working within the system?
This is the key focus of this research. There is a lack of this type of research in
the field of MNC. This is not surprising due to the fact that the relevant routinely
collected hospital information important to assess these contextual details is
confidential and thus hard to obtain. It may also relate to the reluctance of nurses to
report actions that might have been missed in the event of adverse consequences not
only for the patient, but also for themselves and their employment.
This research aims to explore the concept of MNC in an acute tertiary hospital
setting so as to understand and describe this phenomenon and to build a detailed
theoretical understanding of the phenomenon that may inform policy and
management solutions for improving healthcare systems. In doing so, this research
seeks to address the following objectives:
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1. To identify, describe and categorise self-reported MNC in an acute tertiary hospital setting.
2. To identify and describe reasons and factors influencing MNC in an acute tertiary hospital setting.
3. To construct a theoretical understanding for patterns of interactions among
factors influencing MNC in the context of a complex healthcare environment.
This study was conducted at a medium sized acute care hospital in suburban
Brisbane. To address these aims and objectives, the research involved a detailed
analysis of the operational and intellectual context and three complementary studies:
Study 1 involved retrospective analysis of secondary data from the study
hospital including patient satisfaction survey data, nursing employee
engagement data and clinical incidents data.
Study 2 sought to quantify MNC and its reasons through a cross sectional
survey with nursing staff in general medical and surgical wards in an acute
care tertiary hospital using MISSCARE survey.
Study 3 involved a descriptive case study in a medical ward over a two-week
period.
Consistent with most of the current literature on MNC, nursing care elements
most frequently missed were: ambulation, mouthcare, emotional support to patient
and/or family, full documentation of all necessary data, and discharge planning and
teaching.
The identified reasons for MNC included urgent patient situations, heavy
admission and discharge activities, unbalanced patient assignments, and tension and
communication breakdown with nursing teams and medical staff.
The study also identified a range of factors influencing MNC including the
number of working hours per week, frequent transfers between hospital wards,
interruptions, and lack of management support.
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These findings helped to construct a conceptual and holistic understanding of
this phenomenon using Complexity Theory. This conceptual “non- reductionist”
approach to MNC understanding may inform the development of efficient and
effective strategies that may assist with minimizing the impact of MNC and in doing
so improve the safety and quality of healthcare. Key recommendations in this regard
include incorporating nursing reflective practice into healthcare organisations,
encouraging organisational learning, utilizing feedback loops, and informing nursing
management about change theories.
Further research is required to help clarify the phenomenon and to evaluate
intervention strategies. This could include exploring the association between MNC
and patient outcomes, and pre and post intervention studies to assess the
effectiveness of the recommended interventions on the level of MNC in an acute care
context.
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Chapter 1: Introduction
Missed Nursing Care (MNC) is a global phenomenon that describes the
elements of optimal nursing care required by patients that are skipped (in part or in
whole) or delayed by the nurses (Kalisch, Landstrom, & Hinshaw, 2009, p. 1510).
Blackman et al. (2015) described MNC as “nursing care as prescribed by nurses is
not always given to patients in its entirety: nursing care does get missed” (2015, p.
2). MNC has been referred to as an indicator of the quality of healthcare at the
hospital level (Bragadóttir, Kalisch, & Tryggvadóttir, 2017) and quality of nursing
care in particular (Chapman, Rahman, Courtney, & Chalmers, 2017).
MNC constitutes a category of healthcare underuse (Ball, Griffiths, & Target,
2018). Health care underuse is a broad concept which may encompass the failure of
provision of essential care through to care which is not to the standard expected by
the patient or the professional. In this perspective, missed healthcare is dependent on
the context as it is culturally, socially, and economically determined (Lamont &
Waring, 2015; McGlynn et al., 2003).
MNC is a common problem in acute care hospitals (Suhonen & Scott, 2018).
MNC has been regarded by Caldwell-Wright (2019) as a “pandemic issue”. MNC
takes place due to a composite of complex factors (Kalfoss, 2017; Laranjeira, 2015;
Phelan, McCarthy, & Adams, 2018; Willis et al., 2014). MNC is often related to
nursing shortage, which is an increasing global concern that may impact on the
quality of nursing care and patient safety (Aiken, Clarke, & Sloane, 2000; Caldwell-
Wright, 2019). As patients expect excellence in healthcare provision, MNC should
be at the forefront of nurses’ and nursing leadership’s concern (Fitzpatrick, 2018).
Despite the longstanding philosophy in the nursing profession ‘primum non-
nocere’ (first do no harm (Evans, 2016)), MNC appears to have a significant impact
on morbidity and mortality all over the world. A recent systematic review
investigated the relationship between MNC and patient outcomes. This review
included 14 studies. It determined that MNC is associated with patient satisfaction,
medication errors, urinary-tract infections (UTIs), patient falls, pressure ulcers,
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critical incidents, and patients’ readmissions (Recio�Saucedo et al., 2018).
Moreover, a cross sectional observational study was conducted to assess the
relationship between MNC and patient mortality following surgical interventions in
nine countries in Europe. This study was conducted with 26,516 RNs, and 422,730
surgical patients who had been discharged between 2007-2009 from the hospitals
involved. This study found that MNC acts as a mediator between nurse staffing and
patient mortality (Ball et al., 2017).
MNC can also lead to increased healthcare expenses associated with increases
in the period of hospitalisation and readmissions to treat adverse events and
complications associated with missing care (Sasso et al., 2017). MNC can also
reduce the reliability of the healthcare organisation (Chassin & Loeb, 2013). In this
perspective, Piscotty and Kalisch (2014) suggested that open consideration of MNC
phenomenon is a critical prerequisite for the purpose of designing strategies aiming
at improving patient healthcare results in different healthcare systems. Hence, MNC
has become a major target of research in the interests of improving patient safety
worldwide (Wegmann, 2011).
The issue of MNC was brought into the public eye and the media after the
situation in the Mid-Staffordshire Hospital Trust in the UK in 2009. In this incidence,
numerous reports were provided of substandard care provision, substantial
complaints of healthcare receivers, low patient satisfaction scores, and unanticipated
rates of death (Healthcare Commission, 2009). The number of additional deaths over
a two year’s period was anticipated to be about 400–1200 cases (Francis, 2013). The
main causes that have been proposed for these deaths were absence of sufficient care
or “missing care”, such as impairment in medication administration and lack of
adequate documentation (Francis, 2013). Remarkably, the political influence of this
report appears to concentrate on the nursing workforce to provide an explanation of
substandard care (Reeves, Ross, & Harris, 2014). Following this event, research in
this field worldwide was launched in order to recognize the individual,
administrative, and contextual roots of this phenomenon (Srulovici & Drach-Zahavy,
2017).
However, MNC is an under researched area in the Australian context (Scott et
al., 2018). Comparative scarcity of research about the topic of MNC in the Australian
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context could be attributed to the ethical implications of MNC phenomenon and
hesitancy of hospitals and nurses to be involved in research related to such a
disconcerting phenomenon (Scott et al., 2018). Furthermore, MNC has been
identified as leading to nurses’ guilt, emotional stress, and feelings of inability to
provide the required standard of patient care (Harvey, Thompson, Willis, Meyer, &
Pearson, 2018). According to Harvey et al. (2018), MNC represents a failure in
nurses’ predetermined contract arrangements for employment that has legal
consequences for the professional code of practice for nursing personnel. Thus, the
probability for nurses to encounter suspension from work due to missing of care
provision is of high concern for nursing staff (Harvey et al., 2018).
The major focus of Australian studies in this area has been on exploring MNC
at a state level in several healthcare settings rather than at hospital or ward level. A
recent quantitative descriptive study was conducted by Blackman et al. (2018) to
explore MNC and the factors associated with it in public and private hospitals in four
Australian states (New South Wales, Victoria, South Australia, and Tasmania). That
study relied on the MISSCARE survey, which is a tool used to measure MNC (1195
surveys completed by the nurses) and concluded that types of and reasons for MNC
are influenced by the clinical settings the nurses are working in. The study found that
shift type has a significant effect on the extent, types and reasons for MNC. Itfound
that missing higher priority nursing care in the morning shift resulted in increases in
MNC in the afternoon shifts. Furthermore, nurses reported insufficient staffing levels
and skill mix imbalances also increased the level of MNC in the afternoon shifts.
Another factor found to affect MNC in the study was staff patient ratios. In this
perspective, the study found that the level of MNC is lower in Victoria than in other
states. Victoria was the first Australian state that implemented mandating patient
nurse ratio legislation. Worthy of note is that the authors of the paper attributed lower
levels of MNC in Victorian hospitals to this legislation (Blackman et al., 2018).
A recent cross-sectional descriptive study was performed with 2,397 nurses in
Queensland, Australia. The aim of this study was not to examine MNC, but to
explore factors influencing workloads as perceived by nurses in public, private and
aged care sectors in Queensland. However, the findings of the study highlighted the
risk of MNC phenomenon occurring. The nurses in the study discernibly stressed the
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potential of MNC occurrence in light of increases in their workload. They also
indicated the potential negative impact of MNC on the quality of health care, patient
outcomes, and nurses’ satisfaction with their jobs (Hegney et al., 2018). Hence, the
study emphasized the significance of performing research into the MNC issue,
particularly in the Queensland healthcare context.
To the best of the researcher’s knowledge, there have been no published
studies about MNC conducted in Queensland, Australia. The purpose of this work,
thus, is to examine MNC and the factors that appear to impact on it in medical and
surgical wards in an acute care metropolitan hospital in Brisbane, Australia. This is
of particular interest following the legislation mandating minimum patient-to-nurse
ratios, which was implemented in Queensland public health services, particularly in
medical and surgical hospital units, from 1 July 2016 (Forrester, 2016). Mandating of
patient to nurse ratios has been instigated based upon the establishment of an
association between higher nurse to patient ratios and improved patient and staff
outcomes (Aiken et al., 2018; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).
Thus far, mandatory patient nurse ratios are implemented in only two Australian
states; Victoria and Queensland (Olley, Edwards, Avery, & Cooper, 2018), in
addition to California in the US, Ireland and Wales (Aiken et al., 2018). The
minimum nurse to patient ratios in Queensland are 1:4 on morning and afternoon
shifts, and 1:7 on night shifts (Queensland Health, 2016).
This chapter outlines the background to the study, introducing the concept and
background of MNC. It also presents the justification and significance for
performing this research. It outlines the research questions, aims, objectives, and
methods, and the conceptual frameworks that underpin this research. This chapter
concludes with a description of the overall structure of the thesis.
1.1 BACKGROUND TO THE STUDY
Nurses play a prominent role in the provision of healthcare. Errors arising from
nursing duties can contribute to adverse outcomes for patients. Therefore,
understanding the nature of errors and how these errors occur when providing
nursing care is critical to an understanding of the causative dynamics of patient
safety.
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The sophisticated nature of modern healthcare and the interactions of various
systems and factors make the provision of healthcare intrinsically risky (Hughes,
2008). Hence, medical errors may be inevitable, and multidimensional and crucial
public health issues that occur in hospitals can impact on patient safety (Hashemi,
Nasrabadi, & Asghari, 2012; Kalisch & Xie, 2014; La Pietra, Calligaris, Molendini,
Quattrin, & Brusaferro, 2005).
Medical errors are inevitable where human factors also play a role (Roth,
2014). Despite their proficiency and knowledge, healthcare providers are humans
who are subject to intrinsic human fallibility (Crigger, 2004; Queensland Health,
2007; Roth, Wieck, Fountain, & Haas, 2015). The reason for this from the standpoint
of human factors is that errors usually take place due to misalliance between systems
and technology and human characteristics (Mao et al., 2015). In this sense, human
factors in healthcare errors involve all factors that affect healthcare providers and
their attitudes, such as use of technology, working environment, and dealings with
other people (Bleetman, Sanusi, Dale, & Brace, 2011).
To Err Is Human: Building a Safer Health System (Kohn, Corrigan,
Donaldson, America, & Medicine, 2000) was a landmark report published in 2000 by
the US Institute of Medicine (IOM), (currently known as the National Academy of
Medicine), which brought the issue of patient safety and medical error into the
public’s consciousness. This report stated that medical errors were the main cause of
44,000 – 98,000 annual unintended deaths in the USA. Alongside it, An
Organisation with a Memory report published in the UK (Donaldson, Appleby, &
Boyce, 2000) considered safety as a cornerstone of quality healthcare and the report
is recognised as the catalyst for the emergence of an international healthcare quality
and patient safety movement.
A more recent study has suggested that medical error is still the third most
common cause of mortality in the USA (Makary & Daniel, 2016). An adverse event
attributable to medical error generally is a preventable adverse event (Rodziewicz &
Hipskind, 2018). Australian data revealed that the yearly incidence of adverse events
due to medical errors in adult patients leading to patient harm was 6.5% (Clark,
2002). It has also been proposed that half of the adverse events, particularly falls,
medication errors and pressure injuries, were avoidable. Furthermore, medical errors
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have been estimated to increase the patients’ mortality rate by 7 times in the
Australian context (Ehsani, Jackson, & Duckett, 2006; Harrison, Gibberd, &
Hamilton, 1999; Wilson et al., 1995).
In Queensland, Australia, nearly 320 patients experienced avoidable harm
during their hospital stay every year for the years 2009-2012. These avoidable harms
included sentinel events (Queensland Health, 2012). Sentinel events can be defined
as adverse events that happen due to systemic problems and ineffective healthcare
processes leading to patients’ death or serious permanent injury. Sentinel adverse
events were given a code of Severity Assessment Code (SAC) 1 harm (Queensland
Health, 2009). These events are called the Reportable Event (RE) list (Queensland
Health, 2009). In Queensland, 15 sentinel events were reported in 2015-2016. The
number of sentinel events reported all over Australia in the same year was 82
(Productivity Commission, 2018).
Besides their impact on patients’ health, medical errors can place an economic
burden on healthcare organisations. It has been suggested that the cost to USA
hospitals of identified medical errors in 2009 exceeded $1 billion (David,
Gunnarsson, Waters, Horblyuk, & Kaplan, 2013). Similarly, medical errors are
estimated to cost the Australian healthcare system over $1 billion, possibly $2 billion
per annum (Richardson & McKie, 2007). In 2011, the financial burden of adverse
drug events in Australian hospitals was estimated to be about AUD 1.2 billion
(Roughead, Semple, & Rosenfeld, 2013). According to Australian published data, a
single adverse event adds $ 6826 to each patient admission (Ehsani et al., 2006).
Before we proceed, however, we should clarify the meaning of ‘medical error’.
A medical error refers to unintentional action or aberration in the procedures of care
which may or may not lead to patient injury (Makary & Daniel, 2016; Slawomirski,
Auraaen, & Klazinga, 2017). There are two major types of medical errors: errors of
commission and errors of omission (Rodziewicz & Hipskind, 2018; Runciman et al.,
2012). Errors of commission are defined as performing the wrong procedure or
performing the right procedure in an inappropriate manner (James, 2013). On the
other hand, errors of omission are defined as the unintentional failure to do the right
procedures required by the patients (Garrouste-Orgeas et al., 2012).
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It has been found that errors of omission (missed care) constitute a more
prevalent problem than errors of commission (Agency for Healthcare Research and
Quality, 2007; Kalisch & Williams, 2009; Siddins, 2002). According to the seminal
Quality in Australian healthcare study (QAHCS) (Wilson et al., 1995), which
included 14,000 admissions from 28 hospitals in New South Wales and South
Australia, errors of omission and errors of commission represented 52% and 27% of
adverse events in Australian hospitals respectively. Furthermore, it has been found
that the majority of errors reported to the incident reporting systems in Australia
were errors of commission, however, chart reviews indicate that omission errors
result in twice as many adverse events (Andrus et al., 2003; Australian Council for
Safety Quality in Health Care, 2003).
However, it has been widely recognized that errors of commission are more
easily identified than errors of omission (James, 2013; Orique, Patty, Sandidge,
Camarena, & Newsom, 2017). Thus errors of omission may be relatively ignored
(Kalisch & Williams, 2009), and consequently unaddressed, contributing to negative
patients outcomes and reduced safe and high quality healthcare (Sasso et al., 2017).
Omission errors or missed care can be related to medical care provided by
doctors as well as nursing care provided by the nurses (Willis, Blackman, Henderson,
Xiao, & Toffoli, 2015). A systematic review and meta-analysis of the literature
related to MNC revealed that 55% – 98% of nurses missed one or more patient care
procedures. According to Ball, Murrells, Rafferty, Morrow, and Griffiths (2014), 9
out of 10 nurses left basic patient care procedures undone every shift. This PhD
research examined omission errors related to nursing care.
Nurses are the largest group of healthcare providers who are responsible for
patients’ direct healthcare (Akhu‐Zaheya, Al‐Maaitah, & Bany Hani, 2018; Sasso et
al., 2017). The role of nurses in healthcare provision is indubitable. They perform
various activities such as nursing diagnosis healing promotion and mortality
prevention (Nezamodini, Khodamoradi, Malekzadeh, & Vaziri, 2016). Nurses are the
nucleus of the healthcare system. Without the nucleus, the cell will not subsist
(AbuAlRub, 2007).
Nurses are often the initial contact point for most hospitalized patients (Kieft,
de Brouwer, Francke, & Delnoij, 2014). Nursing staff also offer hospitalized patients
8
care throughout the whole day and spend the greatest amount of time with the
patients, more than any other healthcare worker (McHugh & Stimpfel, 2012). Nurses
are responsible for planning, coordinating, providing, and evaluating healthcare
delivered to the patients (Mitchell, 2008). Therefore, most of the care processes
delivered to the patients are undertaken by nurses. Hence, nursing interventions have
a notable impact on the healthcare quality, and ultimately on treatment and patient
healthcare results (Burhans & Alligood, 2010; Draper, Felland, Liebhaber, &
Melichar, 2008; Farquhar, Sharp, & Clancy, 2007; Jones, Gemeinhardt, Thompson,
& Hamilton, 2016; Krau, 2014; Sherwood & Barnsteiner, 2017; Twigg, Gelder, &
Myers, 2015). Given that nurses deliver the majority of prescribed care, they also
fulfil a major role in performance enhancement in healthcare institutions (Akhu�
Zaheya et al., 2018), therefore, their role in delivery of care is an important area to
investigate.
Calls for quality in healthcare, particularly nursing care quality, have escalated
in the modern era due to the sophisticated nature of healthcare systems
(Thorsteinsson, 2002). The Keeping Patients Safe: Transforming the Work
Environment of Nurses report released by USA Agency for Healthcare Research and
Quality in 2004 and The Future of Nursing: Leading Change, Advancing Health
report published by the IOM in 2010 confirmed the critical involvement of the
nursing workforce in healthcare reform and the provision of quality, patient centered,
approachable, and affordable healthcare (IOM, 2011; Page, 2004).
In Australia, The Australian Hospitals Accreditation Program (AHAP) was
developed in 1974 by the Australian Council on Healthcare Standards (ACHS) in
order to inform quality healthcare and patient safety improvement in healthcare
institutions (Singh, 2015).The Australian Council for Quality and Safety (ACQS)
was established in 2000 to provide guidance in relation to national standards,
especially healthcare quality and patient safety. Based on this, healthcare
organisations in Australia are obliged to evaluate patient safety and to provide a
report on that to the government. The government then provides recommendations to
minimize adverse events occurrence (Richardson & McKie, 2007). The quality and
safety of nursing care has also received increased attention in the Australian context
(O'Connell, Duke, Bennett, Crawford, & Korfiatis, 2006). Nurses in Australia play
9
an essential role in meeting National Safety and Quality Health Service Standards.
For example, Australian nurses play a vital role in early identification and
management of patient deterioration, hence reducing the need to perform procedures
to settle patients’ health status and also reducing adverse events occurrence (Twigg,
Duffield, & Evans, 2013).
However, quality of healthcare may be affected by financial downturns and
growth in health services costs (Bazzoli et al., 2007). Indeed, as a response to the
financial challenges (Newman & Lawler, 2009), fueled by technological and medical
advancements in provision of treatment for patients, as well as an increased aging
population (Simonet, 2015), healthcare managers were forced to introduce schemes
to manage the growing costs of healthcare, as described in New Public Management
(NPM) (Newman & Lawler, 2009). NPM serves as an orientation for restructuring of
healthcare and is centred on three E concepts: Economy, Efficiency, and
Effectiveness (Carvalho, 2012). Australia has been classified by Pollitt and
Bouckaert (2011) as “core-NPM country”.
10
The following section is a brief overview of the Australian nursing context,
including the challenges Australian nurses encounter in light of NPM
implementation that may impact MNC occurrence in the Australian healthcare
context.
1.2 AUSTRALIAN NURSING CONTEXT
There are two types of regulated nurses in the Australian healthcare system:
Registered Nurses (RNs) and Enrolled Nurses (ENs). RNs and ENs in Australia are
authorised and controlled by national regulatory arrangements managed through the
Australian Health Practitioner Regulation Agency (AHPRA) (AIHW, 2013;
McKenna, Burke, & Long, 2001). To be an RN, the person should finish a three-year
bachelor’s degree at least and be registered with the Nursing and Midwifery Board of
Australia (NMBA). RNs perform their nursing practice in an independent manner
and they are accountable for the work they perform as well as care delegation either
to ENs or to other healthcare employees (HWA, 2014).
An EN generally performs less sophisticated procedures than RNs and
practices collaboratively with RNs to deliver essential patient care. To be an EN, the
person should finish a Certificate IV, Diploma of Nursing from a vocational
education training provider and, similar to RNs, they should be registered by the
NMBA (HWA, 2014). However, the scope of practice for ENs differs in relation to
the practice context, patient healthcare requirements, competence level of the
individual EN, education and qualifications, in addition to the guidelines adopted by
their hiring institution (Queensland Nursing Council, 1998).
Nurses in Australia represent 62% of hospital employees (Twigg et al., 2013).
According to reports published by the Australian Health Practitioner Regulation
Agency (AHPRA), the number of nurses in Australia in 2018 was three times higher
than the number of doctors: 365,186 nurses to 114,675 doctors respectively
(AHPRA, 2018). Thus, the majority of NPM approaches are directed towards
reducing the size of the nursing workforce in the Australian healthcare system
(Alameddine, Baumann, Laporte, & Deber, 2012; Clarke & Donaldson, 2008;
Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006; Twigg & Duffield,
2009).
11
Nurses in the Australian healthcare system are preparing to encounter the
future challenges of increased demand for healthcare with limited fiscal resources
(Willis, Carryer, Harvey, Pearson, & Henderson, 2017). As elsewhere, increased
demand for healthcare in the Australian healthcare system results from an ageing
population, population growth and increased complexity of patients’ conditions
which results from chronic disease prevalence and increased number of patients with
comorbidities (Australian Institute of Health and Welfare, 2015; Banerjee, 2015;
Henderson, Willis, Blackman, Toffoli, & Verrall, 2016; Higgs, Fernandez, Polis, &
Manning, 2017; Roche, Duffield, Homer, Buchan, & Dimitrelis, 2015). Patients
having complex healthcare conditions are more probably likely to be or to become
extremely ill during their hospital stay (Bright, Walker, & Bion, 2003). As a result,
there is increased in-patient‐associated nursing care complexity in acute care
hospitals (Krichbaum et al., 2007).
As noted before, NPM approaches were introduced for the sake of increasing
efficiency and productivity of the healthcare system while reducing healthcare costs.
However, NPM strategies executed in the Australian healthcare system have been
identified as resulting in negative impacts on the nurses’ working conditions, namely
increased nursing workload (Henderson et al., 2016) and increased levels of nursing
accountability (Brunetto & Farr-Wharton, 2004; Brunetto et al., 2018; Ross, Rogers,
& King, 2018). Elaboration on each of these challenges is provided next.
Workload in general is a function of time, complexity, and volume of
procedures that should be done in a given period of time with respect to a given
number of patients and their nursing requirements (De Cordova et al., 2010).
Increased nursing workload can result in reduced quality and safety of healthcare
(Ross et al., 2018). Interestingly, a systematic review conducted by Lim, Bogossian,
and Ahern (2010) about the sources of stress in Australian nurses revealed that
excessive nursing workload was at the top of these stressors. Moreover, in a study
that included 3000 members of the Queensland Nursing Union (QNU), 90% of
nurses stated that they had excessive workloads (Hegney, Eley, Plank, Buikstra, &
Parker, 2006). An Australian study conducted by Willis et al. (2016), made the
following observation:
12
Nurses now found themselves working longer hours and at a faster pace to
meet productivity and efficiency demands (p 3).
An increased nursing workload in the Australian healthcare system is primarily
related to two factors, namely: increased patient acuity (Henderson et al., 2016;
Verrall et al., 2015) and introducing a purposeful hourly rounding strategy in
Australian hospitals (Harvey et al., 2016; Willis et al., 2016), both of which will be
discussed next.
Firstly, increased acuity of the patients (Nelsey & Brownie, 2012). Patient
acuity is a term frequently utilised to indicate the severity of patient disease and the
accompanied physiological influence (Garland, Ashton-Cleary, & Sinclair, 2016).
Increased patient acuity is associated with greater reliance on outpatient (primary
care) rather than inpatient care (Wakefield, 2013) and the steady reduction in the
average Length of Stay (LOS) in the majority of Australian hospitals in the last ten
years (Brain et al., 2018). The average LOS in Australian hospitals had been reduced
from 3.5 days in 2010–2011 to 3.2 days in 2014–2015, with an average decrease of
1.9% per year (AIHW, 2016).
In this context, it is important to mention that despite the fact that short LOS
lessens the price for each patient admission (Santy-Tomlinson, 2016) and reduces the
risk imposed on older adults due to longer hospital stay such as reduced mobilization
and mortality (van Vliet, Huisman, & Deeg, 2017), shorter LOS is also associated
with increased patient turnover rate (Unruh & Fottler, 2006). Increased patient
turnover rates leads to an upsurge in the numbers of admissions, transfers, and
discharges, which have been considered as the most intensive aspects of care
required during patient hospitalization, and which result in increased in-patient care
needs (Unruh & Fottler, 2006). Also, reduced LOS puts pressures on healthcare staff
who are required to provide intensive healthcare in a shorter period of time (Santy-
Tomlinson, 2016). Therefore, a shorter LOS necessitates the availability of more
nurses to meet higher patient care demands (Cho, Park, Jeon, Chang, & Hong, 2014).
Increased patient acuity has resulted in diverting many relatively simple
transactional (procedural) admissions into the outpatient settings. This in turn
has resulted in relatively more complex inpatient requirements (Buchan,
O'May, & Dussault, 2013) and, again, increased demand on professional
13
nurses (McNair et al., 2016), particularly because staffing levels are
determined based on patient numbers rather than their health conditions
(Henderson et al., 2016) or patient turnover rates (Unruh & Fottler, 2006)
Thus, the ability of the nurses to finish their tasks could be compromised
(Duffield et al., 2011).
Secondly, the purposeful hourly rounding strategy (hourly rounding is defined
as making regular rounds every 1–2 hours by the nurses to fulfil patient individual
needs and to provide proactive patient care (Cann & Gardner, 2012)) has been
introduced as an efficiency measure in many hospitals (Willis et al., 2016). It is also
called ‘intentional or proactive rounding’ (Toole, Meluskey, & Hall, 2016). Despite
being a key patient safety and quality healthcare strategy (Halm, 2009), the
purposeful hourly rounding strategy has been perceived by nurses as extra work
(Shepard, 2013). It has also been identified as time consuming, as needing a
significant amount of documentation, thus leading to increased nursing workload
(Willis et al., 2016). It also undermines the care provision provided by the nurses as
the nursing staff have to halt the procedures they are working on in order to join their
round at the planned time (Verrall et al., 2015). The purposeful hourly rounding
strategy has now been launched in Queensland public hospitals (Queensland
Government, 2016).
Increased nurses’ workloads decrease the autonomy of the nurses (Spence
Laschinger, Finegan, & Shamian, 2002). Accordingly, moral distress will be
prevalent among nurses (Torjuul & Sorlie, 2006; Yngman‐Uhlin, Klingvall,
Wilhelmsson, & Jangland, 2016). According to Woods, Rodgers, Towers, and La
Grow (2015),“moral distress occurs when professionals cannot carry out what they
believe to be ethically appropriate actions because of internal or external constraints
(p.4)”. As a result, higher rates of nursing turnover take place (Takase, 2010).
The second challenge encountered by nursing personnel in Australia is
increased emphasis on nurses’ accountability and reporting of safety incidents
without the provision of extra resources (Brunetto & Farr-Wharton, 2004; Brunetto
et al., 2018; Ross et al., 2018). Increased nurse accountability has contributed to
reducing nurses perceived organisational support ( i.e. employees’ perceptions of
reduced support from their organisation) (Brunetto et al., 2016). Thus, they feel that
14
their organisation does not show concern about their wellbeing and does not
appreciate their efforts (Allen, Shore, & Griffeth, 2003). A recent study published by
Monash University Business School (Holland, Tham, & Gill, 2018) found that high
workload and nurses being undervalued were among the most frequent reasons
reported by the nurses as a reason for thinking of leaving the profession (Holland et
al., 2018).
In light of the above mentioned stressing conditions, Australian nurses are
under increased risk of neglecting delivery of optimum patient care (Ross et al.,
2018; Willis et al., 2014). This can be referred to as MNC, which is the topic under
investigation in this PhD study (Kalisch, 2006; Ross et al., 2018).
1.3 JUSTIFICATION FOR THE PHD STUDY
I have always liked to improve the care I provide to my patients in all senses.
My interests toward patient safety issues inspired me and boosted my perseverance
to conduct this research. The topic of this thesis has co-incidentally become the
global focus of governments who recognise the need to improve patient safety. I
decided to focus on MNC specifically because of its large impact on quality and
safety of patient care. Indeed, research related to MNC has grown in the past 10
years. However, to date, available information regarding MNC is only inherent in
research concentrated on examining MNC using quantitative research approaches,
which may not allow for holistic understanding of this phenomenon. No studies have
examined MNC using mixed methods approaches, which I have used to inform this
research, therefore, more insight is required into the MNC, its reasons and the factors
that influence its occurrence, which will help in developing effective preventative
interventions in order to reduce the rates of MNC. Reducing MNC can positively
influence nurses’ job satisfaction, and minimize their intention to leave and therefore
staff turnover rates (Kalisch, Tschannen, & Lee, 2011; Papastavrou, Andreou, &
Efstathiou, 2014; Tschannen, Kalisch, & Lee, 2010) as well as improve patient
outcomes (Recio‐Saucedo et al., 2018).
15
1.4 SIGNIFICANCE OF THE PHD STUDY
The significance of this research lies in its potential to identify MNC incidents
reported by nursing personnel which may have a direct impact on improving nursing
care quality and patient safety. MNC assessment provides knowledge about the way
nurses prioritize their work and, thus, tasks vulnerable to being missed by the nurses
could be detected early and likely be prevented in the future. For example, if the
trend found that the main item of care missed by the nurses was discharge planning,
then there is a high likelihood that avoidable hospital readmissions will increase
(VanFosson, Jones, & Yoder, 2016). This research may potentially not only serve the
nursing workforce but the nursing profession, healthcare system, and public at large
by assisting in increasing awareness and understanding about the MNC phenomenon,
which might be of considerable significance in order to reduce its occurrence and
thus improve patient, staff and organisational outcomes.
This research may also potentially inform nursing management practices in
order to improve the quality of healthcare delivery. It could provide a new impetus
for nurse leaders and managers to create an environment that fosters nursing process
progression in the direction of providing better and safer patient care as well as better
nursing staff outcomes (Papastavrou, Andreou, Tsangari, Schubert, & De Geest,
2014; Papastavrou, Charalambous, Vryonides, Eleftheriou, & Merkouris, 2016).
1.5 RESEARCH QUESTIONS
The present research was guided by the following research questions:
RQ 1: What is the nature of MNC (extent and types) in medical and surgical
wards in an acute care hospital?
RQ 2: What are the reasons for MNC in medical and surgical wards in an
acute care hospital?
RQ 3: What are the individual nursing characteristics and work conditions that
influence MNC in medical and surgical wards in an acute care hospital?
In this context, individual nursing characteristics refer to the job title of the
nurses and the clinical experience in the nursing profession. Work conditions have
16
been defined as nursing work conditions namely: number of hours worked per week,
type of working hours (day, evening, or night), shift length, and overtime.
1.6 RESEARCH AIM, OBJECTIVES AND METHODS
This research aimed to explore the concept of MNC in an acute tertiary
hospital setting so as to identify the reasons and the factors that appear to relate to it.
In doing so, this research sought to address the following objectives:
1. To identify, describe and categorise self-reported MNC in an acute tertiary hospital setting.
2. To identify and describe reasons and factors influencing MNC in an acute tertiary hospital setting.
3. To construct a theoretical understanding for patterns of interactions among factors
influencing MNC in the context of a complex healthcare environment.
This study was conducted at a medium sized acute care hospital in suburban
Brisbane. To address these aims and objectives, three complementary studies were
conducted:
Study 1: The purpose of this study was to provide background knowledge to
gain an insight about the nature of MNC in an acute care setting. This study involved
retrospective analysis of secondary data from the study hospital. Secondary data used
in this study included: patient satisfaction survey data, nursing employee engagement
survey data, and clinical incidents data (falls, medication errors and pressure
injuries).
Study 2: The purpose of this study was to quantify MNC and its reasons
through performing cross sectional surveys with nursing staff in general medical and
surgical wards in the study hospital using the MISSCARE survey.
Study 3: The purpose of this study was to capture a focused and detailed
understanding of the MNC phenomenon in a medical ward context through
performing descriptive case study at medical ward level. This study was conducted in
a medical ward over a two-week period and involved collection of both primary and
secondary data from the study ward during the defined case study period.
17
1.7 CONCEPTUAL FRAMEWORKS
For the current research, the Missed Nursing Care Model (Kalisch et al., 2009)
and Complexity Theory (CT) (Klijn, 2008) were employed to direct the inquiry on
MNC. The models informed the selection of the research design and methods as well
as the interpretation of the findings of the current PhD thesis. The models provided
an inimitable research approach toward systematically exploring the complex MNC
phenomenon which has not been used in previous studies about MNC in various
contexts. In fact, the selected models have varied propositions as will be discussed
further in this section. However, it was anticipated that both models would enable
complete and holistic understanding of the “bigger picture “of MNC phenomenon.
The first model that guided this research was the Missed Nursing Care Model
(Kalisch et al., 2009). The Missed Nursing Care Model describes the potential
circumstances and factors that may affect MNC (Figure 1.1).
Figure 1.1. Missed Nursing Care Model.
Source: Kalisch et al. (2009).
The Missed Nursing Care Model involves four components namely:
antecedents, nursing process, nurses’ internal processes, and patient outcomes. This
PhD research specifically focused on the antecedents, nursing process, nurses’
internal processes, and MNC components of the Missed Nursing Care Model.
Further discussion about these components that have been the focus of this research
is provided next.
1. Antecedents
18
Antecedents represent the factors that are external to the control of nursing
staff and appear to impact on the occurrence on the MNC phenomenon. The
influencing factors encompass three categories that can be conceptualized as nursing
practice environment:
Demand for patient care.
Resource allocation which includes two subparts: a. Labour b. Materials
Relationships/communication.
Each one of these categories has a group of corresponding factors documented
in the MISSCARE survey utilized in this study. For example, elements related to the
demand for patient care category were found to include: urgent patient situations
(e.g. a patient’s condition worsening), unexpected rise in patient volume and/or
acuity on the unit, and unbalanced patient assignment. Resource allocation was
defined as “allocation of resources to a service, department or project” (Scott et al.,
2018, p. 3). The resources include both labour resources as well as materials (such as
medications and equipment). Relationships/ communication include ineffective
communication with medical staff, nursing staff and support workers.
2. Nursing process
Nursing process in the Missed Nursing Care Model is used to indicate nursing
care elements (Kalisch et al., 2009). In this perspective, the nursing process is a
systematic way to structure nursing care provision (Kozier, Erb, Berman, & Snyder,
2004). Nursing processes in the Missed Nursing Care Model have been divided into
assessment/diagnosis, planning, interventions, and evaluation (Kalisch et al., 2009).
In three studies by Winsett et al. (2016, p. 3), Hernández-Cruz, Moreno-Monsiváis,
Cheverría-Rivera, and Díaz-Oviedo (2017, p. 2), and Higgs, Fernandez, Polis, and
Manning (2017, p. 3) the nursing care process was categorised into four groups
namely: assessment, intervention–individual needs, intervention–basic care, and
planning. Each one of these categories was identified by a set of nursing care
procedures. For example, ‘assessment’ is defined by assessment of the provided care,
such as patient assessment performed each shift by the nurses. ‘Intervention–
19
individual needs’ is defined by managing human reactions rather than health related
issues, such as response to call light within 5 minutes and emotional support for the
patients. ‘Intervention–basic care’ is defined as procedures to encounter basic patient
requirements in cases of patient dependence, such as patient ambulation, turning, and
mouth care. Lastly, planning and education are related to procedures that enhance
patient and family involvement in decision making regarding patient care, such as
patient teaching and discharge planning (Hernández-Cruz et al., 2017). These
specific definitions allow researchers and clinicians to measure and therefore
describe the type, frequency and severity of MNC.
3. Nurses’ internal processes
Nurses’ internal processes come into play once the decision to omit or
omission of care is undertaken. In this context, care omission by the nurses is
inevitable, and internal factors contribute to the MNC phenomenon in determining
which aspect of care is to be skipped or left undone. These internal factors comprise:
1) personal attitudes and values; 2) prioritizing processes; and 3) habitual and
standard team conduct. Accordingly, the MNC phenomenon is the outcome of nurse
judgment in response to scarcity in resources generated from external processes
(Kalisch et al., 2009). Therefore, MNC is an unintentional phenomenon (Gibbon &
Crane, 2018), which takes place as a covert or implicit reaction of nurses to
intensified patient demands at the bedside (Scott et al., 2018) or to considerable
contesting pressures on the nurses to perform several priorities within a limited
amount of time (Gibbon & Crane, 2018).
The second model that guided this PhD research was Complexity Theory
(CT) (Klijn, 2008). According to Loorbach and Rotmans (2006), CT represents an
over-arching method of thinking (i.e., “umbrella”) that other research methods can fit
within. CT has appeared to counter balance the restrictions of the scientific
reductionism approach of thinking (Mitchell, 2009). In this context, it is important to
recognise that reductionism is a mode of thinking that is based on presuming that the
system (which consists of several individual components that interact in a regular
manner) can be best comprehended and fixed by dividing the system into its
individual parts and manipulating each of these part individually (Widmer, Swanson,
Zink, & Pines, 2017). CT also arose to describe the complex behaviours that emerge
20
from the interactions among large assemblies of simple individual parts in the system
(Mitchell, 2009).
CT suggests that “the whole (system) is more than the sum of the parts
(individual agents), while at the same time, developments of the ‘whole’ stem from
the interaction of the parts” (Klijn, 2008, p. 301). CT has been established commonly
in the healthcare sciences (Greenhalgh & Papoutsi, 2018) and complex systems in a
broad range of disciplines, including health services management (McDaniel &
Driebe, 2001), nursing (MacDonald, 2004), and evidence based science (Petros,
2003). CT brings together incongruent concepts and develops fundamental ideas and
a language to communicate them into a systemic structure (Caffrey, Wolfe, &
McKevitt, 2016). This allows for a transdisciplinary research strategy, permitting
diverse kinds of knowledge to be combined to provide an inclusive understanding of
complex issues (Gear, Eppel, & Koziol-Mclain, 2018).
CT is used in descriptive and exploratory research for phenomenon
comprehension. The phenomenon of interest in CT is mainly connected to dynamic
interactions between several simpler constituents (Thompson, Fazio, Kustra, Patrick,
& Stanley, 2016). Thus, CT is an explanatory theory rather than predictive in nature
(Cilliers, 2002; Greenhalgh, Plsek, Wilson, Fraser, & Holt, 2010; Paley & Eva,
2011). In other words, CT seeks to explain how structures are instead of proposing
how they should be (Caffrey et al., 2016). CT is a method of comprehension of the
whole as a reasonably systematized, consistent, and resolute entirety (Meadows,
2008). Thus, it is progressively utilized to understand complex healthcare systems
behaviour (Braithwaite et al., 2017). Figure 1.2 below represents the characteristics
of the complex systems.
21
Figure 1.2. Complex Systems.
Source: Martínez-García and Hernández-Lemus (2013)
According to CT, as a result of continuous interactions between the system and
the environment, the contextual factors are as essential as the inner dynamics of the
system (McDaniel & Driebe, 2001). CT constitutes a lens through which contextual
aspects are given some priority and establishes breadth and depth in the studied
inquiry (Wilson, 2009). According to Kernick (2006), CT demands the
correspondence of research tactic to the studied context and environmental
complexity level. This is important particularly because a challenge inherent in the
classic present paradigm of decision making in healthcare services is that these
decisions, whether related to service provision, fiscal or human resources, are
characteristically formulated detached from the context of healthcare delivery
(Kuziemsky, 2016). Hence, using CT in healthcare research proposes that healthcare
consumers, clinicians, and administrators perform, respond and acclimate depending
on their own perceptions and experiences (Stacey, 2007).
CT views organizations as Complex Adaptive Systems (CAS) (Anish & Gupta,
2010). CAS is an open system with indistinct (fuzzy) margins (Caffrey et al., 2016)
that is capable of modification and learning from its experience (Touati, Maillet,
Paquette, Denis, & Rodríguez, 2019). The system includes several feedback loops,
and several elements. These elements are structuring and restructuring based on
nonlinear collaboration and positive and negative feedback, which can be referred to
22
as self-organisation (Cilliers, 2002). Self-organisation in CAS can be referred to as
internal monitoring machinery (Martínez-García & Hernández-Lemus, 2013). This
gives an indication that the CAS is characterized by uncertainty or transitory
certainty (Farazmand, 2003).
Non-linearity in the CAS means that the magnitude of response or the outcome
is not proportional to the cause (Martínez-García & Hernández-Lemus, 2013). To put
it simply, it means that there might be multiple causes for an outcome and more than
one outcome for any one cause (Stacey, 2012). Hence, resolving of issues might be
more challenging due to reactions of the system to the changes in unanticipated ways
according to the context (Caffrey et al., 2016) and high levels of separation of the
system from responding to environmental effects (Kannampallil, Schauer, Cohen, &
Patel, 2011). This leads to another key feature of CAS, which is the robustness,
which can be defined as the capability of the CAS to preserve its features in spite of
outside effects (Carlson & Doyle, 2002), which has a significant implication in
resilience engineering, which aims to enhance healthcare systems to endure human
error (Kannampallil et al., 2011).
A CAS can be regarded as a tight network of connected and interacting
elementseach of them performing according to an individual plan or local
information (Begun, Zimmerman, & Dooley, 2003). Also, every element in the CAS
affects the other elements and might be performing in an impulsive manner (Plsek &
Greenhalgh, 2001) due to interaction with other systems (Caffrey et al., 2016). As a
result of different elements’ interaction and developing of their roles, emergence of
orders and behavioural configurations take place (Anderson & McDaniel Jr, 2000).
Hence, awareness of relations managing is more momentous than awareness of roles
managing in the context of CAS (Anderson & McDaniel Jr, 2000).
CT aids in inspecting changeable, uncontrollable and instable aspects in
healthcare organizations (Plsek, 2001). According to Cilliers (1999), healthcare
organisations have common features as following:
Presence of interfaces, which can be physical or comprise information
interchanges.
Any system component is influenced by and influences many other
systems.
23
Nonlinear interactions.
The current behaviour is affected by the organisational history.
System elements are oblivious of the system behaviour in general and
reacting only to the elements in their vicinity.
Accordingly, healthcare organisations can therefore be classified as complex
adaptive systems (Begun et al., 2003).
To recap, each system has its key features. A system can be viewed as “a
whole” which includes several interactive parts (agents); these parts affect each other
mutually. System understanding cannot be achieved by looking at the parts
discretely. CT aids in identifying that the elements of the system are not equivalent to
the whole. Nevertheless, their interaction is essential for the sustainability of the
system. System elements share one goal, and to achieve this goal, they progressively
modify, adjust, vary and develop to generate new and unpredictable performances.
According to Lanham et al. (2009), the outcomes of the system are the results of the
interactions between system elements as well as arising from the local patterns of
self-organization.
Application of a CT lens can potentially give new intuitions about the MNC
phenomenon and its management. Ralph and Viljoen (2018) acknowledged that
“issues such as missed care require an acknowledgement of this complexity by
continuing to search for and communicate effective, stakeholder-informed solutions
in environments where quality improvement processes are embedded, iterative,
recursive and ongoing (p. 4)”. CT permits inclusive comprehension of the practice
context, its parts, and values that direct the role of these parts inside the system
(Kannampallil et al., 2011). It gives rich understandings about the hidden “latent”
interdependencies and partial line of sights of various system components outlined
by knowledge, culture and organisation borders (Waring, Marshall, & Bishop, 2015).
As mentioned earlier, MNC is affected by a group of complex factors (Phelan,
McCarthy, & Adams, 2018).Thus, it has been viewed that comprehension, describing
and handling of MNC is better achieved using complex systems thinking rather than
concentrating on one factor and overlooking many interconnected and interdependent
system elements that may potentially affect understanding of the MNC issue.
24
Probably, there might be latent faults in the system (e.g. challenges with retrieving
information from patient health records) that have a great impact on the occurrence
of MNC and these cannot be identified and acted on if we depreciate our thinking
about such a complex issue in the ways we have.
In exploring complex systems, it has been claimed that adopting conventional
reductionist modes of thinking based on linearity and predictability, which is in this
PhD research the Missed Nursing Care Model, must be supplemented with
investigating ways of dealing with uncertainty, unpredictability and emergent
interconnections in complex open systems (Greenhalgh & Papoutsi, 2018). Hence, in
this PhD research, MNC has been reconceptualized as a “Complex Adaptive
System”. Hereafter, the researcher has proposed a complexity-informed methodology
to explore the MNC phenomenon in a complex healthcare system. Additionally, the
researcher has applied complexity theory concepts to evaluate the findings of the
studies that comprise this research which helped in identification of the strategies
that would be effective in tackling this issue in the studied context.
1.8 THE OUTLINE OF THE THESIS
This thesis comprises seven chapters. Beyond this chapter (introduction), the
thesis is structured as follows:
Chapter Two (Literature Review) demonstrates current knowledge about
MNC identified in the published literature in this field. This knowledge includes:
MNC definition and measurement, perceptions of MNC, influencing factors. This
chapter also identifies the gaps in the current research evidence related to MNC.
Chapter Three (Methodology and Methods) outlines the methodology and
methods, and data collection and analysis procedures. Ethical aspects related to this
study are also stated.
Chapter Four (Findings of Study One) presents the findings of Study One, a
retrospective analysis of secondary data.
Chapter Five (Findings of Study Two) presents the findings of Study Two, a
quantitative cross-sectional study with medical and surgical nurses in the study
hospital.
25
Chapter Six (Findings of Study Three) presents the findings of Study Three,
a case study at a medical ward level in the study hospital.
Chapter Seven (Discussion, Recommendations and Conclusion) discusses
the findings outlined in chapters four, five, and six and draws a study conclusion.
Limitations of the research, recommendations, and implications for nursing practice
and avenues for future research are also described.
1.9 CHAPTER SUMMARY
This introductory chapter has presented background to the concept of MNC,
provided an overview about the nursing context in the Australian healthcare system,
and depicted justification for and significance of this research. It has also presented
research aims and objectives, research methods, and conceptual models that guided
design of the current research and discussion of the findings. Finally, the outline of
the thesis has been described. The following chapter, the Literature Review, explores
the current knowledge about MNC identified in the published literature in this field.
26
Chapter 2: Literature Review
2.1 INTRODUCTION
This study aimed to explore MNC and the factors that seemed to be causing it
in an acute care hospital setting. The previous chapter introduced the MNC concept
and described the issues confronting the nursing profession in the Australian context
that might lead to MNC. It also outlined the broad focus of this research and the
conceptual frameworks guiding the design of the current research.
MNC, the phenomenon under investigation in the current research, is a nursing
process measure, which has been defined for the purpose of this research as "any
aspect of required patient care that is omitted (either in part or in whole) or delayed"
(Kalisch et al., 2009, p. 1510). Examining process measures in healthcare is
exceedingly beneficial for healthcare leaders because it allows them to recognize the
latent errors in the system prior to causing harm to patients. As a result, if the errors
are addressed, a positive impact on the quality of healthcare delivery, patient safety,
and healthcare organisation reliability would take place (Reason, 1990). Healthcare
reliability refers to the ability of the healthcare processes to bring off their intended
functions in the healthcare organisations (Luria, Muething, Schoettker, & Kotagal,
2006).
This chapter explores what is currently known about the issue from the
published literature in this field. According to Kyndt and Baert (2013), a literature
review aims to present a comprehensive synopsis of the literature relevant to the
research questions at hand. Accordingly, the purposes of this literature review were
as follows:
Extraction and synthesizing of peer reviewed studies related to MNC in
hospital settings.
Understanding the definitions, measurement, and perceptions of MNC.
Identifying the factors that influence MNC in hospital settings.
27
Identifying the voids and contentions in the current literature to identify areas
for future enquiry.
2.2 REVIEW METHODS AND PROCEDURES
This review used well accepted methods of systematic and relatively comprehensive
literature review. The systematic manner of review included clear identification of
the problem, identification and evaluation of data sources, a search strategy built
around clear inclusion and exclusion criteria, methods linked to the aims and
objectives, and systematic approaches to data analysis.
2.2.1 Problem Identification
Identification of the problem in a clear manner is the first step in conducting
any type of literature review (Whittemore & Knafl, 2005). Creswell (2013) described
research questions as a “signpost” that aids in illustrating research objectives as well
as guiding the research process. The MNC phenomenon investigated in the current
PhD research was identified following a thorough literature review performed by the
researcher. This explored the relationship between nurse staffing and patient
outcomes as being one of the key areas related to quality and safety in healthcare. On
investigating the available literature in this area, there were debates identified about
the processes that mediate the relationship between nurse staffing and patient
outcomes. One of the possible processes identified in the published literature was
missed nursing care (MNC), the rationale being that poor staffing levels relative to
demand may be expressed by nursing tasks left undone. Further examination of the
published literature on MNC revealed few studies on MNC conducted in the
Australian context. No study about MNC was identified in the Queensland healthcare
context. The literature review also gave an insight to the design of this research,
using methods that had not been used previously, allowing for a more holistic
understanding of MNC.
Well demarcated search approaches are essential to improve rigor of any
review of the literature, as inadequate and biased searches could lead to imprecise
findings (Whittemore & Knafl, 2005). An overview of the search process followed in
this literature review is presented in the Preferred Reporting Items for Systematic
28
Reviews and Meta-Analyses (PRISMA) flow diagram (Moher, Liberati, Tetzlaff, &
Altman, 2010) (Figure 2.1).
29
Figure 2.1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow.
Scr
een
ing
Eli
gib
ilit
y Additional records
identified through other sources (n = 45)
Full text articles excluded, with reasons
(n =58).
1. Papers published in languages other than English or at least the abstract not in English.
2. Articles related to MNC in nursing homes.
3. Papers related to MNC in home-based care.
4. Papers related to MNC in primary care.
5. Articles published in newspapers
Papers included in the literature analysis
n=52
Records identified through database searching
(n =794)
Incl
ud
ed
Iden
tifi
cati
on
Records after duplicates removed (n = 713)
Records screened (n = 713)
Records excluded (n =603)
Full text articles assessed for eligibility
(n =110)
30
The primary databases used in the search process for this study were:
Cumulative Index to Nursing and Allied Health Literature (CINAHL).
Medline.
Scopus.
PsycINFO.
Ovid.
PubMed.
These databases were selected as they include large counts of journals,
including nursing related journals. The researcher used a wide range of key words in
the search process, either combined using Boolean operators or in isolation, which
included: missed nursing care, rationing of nursing care, nursing care left undone,
unfinished nursing care, nursing care omissions, and a combination of these terms.
This process was supplemented by scanning the reference list of the identified
articles for additional pertinent resources as well as citation tracking to provide a
well-rounded literature review.
In order to manage this review of the literature, a deliberate choice was made
by the researcher to explicitly concentrate on studies about MNC as a single
construct rather than focusing on studies related to individual tasks missed. In
addition, the researcher excluded the studies that examined several types of errors
without stating that these errors were related to missing care or other types of errors.
2.2.2 Inclusion and Exclusion criteria
To produce a focused literature review, articles included in this review were
selected based on the following inclusion and exclusion criteria:
Inclusion criteria (literature studied):
Original articles published in peer reviewed scientific journals.
Articles explicitly related to the perceptions of MNC, rationing of nursing
care, unfinished nursing care and nursing care left undone in hospital settings
(acute and chronic settings).
Articles related to the factors that affect MNC in hospital settings.
Articles using quantitative, qualitative and mixed methods approaches.
31
Articles written in English language due to familiarity of the researcher with
English Language.
Articles published in other languages but which have an English version.
Articles published from 2007 to the current time.
Exclusion criteria (literature discarded):
Articles published in languages other than English or at least the abstract not
in English.
Articles related to MNC in nursing homes.
Articles related to rationing of home-based care.
Articles related to MNC in primary care.
Articles published in newspapers.
2.2.3 Studies Selection and evaluation
All articles identified were reviewed to exclude duplicates and studies that
were simply opinion pieces or perspectives. The titles of articles were then reviewed
to examine their relevance to the topic. The abstracts of the remaining articles were
then reviewed to identify their relevance and significance to the topic. Finally, the
full text of those articles selected were examined in depth to identify relevance,
significance and impact in terms of making a significant contribution to the
understanding of the current state of knowledge. This last step included evaluation of
the methods of enquiry used.
2.2.4 Search Results
Initial search in the databases yielded 798 references. Screening of the titles to
delete the duplicates yielded 713 studies that necessitated additional examination.
Additional abstract screening yielded 110 studies that were retained for full text
review. From these, 58 studies were excluded as they did not meet the inclusion
criteria. Thus, the search process resulted in locating 52 research papers that were apt
for the intentions of this literature review. The identified studies were a mix of
quantitative, qualitative and mixed methods study. The process of systematic
literature search and selection, in addition to the count of studies at each stage, are
shown in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) flow diagram (Moher et al., 2010) (Figure 2.1) page 29.
32
Most of the studies from this review were multisite, correlational, non-
experimental, cross-sectional or exploratory in nature. Most of these studies aimed to
identify missed care elements and the factors contributing to it.
Four systematic literature reviews examining MNC were identified in the body
of literature. The most recent systematic review aimed to assess the relationship
between MNC and nurse staffing (Griffiths et al., 2018). Another systematic review
explored the impact of MNC on patient outcomes (Recio‐Saucedo et al., 2018).
It has also been identified that researchers tend to explore missed care at
particular specialty units within the hospital. Ten studies that were conducted at
specialty units were located as following:
Pediatric and neonatal intensive care units.
Oncology units (Friese, Kalisch, & Lee, 2013; Leary, White, & Yarnell, 2014;
Papastavrou et al., 2016; Villamin, Anderson, Fellman, Urbauer, & Brassil, 2018).
Twelve Australian studies related to MNC or rationing of nursing care in
different hospital settings were identified in the literature. The characteristics of these
studies are as following:
Six quantitative studies. Three of these studies were surveys for the nurses and
midwives at state level to identify reasons and factors for MNC in three states
(New South Wales, Victoria, and South Australia) (Blackman et al., 2015;
Blackman, Henderson, Willis, & Toffoli, 2015; Willis et al., 2015). One study
investigated the association between MNC and teamwork in four hospitals in
Victoria (Chapman et al., 2017). One study investigated MNC in an acute care
hospital in NSW (Higgs et al., 2017). A more recent study identified the MNC
elements and the predicting factors in four states in Australia: New South Wales,
Victoria, Tasmania, and South Australia (Blackman et al., 2018)
Four qualitative studies analysed nurses’ qualitative comments to the nurses’
survey (Harvey, Thompson, Pearson, Willis, & Toffoli, 2017; Harvey et al., 2016;
Henderson et al., 2016; Verrall et al., 2015)
Case study in one oncology/haematology unit in a tertiary hospital in Victoria
(Marven, 2016).
33
The aim of this literature review was to review the body of evidence in relation
to MNC elements and factors leading to it. Hence, key issues and findings from the
included studies relating to the aim of this review were synthesized using thematic
analysis technique. In doing so, three overarching themes emerged and are reported
narratively in this literature review. These were MNC definitions and measurements,
perceptions of MNC, and factors influencing MNC. Within each thematic category, a
group of subcategories also were identified and reported. The themes identified in
this literature review are portrayed in a literature map (Figure 2.2). A literature map,
which was described by Creswell (2013), has been defined as a visual summary of
the research that has been performed by others regarding the studied topic. The
following sections in this chapter describe and discuss each of these themes.
Figure 2.2. Literature map
2.3 MNC DEFINITIONS AND MEASUREMENT
2.3.1 MNC Defined
There has been a group of conceptual definitions used in the literature to
describe MNC. The authors in this area have used several terminologies and so far
have reached no unanimity over the use of these terms (Papastavrou et al., 2014).
Despite variations in their conceptual and operational descriptions, these concepts
have a common feature, which is that they constitute endeavours to recognize the
omitted nursing care items (totally or partially) in the cases where the resources
available for the nurses are not sufficient to deliver all the required care (Ausserhofer
et al., 2014). In other words, these terms provide indicators of care prioritizing and
taking decisions about which care to provide, and which care to leave (Blackman et
al., 2018).
MNC Definitions and Measurement
Perceptions of MNC
Factors influencing MNC
34
The concepts used to describe MNC in the literature and their definitions are as
follows:
Missed Nursing Care: “any aspect of required patient care that is omitted
(either in part or in whole) or delayed” (Kalisch et al., 2009, p. 1501)
Implicit rationing of nursing care: the withholding of or failure to perform
essential procedures for patients due to deficiency in nursing resources
(staffing, skill mix, time)” (Schubert et al., 2005).
Priority setting: arranging the nurses’ duties and rationing of the available
time to deliver care for patients according to the patients’ requirements in an
attempt to improve patient outcomes (Arvidsson, André, Borgquist, &
Carlsson, 2010)
Tasks left undone (TU): procedures not performed by the nurses in the last
shift due to lack of time (Sochalski, 2004).
Unfinished Nursing Care (UNC): an issue of insufficient time available for
the nurses to finish the scheduled patients required procedures during the
shift.
Unmet nursing care needs: missing or omission of essential care needs (Lucero, Lake, & Aiken, 2009).
Notably, the most common concepts used in the body of the literature were
Missed Nursing Care (MNC), implicit rationing, and tasks undone. In addition to
their different definitions, the studies which used these concepts were from various
settings and used different conceptual frameworks (Bassi, Tartaglini, & Palese,
2018).
This thesis purposefully adopted the MNC term. The justification for this was
that the MNC concept differs from other concepts, such as implicit rationing. MNC
could result from factors other than lack of resources, such as communication issues
(Kalisch, Xie, & Dabney, 2014), which could provide a clearer picture for the
phenomenon of interest in the studied context.
Utilization of the ‘rationing’ term to define this problem instead of ‘missed
care’ directs the attention toward prioritizing care performed by the nurses or other
healthcare providers. However, in missed care, the accountability of leaving care
undone is attributed to nurses (Willis et al., 2014). Furthermore, the use of the MNC
35
term is consistent with the Australian studies conducted in this field (Blackman et al.,
2015; Blackman et al., 2018; Chapman et al., 2017).
2.3.2 Measurement of MNC
Examining MNC has been generally achieved by means of several survey
questionnaire-based tools. According to a state of science review performed by
thirteen tools to measure nurses’ perceived MNC, unfinished nursing care and nurse
care rationing in acute care general hospitals were found in the literature. Only one
tool in the literature was used to assess the MNC as perceived by patients (Kalisch et
al., 2014). Development of these tools relied on the definition of uncompleted
nursing care items adopted by the survey developer, which have been illustrated in
the definitions section in this chapter.
The main inquiries in all tools that measure MNC are about the care nursing
staff provided on previous shifts and identify the care items they were incapable of
accomplishing in the period of time acknowledged on the survey. However,
differences between these tools are identified in the following areas:
1. Recall period; which is the period over which the nurses were being asked to
recall missed care occurrences.
2. Scope and exhaustiveness of nursing procedures inventory.
3. Scoring measures.
4. Deliberation on the significance of the perceived procedures and delegated
procedures.
5. Particular reasons for unfinished care.
Detailed discussion of the differences between various instruments and their
psychometric properties is beyond the scope of this thesis.
According to , there have been three parent tools for all of the tools used in the
literature to assess missed care occurrence: MISSCARE survey (Kalisch & Williams,
2009), Basel Extent of Rationing of Nursing Care (BERNCA) (Schubert, Glass,
Clarke, Schaffert-Witvliet, & De Geest, 2007), and Tasks Undone (TU-7) (7 items
list) (Aiken et al., 2001).
MISSCARE survey was developed in the USA to examine MNC in medical
and surgical wards (Kalisch & Williams, 2009). It has been used in a wide array of
36
researches inside and outside the USA. The acceptability of the survey tool was
found to be high as 85% of the participants did not ignore or omit any item in the
survey tool. Factor analysis using Varimax rotation, which was used to evaluate the
construct validity of the tool, has identified communication, labour resources, and
material resources as factors leading to MNC. One-way ANOVA and Bonferroni
post-hoc analysis used to evaluate the validity of the results have yielded an
acceptable index (0.89). The range of Cronbach αvalues was from 0.64 to 0.86.
Confirmatory factor analysis revealed a good data fit. The reliability of the survey
tool was assessed by its administration to the same subjects, two weeks apart.
Pearson correlation coefficient on a test-retest of the same subjects generated a value
of 0.87 on part A and 0.86 on part B. The findings of this study indicated the
comprehensive nature of the MISSCARE survey both qualitatively and
quantitatively. Moreover, it provided motivation to conduct future research to assess
the variability across and within the hospitals (Kalisch & Williams, 2009),
MISSCARE survey has been translated and culturally adapted into languages
other than English to be utilized in other countries such as Greece, Iceland, Turkey,
Brazil, Spain, South Korea, Italy and Jordan (Bragadóttir, Kalisch, Smáradóttir, &
Jónsdóttir, 2015; Hernández-Cruz et al., 2017; Kalisch, Terzioglu, & Duygulu, 2012;
Papastavrou et al., 2016; Saqer & AbuAlRub, 2018; Siqueira, Caliri, Kalisch, &
Dantas, 2013; Sist et al., 2017). Adaptation of survey terminology to fit the nursing
context in South Australia was performed by Blackman et al. (2015). . The chapter
on methodology and methods includes further elaborations on the MISSCARE
survey that was chosen to be used in this research.
Basel Extent of Rationing of Nursing Care (BERNCA) is a validated 4-point
Likert tool (no rationing/rarely/sometimes/often) used to assess nursing care
rationing. BERNCA includes 20 questions which are negatively worded about
nursing care areas related to activities of daily living, care and support, rehabilitation,
surveillance, and security (Papastavrou et al., 2014).
BERNCA was generated in Switzerland (Schubert et al., 2007), and adapted
for use in the USA by Jones (2014), and was renamed Perceived Implicit Rationing
of Nursing Care (PIRNCA). In addition, it was translated into Greek language to be
37
used in the Cyprus context. BERNCA also has been adapted for use in the nursing
homes contexts (Zúñiga et al., 2016).
BERNCA was verified as a valid and reliable measure. Cronbach's alpha (0.93)
refers to high internal consistency of the instrument. Exploratory factor analysis was
performed and proved the construct validity of this tool (Schubert et al., 2007).
BERNCA was revised by Schubert et al. (2013). The revision included adding 20
more nursing care interventions. In addition, the revised version included a “not
required option” in the measuring scale. The revised version has also proved to be
valid and reliable (Cronbach's alpha 0.94).
The key difference between both tools, MISSCARE survey and BERNCA,
were as following:
They gauge different nursing care aspects (Jones, Sportsman, Hamilton,
Gemeinhardt, & Carryer, 2014).
MISSCARE survey has two sections. The first section is the elements of
MNC. The second section is the possible reasons leading to MNC, which
include workforce resources, material resources and communication issues
(Kalisch & Williams, 2009). However, the BERNCA has one section (20
items) that relates to the nursing care items frequently unperformed by the
nurses due to lack of time, insufficient nurse staffing and/or insufficient skill
mix (Schubert et al., 2008).
MISSCARE survey asked about the nursing tasks missed by all nursing
personnel including the surveyed nurse. However, the BERNCA only asked
about the nursing tasks rationed by the respondent nurse.
They differ in the recall period. MISSCARE survey does not specify a time
for reporting of MNC (Kalisch & Williams, 2009). However, BERNCA asks
about missing procedures in the previous seven working days (Schubert et
al., 2008).
They differ in the number of items which are limited by a timeframe.
Timeframe leads to generation of greater approximations of uncompleted
nursing care elements for each item (Jones et al., 2016). MISSCARE survey
includes eight items with a timeframe (for example, medication
administration within 30 minutes), compared to three items in the BERNCA.
38
Thus, MISSCARE survey gives rise to greater estimates of uncompleted
nursing care (Jones et al., 2016).
Patient version is available for the MISSCARE survey (Kalisch & Xie, 2014),
but not for BERNCA.
BERNCA has been adapted also into the Task Undone-13 (TU-13) tool. This
tool includes thirteen nursing tasks and asks the nurses if they left them undone or
not. Nursing care included in this tool was as follows:
1. Adequate patient surveillance
2. Skin care
3. Oral hygiene
4. Pain management
5. Comfort/talk with patients
6. Educating patients and family
7. Treatments and procedures
8. Administer medications on time
9. Prepare patients and families for discharge
10. Adequately document nursing care
11. Develop or update nursing care plans/care pathways
12. Planning care
13. Frequent changing of patient position
Tasks Undone -13 (TU- 13) has been used in several European studies (Ball et
al., 2016; Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014), and also used in the
seminal Registered Nurse forecasting study (RN4CAST) (Sermeus et al., 2011).
RN4CAST study was conducted in 12 European countries (Belgium, Finland,
Germany, Greece, Ireland, Norway, Poland, Spain, Sweden, Switzerland, The
Netherlands and England), the USA, and three countries not from the European
Union (Botswana, China, and South Africa) (Bekker, Coetzee, Klopper, & Ellis,
2015; Sermeus et al., 2011). This influential study, which received its funding from
the European commission, aimed to investigate the impact of nursing contextual
factors, such as staffing and practice environment on the nurse and patient outcomes,
in order to improve and enrich traditional nurse forecasting models (Ausserhofer et
39
al., 2014). This study also has a direct impact on quality and safety of patient care by
ensuring the appropriate nursing staff are attracted and retained in order to meet the
present and coming healthcare requirements (Aiken, Sloane, Bruyneel, Van den
Heede, & Sermeus, 2013).
A recent study was performed by Orique et al. (2017) to examine the
measurement of MNC using Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) data. The HCAHPS tool is mainly used to assess the
experience of patients toward hospital care services (Centers for Medicare &
Medicaid Services, 2017). The data from this survey collected in medical, surgical
and maternity units were analysed for the sake of this study. MNC was identified
from the qualitative comments posed by the patient as well as the questionnaire
items. This study found that there were no significant relationships between patient
age, gender, education level and MNC. However, there was a significant relationship
between MNC and patient health condition, where patients who had poor health
status experienced higher levels of MNC. This finding could be related to ‘Failure to
Maintain’, which act as a quality indicator for MNC in elderly frail people (Bail &
Grealish, 2016). The survey elements scores indicated that the most common missed
care items were patient education and post discharge instructions. However, the
patient comments revealed that the care elements regularly missed were response to
call lights, symptom managing, education, and assistance in toileting. Study findings
implied that use of the mentioned tool to assess MNC could give pointers to the
nurse to patient ratio at the national level and allow for benchmarking of the hospital
performance with other healthcare organisations.
2.4 PERCEPTIONS OF MNC
Most of the studies located in the literature identified healthcare providers’
(nurses’) perceptions of MNC. Two studies identified the healthcare receivers’
(patients’) perceptions of MNC. Two studies identified separate aspects of MNC
within one study, one which focused on nurses, the other on patients. The following
section depicts the perceptions of MNC by nurses as well as by patients.
40
2.4.1 MNC as perceived by healthcare providers (nursing staff)
MNC was initially recognised in a qualitative study aimed at identifying the
nature of nursing care omissions in medical and surgical units during patient
hospitalization (Kalisch, 2006). This study was performed in two US hospitals by
conducting 25 focus groups with 173 nursing staff including RNs, Licenced Practical
Nurses (LPNs), and Nursing Assistants (NAs). Qualitative analysis in this study
concluded there were nine areas of missed nursing tasks namely: ambulation, posture
changes, hygiene and oral health care, food delivery, patient education, emotional
support, fluid intake and output documentation, discharge planning for the patients,
and general nursing surveillance activities. The factors that were identified to impact
MNC occurrence in this study were insufficient time, insufficient staff and skill mix,
lack of teamwork, resources inadequacy, weak handover, ineffective assignment of
nursing workforce in a setting (poor utilization of the present resources), weak
orientation, unpredictable work intensification, and denial (avoidance of the nurses to
ask if the care that they delegate to other nursing personnel was missed and assuming
it was performed). Despite lack of generalizability of this study due to its relatively
small sample size, it was considered as the foundation for generating the MISSCARE
survey (Kalisch & Williams, 2009), which is identified globally as a tool to measure
MNC, as revealed in the previous section.
Winters and Neville (2012) replicated Kalisch’s initial study in the New
Zealand context but included only RNs in their study. The most frequent care
elements missed according to that study were hygiene precautions. Other elements
frequently missed were ambulation, toileting, turning, and skin integrity evaluation.
However, medication administration was the least frequently missed according to all
the participants in the study. Thus, it can be concluded that the physiologic care
procedures that have a direct impact on the patient healthcare results, such as
medication administration, are frequently prioritized by the nurses. However, basic
care interventions such as ambulation and assisting in toileting needs tend to be
delayed or even left undone. The factors influencing MNC in this study were:
interruptions, especially by telephone calls, unexpected rise in the nurses’ workload
due to admission of the patients to the unit, and nurse shortages.
41
Marven (2016) conducted a case study utilising mixed methods approaches in
one oncology ward in Victoria, Australia. This study relied on three data sources:
online modified RN4CAST survey, secondary data for the studied ward, and focus
groups to obtain in depth understanding of the reasons leading to MNC. The
response rate to the survey in this study was 34% (n= 17 nurses). The most frequent
elements of MNC were: talking to patients (88.2%), developing and updating care
plans (76.5%), followed by patient education (64.6%), and preparation for patient
discharge (58.7%). The least frequent MNC elements were: pain management
(11.8%), skin care and assessment (23.5%), planning care (29.4%), and performing
frequent changes of patient position (29.4%). The reasons for MNC were insufficient
skill mix, nursing work organisation, and performing non-nursing duties.
The literature showed several studies conducted in various contexts to
investigate MNC (its types and reasons). Most of the identified studies about MNC
perceptions were quantitative, cross sectional and descriptive studies. The main aim
of these studies was to identify the elements of and reasons for MNC using a
quantitative survey tool. Reasons for MNC in these studies were generally identified
based on the findings of the survey tool with no identification of the effect of
particular factors on the occurrence of MNC. These studies revealed inconsistent
findings regarding the elements of and reasons for MNC, which may be due to
employing varied research tools to gauge MNC. However, notwithstanding the
methodological discrepancies, the varied approaches, and the wider policy-level
context for the majority of studies, there was a broad agreement in the published
literature regarding the types of missed or rationed nursing care items (Papastavrou,
Andreou, Tsangari, Schubert, & De Geest, 2013).
The literature reviewed revealed that MNC as perceived by nursing staff was
mainly in the areas related to basic patient care (e.g. ambulation, feeding, turning and
mouth care) (Chapman et al., 2017; Friese et al., 2013; Maloney, Fend, & Hardin,
2015; Palese et al., 2015; Villamin et al., 2018; Winsett, Rottet, Schmitt, Wathen, &
Wilson, 2016). Other studies revealed that educational, emotional and psychological
care were most frequently missed (Al�Kandari & Thomas, 2009; Ball et al., 2016;
Bekker et al., 2015; Hernández-Cruz et al., 2017; Marven, 2016; Scott et al., 2013;
42
Zander, Dobler, Bäumler, & Busse, 2014). (Summary of the quantitative studies that
examined nurses’ perceptions toward MNC can be found in Appendix 1 page 271.)
2.4.2 MNC as perceived by patients
Engagement of patients is considered an essential part of quality healthcare and
patient safety improvement (Jha, Orav, Zheng, & Epstein, 2008). Rosenthal and
Shannon (1997) stated there are several practical, empirical, and theoretical evidence
that provide a strong justification for assessing patient perceptions:
1. Patients’ perception measures are more sensitive to variations across
healthcare systems than other conventional quality measures.
2. Based on the autonomy principle, one of the rights of knowledgeable patients
is to determine what optimal interventions are to be performed for them.
3. Patients’ perceptions may have a direct association with other quality
indicators and may be reliable.
4. Patients’ perceptions of and satisfaction with healthcare have a direct
association with the decisions of patients to look for medical management, to
change healthcare suppliers, and to conform to the proposed management.
Kalisch, McLaughlin, and Dabney (2012) conducted a qualitative study with
38 inpatients in seven multiple patient care units in an acute care hospital. The aim of
this study was to identify the reportable missed nursing tasks as reported by the
patients. MNC areas were identified in this study as fully reportable, partially
reportable, and not reportable element. Fully reportable MNC elements are the
aspects of nursing care that patients could report on or recognise that they were
missed by nursing staff. Partially reportable MNC are nursing care aspects that were
partially identifiable by the patients. Not reportable MNC elements are those nursing
care aspects the patients could not recognise that they were not performed by nurses.
MNC elements, such as oral care, listening to patients, call lights and alarms
response, feeding assistance, bathing, and pain medications were fully reportable.
Partial reportable missed tasks included patient education, recording vital signs, and
hand washing. Non-reportable missed tasks included patient assessment and
surveillance, and intravenous site care. Bathing, vital signs, and hand washing were
the less frequently missed nursing tasks. Based on the finding of this study, a
43
MISSCARE survey–Patient was constructed and tested and was used to assess
patient reported MNC in a subsequent study (Kalisch et al., 2014).
The first study that used MISSCARE survey–Patient to examine patients’
perceived MNC was conducted with 729 patients in medical, surgical and
rehabilitation units in two hospitals in the Midwest part of the USA. The basic care
domain was the most frequently missed nursing task. Other tasks left undone by the
nurses were mouth care (50.3%), ambulation (41.3%), getting the patient into the
chair (38.8%), giving information about procedures or tests (27%), and bathing
(26.4%). Not listening to patient concerns and not responding to call lights were
among the least reported missed nursing tasks. No significant differences in MNC
were found between the two different hospitals. Surprisingly, this study found that
adverse events experienced in both hospitals, which included IV running dry,
infiltrating IV, pressure ulcer, patient falls, and medication errors, were greatly
associated with MNC (Kalisch et al., 2014). This finding was substantiated in an
exploratory study to identify the reasons for adverse events as perceived by patients
and relatives in Sweden. According to this study MNC, particularly basic care such
as mouth hygiene, was the main cause of adverse events (Andersson, Frank,
Willman, Sandman, & Hansebo, 2015).
2.4.3 MNC as perceived by both patients and nurses
Combining the perceptions of both patients and nurses regarding MNC can
give a more comprehensive picture of the quality of healthcare delivered. Thus,
Moreno-Monsiváis, Moreno-Rodríguez, and Interial-Guzmán (2015) conducted a
descriptive correlational study to identify MNC, and the factors associated with
missed care, as perceived by 160 nurses and hospitalized patients in a private
institution in Mexico, using the MISSCARE survey. The nursing care most often
skipped as perceived by nurses was basic care intervention (M=80.2; SD=19.40),
rather than continuous assessment intervention (M=94.56; SD=11.10). The most
frequent basic care procedure missed was oral care (32.1%). Other missed tasks
included hand hygiene (29.4%), patients’ ambulation (20.3%), and posture change
(17%). Regarding the procedures related to the continuous patient evaluation, the
most frequent missed task pertained to full documentation of the data needed for the
patients (9.5%). The most common skipped nursing tasks as perceived by the
44
patients were related to patient education and discharge (M=45.00; SD=23.22).
Labour resources (M=80.67; SD=17.06) and material resources (medicines and
equipment) (M=69.72; SD=23.45) were the main reasons for the MNC.
A similar study was conducted but in this case it was conducted in two
institutions in Mexico, private and public hospitals (Monsivais, Guzman, Interial,
Rivera, & Arreola, 2016). In this study, the number of participants was 32 nurses
from public hospital and 160 nurses from private hospital, 180 patients from the
public hospital and 160 patients from the private hospital. The study used the
MISSCARE survey for both nurses and patients. Higher levels of MNC in the public
hospital than in the private hospital were found. Similar to the previous study, the
most frequent missed element of care according to nurses was basic care
intervention, while the least frequent missed elements of care were related to care
evaluation. According to patients, similar findings were found to the previous study
as patient education and planning for discharge were the most frequent missed care
elements. The factors that were attributed to MNC were also similar to the previous
study.
2.5 FACTORS INFLUENCING MNC
Factors identified in the literature as leading to MNC were categorized into
nursing practice environment factors and nurse and work features factors. Nursing
practice environment factors involve interruptions, managerial support, type of
nursing interventions, teamwork, and nurse staffing (ratios and nursing skill mix).
Nursing and work features include nurses’ job titles, professional experience, and
type of working shift. The following section demonstrates the contribution of these
factors to the occurrence of MNC.
2.5.1 Nursing Practice Environment
Nursing practice environment is defined as the structural features of a practice
context that enable or restrain professional nursing practice (Lake, 2002). Practice
environment of the nurses represents an indicator of the quality of nursing care,
which has a high influence on the quality of healthcare as well as patient safety
(Chiang, Hsiao, & Lee, 2017). An unpleasant practice environment was one of the
factors that led to the emergence of MNC according to a qualitative study conducted
45
by Dehghan-Nayeri, Ghaffari, and Shali (2015). In the literature, four cross sectional
studies were located that investigated the relationship between MNC and nursing
practice environment. This section describes and evaluates these studies and their
findings.
Papastavrou et al. (2014) conducted a descriptive, multisite correlational study
to explore the association between nursing practice environment and nursing care
rationing using BERNCA and the Revised Professional Practice Environment
(RPPE) surveys. RPPE is a survey tool used to assess the professional environment
of nursing clinical practice. The data for this study were gathered from 393 Greek
nurses working in medical and surgical wards over a period of 9 months. According
to regression analysis, this study found that 18.4% of the rationing was accounted for
by the nursing practice environment, particularly teamwork, leadership, and
communication between staff regarding the patients’ conditions. It was found that
any increase in these elements related to low rationing levels. The main shortcomings
for this research were relying on the nurses’ perception about missed nursing tasks,
negative phrasing of the BERNCA questions, which might be difficult to interpret,
and the correlational design of this study. The study recommended that further work
should focus on the methods that can facilitate the dissemination of patient
information between different staff as this issue is greatly related to the concept of
rationing of nursing care.
Another study was conducted by Hessels, Flynn, Cimiotti, Cadmus, and
Gershon (2015) to investigate the association between MNC and nursing work
environment in acute care hospitals in New Jersey in the US. This study depended on
surveying 7000 nurses in 70 acute care hospitals. The practice environment was
measured using the Practice Environment Scale of the Nursing Work Index (PES-
NWI), which is a tool used to measure the quality of the nursing practice
environment. The PES-NWI tool is a 4-point Likert-type scale that consists of 31
items. The subscales of the PES-NWI encompass: nurse participation in hospital
affairs, nursing foundations for quality care, nurse manager ability, leadership, and
support of nurses, staffing and resource adequacy, and collegial nurse-physician
relations (Warshawsky & Havens, 2011).MNC was measured in this study using the
TU tool. After controlling nurses and hospital characteristics, Ordinary Least Squares
46
(OLS) and regression analysis were utilised to determine the relationship between
practice environment and MNC. It was found for every point increase in the hospital
score on the PES-NWI, there was a 13.7% decrease in the levels of omitted nursing
tasks in the hospitals. Nurse staffing increases by one SD (0.23) predicted a 3.1%
decrease in the level of MNC. This study implied that identification of the modifiable
characteristics of the work environment could help hospital management, nursing
management, and direct care nurses, to reduce the MNC level significantly. This
finding was consistent with Zander et al. (2014).
Smith, Morin, Wallace, and Lake (2017) conducted a cross sectional study to
evaluate the relationship between nurse work environment, collective efficacy, and
MNC in US hospitals. Collective efficacy can be defined as the communal belief of a
group regarding the capabilities of the group members to organize and implement a
course of actions needed to meet the goal of the institution (Bandura, 1997). The
author of this paper described collective efficacy as the capability of the group of
nurses to resolve issues. This study was conducted in five hospitals using web-based
PES-NWI, MISSCARE survey, and Collective Efficacy Beliefs Scale (CEBS).
CEBS is a seven-item scale used to assess the collective efficacy (Riggs & Knight,
1994). This study found that there was a relationship between practice environment
and MNC. Path analysis revealed a strong association between the nurse practice
environment and collective efficacy, and a strong association between collective
efficacy, nurse practice environment, and reduced prevalence of MNC. This study
implied that the practice environment should be strengthened to enhance the
collective efficacy and reduce the MNC incidence.
Recently, a cross sectional study to investigate the relationship between
nursing practice environment and safety culture on MNC in a tertiary hospital in
Korea was conducted. This study used a Korean version of the Practice
Environmental Scale of Nursing Work Index to measure the practice environment.
Safety culture was assessed using Perception of Patient Safety Culture Scale, derived
from the Hospital Survey of Patient Safety Culture (HSOPSC), which is the main
tool used to examine safety culture in hospital settings (Sorra & Dyer, 2010). MNC
was measured using the MISSCARE survey modified to the Korean context.
Significant negative associations between MNC and nursing work environment (r =
47
−.43, p < .001), patient safety culture (r = −.37, p < .001) was concluded in this
study. The findings of this study were limited by the small sample size (n = 186),
limited generalizability, and exclusion of some hospital units such as the emergency
department. The main implication of this study was that MNC could be reduced by
modifying the nurse practice environment and safety culture rather than by individual
nurse characteristics (Kim, Yoo, & Seo, 2018). Likewise, patient safety culture was
found to explain 30% of MNC variations in another cross sectional study conducted
with 311 nurses working in 29 units in 5 hospitals (Hessels, Paliwal, Weaver,
Siddiqui, & Wurmser, 2018).
The following section presents nursing practice environment dimensions and
their association with the MNC phenomenon. Elements of nursing practice
environment affecting MNC and discussed in the next section were as follows:
interruptions, managerial support, type of nursing intervention, teamwork and nurse
staffing.
Interruptions
Interruptions represent the main factor that leads to practice environment
failures in hospital contexts (Kohn et al., 2000). Interruptions have a negative impact
on the nurses’ performance (Bailey & Konstan, 2006) by distracting nurses from
doing their scheduled tasks (Baethge & Rigotti, 2013), influencing the time needed
to perform a task, and the decision making process (Li, Magrabi, & Coiera, 2012).
Numbers of interruptions in the nursing practice environment were estimated to
range from 0.4–41.7 per hour (Biron, Loiselle, & Lavoie-Tremblay, 2009; Monteiro,
Avelar, & Pedreira, 2015). Nursing tasks left undone were proposed as one
mechanism that mediates the relationship between interruptions and nurse and
patient outcomes (MacPhee, Dahinten, & Havaei, 2017).
According to Ansell, Meyer, and Thompson (2014), time constraints, work
interruptions, and rationalized judgment increase the rates of missing respiratory rate
measurement. These interruptions could be related to the interactions between
healthcare professionals, which lead to distraction and concentration loss,
accompanied by care discontinuity (Hall et al., 2010). In addition, delays in
providing treatment to the patients were found to result from interruptions
experienced by the nurses. Particularly, interruptions had a negative impact on the
48
efficacy of the medication administration process (Cooper, Tupper, & Holm, 2016),
although medication administration according to Winters and Neville (2012) was one
of the least frequently missed care elements. It has been postulated that interruptions
experienced by RNs due to responding to phone or call bells are the reason for that.
Moreover, an observational study of nurses during medication rounds revealed that
interruptions happened in 99% of medication administration cases. Thus, nurses were
forced to discontinue medication administration or preparation. As a result, at least
one technical failure in about 34% of medication administration cases would take
place. This study proposed that interruptions lead to increases in the workload of the
nurses while administering medications (Johnson et al., 2017). In this regard, nursing
management should create effective strategies to reduce the interruptions, and thus
promote patient safety and improve quality of nursing work (Monteiro, Avelar, &
Pedreira, 2015).
Lack of Managerial support
Nursing management and leadership are not able to aid nursing staff in making
decisions about care prioritization on a day-to-day basis. However, they are able to
recognize unnecessary workload, unnecessary interruptions, processes requiring
development, and provision of materials. The issues that lead to intensification of
nursing daily workload should not be left to the nurses to rectify. Therefore, nurses
will be able to focus on patient care provision (Dehghan-Nayeri, Shali, Navabi, &
Ghaffari, 2018; Swiger, Vance, & Patrician, 2016), and reduce the possibility of
MNC. Thus, lack of administrative support was one of the factors that affected the
rate of MNC in several contexts (Blackman et al., 2015; Henderson et al., 2016).
Also, enhancing the communication between management and frontline staff
could lead to reducing the burden of MNC (Winters & Neville, 2012). A qualitative
study to identify the factors that affect MNC from the perspectives of nursing
managers in a university hospital in Portugal revealed that the factors driving nursing
staff to miss care were controlled by structural and contextual factors of the system,
missed care reporting barriers, and missed care impact on patient care outcomes
(Laranjeira, 2015). Other studies revealed that absence of support; system and
organizational failures were the main factors leading to nursing care rationing
49
(Rochefort & Clarke, 2010; Schubert et al., 2008; Sochalski, 2004; Zander et al.,
2014).
Type of Nursing Intervention
According to Upenieks, Kotlerman, Akhavan, Esser, and Ngo (2007), nursing
interventions come in three forms: value-added elements, non-value-added elements,
and necessary items. Examples of these items include administering medications and
monitoring vital signs as a value-added item of care, looking for a staff member or
appliance as non-value-added activity element, and documenting schedule of care
and orders transcribing as a necessary element. The time nurses consume on
particular procedures depends on the organisation and automation of the practice
environment. Moreover, it depends on the nurses’ acquaintance with the ward as well
as having experience in the required procedure or task (Swiger et al., 2016).
However, while nurses should employ 60% of their time on direct bedside
management and compassionate care (Institute of Medicine, 2010) non- value added
procedures take about one third of the time of RNs (Whitby, McLaws, & Slater,
2008), and thus increase the nursing workload (Upenieks et al., 2007; Willis et al.,
2014) and possibly lead to MNC. Storfjell, Ohlson, Omoike, Fitzpatrick, and
Wetasin (2009) revealed that nursing executives should direct their attention toward
non- value added and necessary procedures that hinder the nursing staff from
performing direct bedside procedures.
Analysis of commentaries in several studies conducted in SA, NSW, Victoria,
Tasmania and New Zealand revealed that MNC is related to increased amount of
documentation required by the nurses, performing non-nursing tasks, and increased
workload (Harvey et al., 2017). According to a qualitative study conducted with 20
nursing oncology unit managers in Iran, nursing care documentation consumed
significant time, which might lead to documenting only summary reports, nurses’
hesitancy to return to patients' records, and thus reduced efficiency of healthcare
provision (Dehghan-Nayeri et al., 2018)
McNair et al. (2016) conducted a study to evaluate the association between the
use of time by the nurses (assessed by observation using worksheets) and nurses’
reports of MNC assessed by MISSCARE survey in 15 medical surgical units in two
hospitals in California. It was found that documentation procedures take 25% of the
50
nursing time. However, this did not lead to greater rates of MNC in other tasks.
Spending more time in some procedures was not associated with reporting less
missed care in these procedures. Thus, no evidence of association was found between
time use and MNC. The authors of this paper provided three possible justifications
for their findings; the prioritizing of care, which may be the basis behind MNC, is
different because nursing care is setting dependent and value laden, with priority
given to particular task types, chiefly the tasks appreciated by organisational and
nursing unit managers. Prioritization thus differs in different contexts and different
population groups. The second reason is the potential incongruity between
perceptions of nurses about the way they should expend their time and how that time
is spent in reality. The third reason is known as the ecological fallacy, particularly
the Simpson paradox, which means that the association could not be detected due to
the research combining both hospitals together (McNair et al., 2016).
Teamwork
Kalisch (2009) conducted a mixed methods study to compare the perceptions
of RNs versus Nurse Assistants (NAs) regarding the types and factors of MNC, and
to explore the relationship between these perceptions and selected teamwork factors.
The first phase in this study comprised distribution of the MISSCARE survey to 633
RNs and 121 NAs working in 18 units in one of the hospitals in Michigan in the
USA. The second phase included conduct of two focus groups with the RNs and
another two focus groups with NAs. The reasons for MNC derived from RNs and
NAs focus groups were inconsistent. For example, RNs reported staff inadequacy,
lack of knowledge about the significance of certain basic care by NAs, lack of
motivation in NAs, poor communication during or after the shifts, busyness of the
RNs and inability to follow up, and provision of incomplete reports by NAs to the
RNs. However, NAs stated that lack of respect from the RNS, absence of reporting
about the patients at the start of the shift, and lack of contact and communication
between RNs and NAs, were the reasons for MNC. The variations in the perceptions
of both RNs and NAs about MNC highlighted the absence of significant parts of
teamwork, such as mutual trust and team orientation.
A cross sectional descriptive study to evaluate the impact of teamwork in
nursing on the MNC was conducted in the Midwest region in the USA. This study
51
was conducted in 50 units including medical-surgical, intermediate, intensive, and
rehabilitation. Nursing Teamwork survey and MISSCARE survey were combined
into one document and were used to gather the data in this research. Negative
association between MNC and teamwork was concluded (p<.01). Similar to the
previous study, it was found that MNC was significantly associated with a group of
factors related to teamwork including trust, backup, orientation, and team leadership.
This study highlighted the need to spend more time in approaches to improve the
teamwork to reduce MNC incidents (Kalisch & Lee, 2010).
Subsequently, Kalisch and Lee (2012) sought to compare nurse leaders and
nurse staff perceptions regarding the extent, types and reasons of missed care, and
nursing teamwork as well, using the instruments of the previous study. It was
concluded that nurse leaders identified more missed tasks and teamwork than nursing
staff. Material and labour resources were more frequently reported by the nursing
staff than by nursing leaders as reasons for the MNC. Inconsistencies in the
perceptions of MNC and teamwork between staff and leader represent a barrier for
problem resolution, which in turn results in low performance and satisfaction.
Bragadóttir et al. (2017) in their recent study found significant association
between MNC and teamwork level. This study was conducted in 8 hospitals (both
teaching and non-teaching) in Iceland with 864 nurses (both registered nurses and
practical nurses) working in medical, surgical and intensive care units. The
researchers in this study utilized a combined version of MISSCARE survey and
Nursing Teamwork survey. Nursing teamwork predicted 14% of variations of MNC.
Chapman et al. (2017) conducted a cross sectional study to investigate the
association between MNC and teamwork in four Australian public hospitals in
Victoria, using MISSCARE survey and teamwork survey. The participants in this
study were RNs and ENs in medical, surgical, ICU, specialist wards including
coronary care, ED and rehabilitation units. The response rate in this study was about
90%. The most common missed care procedures were ambulation, turning, and oral
care. The primary reasons were ordered as follows: labour (particularly urgent
patient situations, inadequate staffing, and unanticipated increase in patient volume),
material (particularly medications), and communication issues (tension with the
52
medical staff). The highest percent of MNC was found to be in EDs and the lowest
was found to be in ICU. Teamwork was responsible for 9% of MNC in this study.
Nurse staffing (ratios and skill mix)
The concept of staffing in general refers to the capability of human resources to
meet the requirements of workload (Castner, Wu, & Dean-Baar, 2014). Nurse
staffing is defined as the determination of the proper type and count of nursing
personnel in order to meet the patient care workload (Duffy, 2016). In general, the
“nurse staffing” term indicates quantity or count of nursing staff (Vanfosson, 2017).
Nurse staffing is a key element in the nursing practice environment (Aiken et al.,
2012). Thus, measurement of nurse staffing constitutes a key element in
identification of the nature of the nursing practice environment.
There have been several measures used in the literature for nurse staffing.
These measures have been classified into measures based on administrative data and
measures based on nurse reporting. The nurse-reported staffing adequacy measures
are preferable in research aimed to improve the working conditions of the nursing
staff.. However, in research about healthcare quality, it is better to employ
administrative data staffing ratios (Kalisch, Friese, Choi, & Rochman, 2011). Nurse
staffing measures include:
1. Number of Full-Time Equivalent (FTE) per patient day.
2. Hours per patient day (nursing hours per patient day, NHPPD; RN hours per
patient day, RNHPPD).
3. Number of patients assigned for each nurse per shift (patient workload).
4. Nurse to patient ratio, skill mix, particularly RNs skill mix (Kane, Shamliyan,
Mueller, Duval, & Wilt, 2007).
5. Nursing perceived staffing adequacy (Aiken et al., 2001; Mark, 2002;
Schmalenberg & Kramer, 2009).
6. Patient acuity (Hurst, 2003; Kalisch et al., 2011).
7. Admission and discharge rates (patient turnover) (Unruh & Fottler, 2006).
8. Bed occupancy (Stevenson et al., 2011).
RNHPPD relates to the amount of time of patient day that is spent by RNS.
However, NHPPD relates to the overall time of patient day spent by the whole
53
nursing staff after excluding vacation, sick and education leave (Kalisch, Tschannen,
& Lee, 2011).Given the various measurement strategies for nurse staffing, it is
injudicious to propose that these measures evaluate identical hypotheses. Hence,
comparing them is a challenging issue (Min & Scott, 2016)
A vigorous body of literature explored the relationship between nurse staffing
and patient care results. The majority of this research revealed low staffing levels
associated with negative patient outcomes, such as patient mortality (Kane,
Shamliyan, Mueller, Duval, & Wilt, 2007), patient falls (Griffiths et al., 2014),
pressure ulcers and medication errors (Cho, Chin, Kim, & Hong, 2016), decreased
LOS and readmission rates (Griffiths et al., 2014). Nevertheless, the researchers in
this field were not definite regarding the causal mechanisms behind this association.
MNC represents one proposed mechanism to explain this relationship (Griffiths et
al., 2018).
A recent systematic review of the literature revealed eighteen studies that
aimed to investigate the relationship between MNC and nurse staffing (staffing ratios
and skill mix). These studies utilized different data sources for nurse staffing, such as
nurses’ self-report and administrative data in addition to the survey tool to measure
MNC (whether by nurses or by patients). The majority of these studies revealed a
significant negative correlation between nurse staffing levels and MNC, which
means that higher levels of nurse staffing are associated with lower levels of MNC
(Griffiths et al., 2018).
In a study conducted by Kalisch, Tschannen, Lee, and Friese (2011) in 110
patient care units in 10 hospitals in the US , it was found that there was a negative
association between MNC and HPPD, and RNHPPD. A secondary data analysis
study conducted by Friese et al. (2013) to assess the relationship between MNC and
staffing levels in oncology units (n= 352) revealed that an increase of one patient per
one nurse led to a 2.1 times increase in MNC. Ball et al. (2014) conducted a study to
assess the relationship between nursing care left undone and nurse staffing in 46
acute care hospitals in the UK (n=2917) using the Tasks Undone survey tool (TU-
13). This study found that as the patient to nurse ratio decreased, odds of MNC were
reduced as well. A multi-country study in 12 European countries performed by
Ausserhofer et al. (2014) using the RN4CAST questionnaire revealed that nurses’
54
reports of nursing care left undone were lower in hospitals that had lower patient to
nurse ratios (p<0.0001).
A cross sectional study was conducted by Cho, Kim, Yeon, You, and Lee
(2015) to compare the relationship between MNC and staffing levels in units that had
high staffing ratios (7 patients per one nurses) and units that had low staffing ratios
(17 patient per one nurse) in South Korea. This study relied on the MISSCARE
survey, and the number of respondents in units that had high staffing ratios was 115
nurses and in units with low staffing ratios was 117 nurses. According to this study,
the mean score of MNC was lower for the nurses in the case of high staffing ratios
(M=1.39 versus 1.51 in units with low staffing ratios). Following that, another study
in South Korea was conducted to investigate the relationship between nursing care
left undone and nurse staffing, but in this study, it depended on a survey tool derived
from BERNCA. The nurse staffing level in this study was measured by the number
of patients assigned to nurses on their last shift as reported by RNs. The mean
number of patients assigned per individual nurse on their last shift was 12.3 (SD =
9.1). Multilevel logistic regression revealed that for every additional patient a nurse
cared for, there was a 3% higher chance of nursing care being left undone
(OR = 1.03, 95% CI = 1.01–1.05) (Cho et al., 2016).
Ball et al. (2016) in her study conducted in 79 acute Swedish hospitals
(N=10,174 RNs) revealed that odds of MNC decreased by 85% with RN staffing
levels of one RN caring for fewer than four patients (OR 0.148, P < 0.001). Orique,
Patty, and Woods (2016) found in a study conducted in one acute care hospital in
California that as the number of the patients increased, the missed care score
increased. This finding was parallel with the study that was conducted with 314
nurses in 12 medical care units in Italy (OR=0.91; p 0.001) (Palese et al., 2015).
One study investigated the relationship between missed nursing care as
reported by patients (n= 729) and nurse staffing measured using RNs’ skill mix,
RNHPPD, and HPPD in two hospitals in the US. In this study, Dabney and Kalisch
(2015) revealed that there was a significant correlation between staffing variables
and missed timeliness of nursing care interventions. However, basic care and
communication were not associated with RNHPPD and HPPD. This study found no
correlation between overall score of missed nursing care and nurse staffing variables.
55
In addition, two studies revealed no association between staffing levels and
MNC (Kalisch, Doumit, Lee, & El Zein, 2013; Schubert et al., 2013). In the study
conducted by Kalisch et al. (2013), which aimed to assess the relationship between
MNC and staffing levels in the US and Lebanon, staffing levels were measured
depending on the number of patients nurses provided care for in the previous shift.
This study revealed no association between staffing levels and missed care in either
country. However, Schubert et al. (2013) revealed that nursing care rationing
(measured using BERNCA) had a strong association with nurse perceived staffing
adequacy at unit level (p 0.042), but not with the number of patients per nurse (p
0.144). This study recommended using other measures for nurse staffing levels such
as HPPD to be able to determine the association between nurse care rationing and
nurse staffing.
Regarding the association between nursing skill mix and MNC, one study
found that insufficient numbers of assistive nursing staff represented a contributing
factor to MNC (Gravlin & Bittner, 2010). However, according to Palese’s study in
Italian medical units, provision of more care by support workers is associated with
higher levels of missed care as perceived by nurses (Palese et al., 2015). Ball et al.
(2016) found a possible justification for the mixed results regarding the association
between skill mix and MNC. According to that study, it was found that the positive
effect of support workers in reducing missed care tasks started to take place when
support workers provided care for less than four patients (OR=0.71, p .021).
A summary of the studies that purposefully concentrated on exploring the
relationship between nurse staffing and MNC, whether depending on nurse self-
report of nurse staffing or using administrative data as a nurse staffing measure, can
be found in Appendix 2 on page 279.
2.5.2 Individual Nursing Staff Features and Work-Related Conditions
A recent systematic review of the literature revealed that individual and ward
features explained 12–32% of variations in MNC. Individual nursing features include
nurse experience, qualifications which can act as an indicator of the competency of
the nurses. Work related conditions include the type of shifts nurses work in (day and
night shift), shift length, and overtime. Contrary to the consistent results revealed
from the literature regarding the association between practice environment and
56
MNC, the literature revealed inconsistent findings regarding the association between
individual features and nursing work related conditions and MNC, which warrants
additional studies to illuminate this association.
Individual Nursing Features and MNC
Preserving experienced nurses in hospital wards is vital for high quality
nursing care delivery (Dunton, Gajewski, Klaus, & Pierson, 2007). Previous studies
of MNC revealed inconsistent results regarding the association between MNC and
years of professional experience. Having longer experience years was associated
with lower MNC rates, particularly with lower priority care omissions such as
discharge planning and patient education (Blackman et al., 2018). Moreover,
Ausserhofer et al. (2014), Castner et al. (2014), Al‐Kandari and Thomas (2009),
Bruyneel et al. (2015), and Bragadóttir et al. (2017) reported that greater experience
was associated with lower level of MNC perceptions. However, according to an
Australian study, the staff working 6 months or less reported less MNC than those
working more than 10 years (Chapman et al., 2017).
The impact of experience on nurses’ standpoints regarding missed care is a
somewhat complicated matter (Bragadóttir et al., 2017). Previous findings about the
association between MNC and nurses’ experience stated that the nurses with greater
experience generally had a good relationship with other healthcare team members
(Elrehem, El, & Seloma, 2014). Thus, senior and junior nurses could collaborate with
each other and learn from each other to accomplish common purposes (Kieft et al.,
2014). According to a qualitative study in South Australia, junior personnel with
insufficient knowledge and experience frequently replaced RNs. In this case, many
tasks might be skipped (Verrall et al., 2015). Moreover, in a study that investigated
expertise contribution to the process of error recovery, it was postulated that nurses
having 10 or more years’ experience had the ability to recognise and recover the
errors more than did nurses with less experience. The errors that were frequently
recovered by the experienced nurses were mainly related to skills and procedures
(task based errors), such as medication administration, rather than information based
errors which happen due to faults in clinical decision making (Wilkinson, Cauble, &
Patel, 2014). Another elucidation for these findings could be that nurses with
significant experience have higher patient safety competency perception (Hwang,
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2015), and high “corporate knowledge” (Henderson et al., 2016). Also,
inexperienced nurses do not have sufficient information about equipment and
instruments, routinely performed procedures, and patients’ requirements (Dehghan-
Nayeri et al., 2018).
However, nurse assistants who had less experience than RNs were found to be
associated with lower perceptions of MNC (Kalisch et al., 2011; McMullen et al.,
2017). In addition, in an Australian study in four acute care hospitals, it was found
that ENs perceived MNC less than RNs (Chapman et al., 2017).
McMullen et al. (2017) justified this finding for two reasons: first was the RNs’
alertness about the volume of work that needed to be achieved with subsequent high
accountability of the care elements missed; second was misunderstanding by NAs of
some questions, such as questions about care planning, as these items were not in
their scope of practice. It has been found that nurses having less experience do not
have enough experience to perform some sophisticated procedures such as patient
education and planning for discharge. These procedures are delegated frequently to
proficient nurses in their roles as case managers (Sinn, Tran, Pauley, & Hirdes,
2016).
Other studies revealed that greater experience was associated with greater
perception of MNC (Bragadóttir et al., 2017; Chapman et al., 2017; Higgs et al.,
2017; Kalisch et al., 2013; Kalisch & Lee, 2010; Palese et al., 2015). Nurses with
more experience may have the feeling of reduced capability to deliver patient care,
compared with what they were used to in previous circumstances, such as in the case
of insufficient labour and material resources (Palese et al., 2015). A group of studies
found no significant correlation between MNC and nurses’ experience (Cho et al.,
2015; Papastavrou et al., 2016; Schubert et al., 2013).
Nursing work related conditions
A study by Griffiths et al. (2014) aimed to explore the association between the
shift lengths and the perceptions of nursing staff on the nursing procedures undone,
and quality and safety of the care delivered to the patients. This study was conducted
in 12 European countries in 488 hospitals. Of the participating nurses, 50% were
working shifts of 8 hours or less, and 15% were working shifts of 12 hours or more.
Poor quality and safety care scores, and a higher percentage of nursing tasks left
58
undone (RR=1.13; 95% CI, 1.09–1.16), were reported by the nursing staff who were
working 12 hours or more. Overtime was also associated with leaving more nursing
procedures undone in this study (RR=1.29; 95% CI, 1.27–1.31).
In a similar vein, Cho et al. (2016) conducted a study in 60 hospitals in South
Korea to investigate the association between patient safety, quality of care and care
left undone, and nurse staffing and overtime, as perceived by RNs. All variables in
this study were measured by surveying the nurses (the survey that was used to assess
care left undone was the BERNCA). However, overtime was assessed by subtracting
the scheduled hours for RNs from the actual hours worked. RNs working overtime
reported 86% increase in care left undone (OR = 1.86, 95% CI = 1.48–2.35). The
association of overtime with higher levels of nursing care left undone was
commensurate with the finding of Griffiths et al. (2014).
According to a study conducted in medical and surgical wards in 46 acute
hospitals in the UK, it was found that the level of nursing care left undone was 1.13
times higher for nurses working a 12 hour or longer shift compared to those working
eight hours or less (RR = 1.13, 95% CI 1.06–1.20, p < 0.001) (Ball et al., 2017).
Type of shift (day or night shift) was found to be an important predictor for
MNC (Blackman et al., 2015). In addition, two cross sectional studies revealed that
less missed care was reported by night shift nurses (p<.01) (Kalisch et al., 2011;
Kalisch et al., 2011). In contrast, Al‐Kandari and Thomas (2009) revealed in their
exploratory study in Kuwaiti hospitals that most nursing tasks were missed in the
night shifts. Missing nursing tasks in the night shift was attributed in this study to
intensification of the nurse workload due to a lower number of nursing staff in the
night shifts. Another explanation for the increase in MNC in the night shifts could be
that nurses in the night shifts experienced more fatigue due to lower sleeping periods
than day shift nurses, and night shift nurses commonly had higher loads of patient
assignment, thus they were more vulnerable to errors (Roth et al., 2015). Another
reason given was that night shift workers could have worse health than day shift
workers (De Cordova, Bradford, & Stone, 2016).
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2.6 RESEARCH GAPS
MNC is an emerging area of focus in quality healthcare and patient safety
research due to its impact on patients and nursing staff. MNC also negatively impacts
on the organisational outcomes, such as nursing turnover, intent to leave, and
absenteeism. Nevertheless, research within this field is still evolving and the
available knowledge about the way the MNC phenomenon is comprehended is still
unclear. The review of the literature revealed three challenges that limit the scope of
current understanding about MNC. These challenges are either related to the inherent
characteristics of this phenomenon or due to underlying methodological limitations
observed in the published literature in this field. These challenges suggest that a
comprehensive understanding of this phenomenon is yet to be fully established.
These challenges will be discussed next.
Firstly, MNC is a context dependent phenomenon. In this perspective,
knowledge and understanding of context (contextualisation) is of central relevance
for better understanding of MNC. Contextualisation in general refers to issues in
local service provision (Dizon, Machingaidze, & Grimmer, 2016). However, much of
the previous literature on MNC depends on quantitative research approaches,
particularly cross-sectional studies that assessed the nurses’ perceptions about MNC,
which meant that most of the MNC literature disregards contextual determinants that
may impact the occurrence of MNC in the local context of healthcare organisations.
The reason for this could be the considerable challenges experienced by researchers
in accessing confidential data from hospitals’ records required to illuminate the
contextual influence on MNC occurrence. According to Azuero (2018), getting
access to data such as clinical and administrative data from hospital databases is one
of the intimidating hurdles encountered in nursing research. This lack of contextual
considerations is a significant factor that has hindered detailed exploration of this
phenomenon in the local context. Thus, the validity of results for many studies in the
MNC field is viewed as problematic and has influenced the ability of the researchers
to characterise effective measures for quality improvements in healthcare
organisations.
In this vein, contextualised research (i.e. research informed by consideration of
context) would provide a rich lens of understanding and complement the body of
60
knowledge about MNC, which would also be helpful in developing a more
comprehensive theory about the phenomenon. It also might provide an evidence base
for design of appropriate initiatives to tackle this issue and reduce its impact on
patient safety and healthcare quality.
Secondly, much of the existing research about MNC depended on nurses’ self-
reporting of MNC perceptions. Little is known about how patients perceive MNC.
Thus, studies that investigate patients’ perceptions of MNC may provide a spotlight
on other variables that impact quality of nursing care and thus patient healthcare
results (Kalisch et al., 2012).
Thirdly, there are few studies in the body of literature worldwide related to
MNC that have been conducted in contexts that have implemented mandated nurse-
staffing ratios. This gap creates a considerable debate about the benefits of execution
of such nurse staffing methods and their impact on quality of healthcare delivery and
patient safety. This gap also determined the researcher’s consideration to provide
solid evidence to inform presumptions about the likely impact of nursing staffing
ratios on patient safety, particularly missed care.
Therefore, as explained in more detail in the methodology and methods
chapter, in order to help to advance knowledge and to gain complete, enriched and
contextualised understanding of this topic, this research examined MNC in an acute
care hospital setting that had recently implemented mandated nurse staffing ratios. It
used a mixed methods research approach that has not previously been used in
research within this field. The methods employed in this research were: retrospective
analysis of secondary data (contextual information), nurses’ MISSCARE survey, and
descriptive case study (which involved secondary data, nurses’ and patients’ surveys)
at ward level. The methods used in this research were selected to address the
previously mentioned gaps in the current literature on MNC. The methods used have
been viewed as invaluable in identifying nursing care omissions, recognizing the key
drivers for these omissions in an acute care setting, and building conceptual
understanding of the patterns of interactions between these drivers in the local
context.
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2.7 CHAPTER SUMMARY
This chapter has provided a review of the literature on the MNC issue. The
literature review identified the main themes investigated in the literature with regards
to MNC. Furthermore, this chapter identified the shortcomings in the current body of
evidence in this area, and hence the need for the current PhD research. The following
chapter describes the methodology and methods used to achieve the objectives of this
research.
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Chapter 3: Methodology and Methods
3.1 INTRODUCTION
The central aim of healthcare research is to generate data that are valid and
reliable and can be used to establish a satisfactory, cost-effective, and efficient health
service (Bowling, 2014). However, in the world of management science, the best
working practices that suit one institution do not inevitably suit another, despite both
having similar dimensions and activities (Smit, Cronje, Brevis, & Vrba, 2011).
Hence, extensive evaluation is necessary to identify the factors that inform best
practice and to recommend the best fit for a particular context (Stange & Glasgow,
2013).
This study is focused on an acute care hospital in Brisbane, chosen because of
convenience and the preparedness of the hospital nursing administration to support
the study. The acute care hospital setting is an appropriate context for analysis of the
role of the nursing profession, as most nursing personnel are employed in the acute
care context at some stage during their career (Swiger et al., 2016).
The previous chapter reviewed the current literature about missed nursing care,
which has become a central focus in healthcare research, particularly quality and
safety research, and identified the methods that had been used to investigate this
phenomenon. It also identified the gaps in research and led the researcher to explore
MNC in the acute care setting, using methods that had not been used in the previous
research.
This chapter outlines the methodological approaches and methods used to fulfil
the overall goals of this research. The chapter starts with a discussion about research
paradigms and provides a justification for adopting the chosen paradigm. It also
provides a description of the study institution followed by details of the research
design, research strategy, data gathering, data analysis procedures, and limitations of
the methods used in this research. Finally, access to the research facility and the
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ethical considerations encountered during the process of data collection are
examined. This chapter is concluded with a brief summary.
3.2 RESEARCH PARADIGMS
3.2.1 Theoretical underpinning
Before addressing the paradigmatic underpinnings of this research, it is
imperative to provide an overview of the definition of research paradigms, its
components, and different types of research paradigms. Paradigm or worldview is an
overarching framework of understanding which has emerged as an important adjunct
to research since the publication of The Structure of Scientific Revolutions by Kuhn
in 1962 (Aliyu, Bello, Kasim, & Martin, 2014). Research paradigm has several
definitions (Mkansi & Acheampong, 2012). However, to put it simply, it can be
referred to as a way of thinking about and performing research (Antwi & Hamza,
2015) or the lens by which the researcher can view and comprehend the reality (Shek
& Wu, 2018).
A research paradigm consists of four components: ontology, epistemology,
methodology, and methods (Scotland, 2012). Ontology identifies the nature and
shape of social reality and what can be recognized about this reality (Antwi &
Hamza, 2015). Epistemology examines the nature of knowledge (Chilisa &
Kawulich, 2012). According to Gray (2009), “ Epistemology provides a
philosophical background for deciding what kinds of knowledge are legitimate and
adequate”.
Ontology and epistemology have intimate associations. It has been said that
ontology and epistemology may be viewed as a sweater, which can be put on while
considering the philosophical underpinnings and removed when actually conducting
the research (Furlong & Marsh, 2010).
Crotty (1998) conceptualized research methodology as the pathway or
approach of action that justifies the selection and employment of certain methods.
Research methods are defined as the means of conducting and execution of the
research (Adams, Khan, Raeside, & White, 2007). According to Miles, Huberman,
and Saldana (2014), research methods are the processes and techniques used in the
study, while research methodology is the lens that the researcher sees through and
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uses to take decisions related to the study. Congruently, a methodology can be
viewed as a map, and the method can be viewed as a sequence of steps to move
between two points on this map (Jonker & Pennink, 2010). The proper
methodological tactic in social science research is the approach that provides pre-
eminence to the goal and the philosophical tract to which the studied phenomenon
conforms (Nudzor, 2009). Hammersley (2006) claims that the selection of methods
must depend on the objectives and the situations of the pursued inquiry.
According to Saunders (2007), Guba and Lincoln (2000), and Hallebone and
Priest (2008), there are four types of research paradigms: positivism, post positivism,
constructivism, and pragmatism. The following section discusses and elaborates on
these paradigms and points to the paradigm that was adopted in this research.
3.2.1.1 Positivism
Positivism can be viewed as a strategy used to conduct social research which
calls for applying the natural science research pattern as the point of exodus for
examining social events and providing elucidations for the social world (Denscombe,
2009). To put it more simply, positivists are interested in revealing the realities and
truths conceived using particular correlations and associations between variables
(Denscombe, 2007). Positivist researchers reckon that entire comprehension can be
gained by relying on experiments and observations (Ryan, 2006). They strive to
follow a planned and structural tactic in convening their research by determining an
obvious research subject, structuring the suitable hypotheses and by pursuing an
appropriate methodology (Carson, Gilmore, Perry, & Gronhaug, 2001). Thus, a
positivism paradigm can be referred to as the scientific paradigm (Mack, 2010), and
the researcher in this paradigm can be referred to as a values free researcher (Nudzor,
2009).
Positivism paradigms represent the primary base of quantitative research
(Ponterotto, 2005; Sale, Lohfeld, & Brazil, 2002). The researchers in positivist
paradigms are seen as objective and unbiased in endeavouring to find causal
associations using objective evaluation and statistical analysis (Patel, 2012),
particularly descriptive and inferential statistics (Scotland, 2012). Positivists consider
that similar findings will be generated by different investigators investigating the
same real phenomenon by applying quantitative analytical tests and pursuing similar
65
research procedures in examining of a larger sample (Creswell, 2009), which means
that they aim to make generalizations from the research results regardless of the time
of conducting the research and the research setting (Hudson & Ozanne, 1988).
Research replicability is one of the core elements that characterize the
positivism paradigm. This element depends on a group of propositions which include
the following (Matusov, 1996):
The possibility of disconnection between the studied event and the
investigator.
Stability of the studied event characters.
Stability of the investigator character.
These propositions were viewed as questionable and problematic in social
sciences (Matusov, 1996). A positivism paradigm believes there is a singular
objective truth related to any research event or condition irrespective of the
researcher’s belief or viewpoint (Hudson & Ozanne, 1988; Žukauskas, Vveinhardt,
& Andriukaitienė, 2018). The issue of separation between the researcher and the
researched phenomenon, and of considering that the researcher and the researched
phenomenon have an independent existence (Aliyu et al., 2014; Hirschheim, 1985),
has been claimed as problematic. It has been argued that it is impossible for the
researcher to investigate particular events without permitting for researcher interests
and values interfering or interacting with the investigation (Somekh & Lewin, 2005).
Furthermore, a positivism paradigm is characterized by it proffering
comprehension of the social event or phenomenon in a vacuum. In other words, a
positivism paradigm divests or strips the context from the research. This feature is
one of the central points of criticism directed toward the positivism paradigm: that
complete understanding of the researched phenomenon is limited by adopting this
paradigm (Shek & Wu, 2018). As such, the scientifically specified positivism
paradigm was considered to be unable to completely examine or admit the missed
nursing care phenomenon intricacies that have been investigated in this research.
In light of the positivism paradigm limitations, a change from positivism to a
post-positivism paradigm was witnessed in the mid part of the 20th century (Chilisa
& Kawulich, 2012).
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3.2.1.2 Post positivism
Post positivism (a critical realist paradigm) (Wahyuni, 2012) represents a less
rigorous variant of positivism (Chilisa & Kawulich, 2012). Contrary to the positivism
paradigm, a post positivist paradigm is more flexible and does not set out to establish
the right and particular scientific method to create universal laws and cause–effect
relationships (Wildemuth, 1993). In addition, post positivism can be differentiated
from positivism based on the focus. Positivism focuses on validation of theory while
post positivism focuses on falsification of theory (Ponterotto, 2005).
According to Gratton and Jones (2004), in a post positivism paradigm, the
understanding could not be acquired based solely on measurement. This paradigm
conceives that social adaptation is the source of knowledge. One of the most
prominent characteristics of post positivist research is using triangulation within and
between methods (Bisman, 2010). It has been claimed that by triangulating the data
we obtain a deeper understanding of the reality but could endanger the objectivity
(Chilisa & Kawulich, 2012). Thus, it has been well established that mixed method is
the preferred technique/ method of post positivists in order to explore multiple
viewpoints to gain deeper consideration of the research problem (McEvoy &
Richards, 2006).
However, the post positivism paradigm has been criticized for the following
reasons:
It rejects the presence of laws and truths (Tekin & Kotaman, 2013)
It takes a distanced view of the research event and the researcher (Ryan,
2006),
The limitations of the post positivist paradigm resulted in the prominence of
another paradigm , the constructivism (interpretivism) paradigm (Mack, 2010).
3.2.1.3 Constructivism (interpretivism)
Researchers in this paradigm believe that there are several truths and realities
concerning social events (Hudson & Ozanne, 1988; Žukauskas et al., 2018). These
realities are viewed as a variety of intangible rational constructs that build upon
human involvement (Mittwede, 2012). This paradigm aims to generate subjective
rather than objective connotations as it depends on an individual’s understanding of
67
the social event (Schwandt, 1994). A constructivist paradigm mainly supports
qualitative research approaches (Teddlie & Tashakkori, 2012).
There are several differences between this paradigm and a positivism
paradigm. Firstly, while constructivism aims to establish a theory, positivism aims to
ascertain an already established theory (Parvaiz, Mufti, & Wahab, 2016). Secondly,
contrary to the positivism paradigm, this paradigm does not focus on generalization
(Neuman & Kreuger, 2003). According to Huberman and Miles (2002), the
generalisability in this paradigm “ is unachievable, unimportant or both (p 172)”.
Thirdly, this paradigm assumes that there are interdependence and collective
interactions between the investigator and the research participants (Hudson &
Ozanne, 1988), which can be referred to as a collaborative approach (Edirisingha,
2017) rather than in the case of positivism where there is a detachment between the
researcher and the informants (Matusov, 1996). Due to its subjective nature, this
paradigm has been criticized by positivists as it generates results that have deficient
reliability, validity, representativeness and generalisation (Nudzor, 2009).
3.2.1.4 Pragmatism
Pragmatism has been widely denoted as being an ‘‘approach’’ rather than a
paradigm (Morgan, 2007). According to Cameron (2011), pragmatism is a workable
approach that acts as a pier between paradigm and methodology. This approach
mainly concentrates on the idea of transferability and seeks to identify if the lessons
gained in one setting can be applied in another setting (Creswell, 2009; Morgan,
2007). This bring us to one of the essential aspects of pragmatism which is
knowledge contextualisation (Ruwhiu & Cone, 2010).
In addition, pragmatism considers the problem investigated in the research as
the most essential matter, appreciating utilizing both objective and subjective
interpretations to unearth the solutions to the research questions (Morgan, 2007;
Yvonne Feilzer, 2010). This attests to the pragmatism belief in complementarity,
which means that both qualitative and quantitative strategies can be incorporated to
‘‘complement’’ the strengths and weakness existent within each (Shannon-Baker,
2016). Pragmatism viewed from one side shatters the frontier between positivist and
constructivist paradigms. However, it establishes a link to both paradigms by
considering the meaningful parts in both paradigms (Biesta, 2010; Shannon-Baker,
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2016). Thus, pragmatism has been identified as a suitable paradigm to convene
mixed methods research (Cameron, 2011; Creswell & Clark, 2007; Everest, 2014;
Parvaiz et al., 2016; Tashakkori & Teddlie, 1998). Pragmatism essentially uses
“abductive’ thinking, which shifts back and forth between an inductive
(interpretivism) and a deductive (positivism) mode of thinking (Morgan, 2007).
However, deploying a pragmatism approach in research has some challenges
and difficulties which include the following:
Pragmatism is a time consuming approach and needs high commitment
levels from the researcher (Tuyet, 2016). In doing so, sensible essence for the
points of similarities and points of contradictions between both data sources
can be established (Morgan, 2007).
It needs the researcher to establish an equilibrium between the objective
quantitative (deductive) data and the subjective qualitative (inductive) data.
Thus, the researcher will be able to take the merits from both types of data
(Creswell, 2009).
3.2.1.5 The paradigm applied in this PhD research
Identification of the research questions is a valuable starting point in
considering research philosophies (Abernethy, Chua, Luckett, & Selto, 1999).
According to Tuli (2011), the paradigm is the key framework of reference that
directs the investigator. Selection of a single paradigm narrows the vision to
investigating only those phenomena it identifies in detail (Monti & Tingen, 1999).
Selection of a single paradigm not only directs the choice of research methods but
also results’ explication (Neuman & Kreuger, 2003).
A pragmatist paradigm was adopted in this research for the following reasons:
The focus of the researcher was on answering the research questions raised in
this thesis using workable approaches (Everest, 2014; Mackenzie & Knipe,
2006; Patton, 1990).
The majority of the extant previous research about MNC has almost entirely
used the positivist scientific approach. As noted earlier in this chapter, the
positivist scientific approach fails to capture the context (Tomoaia-Cotisel et
al., 2013). It has been identified that detaching a phenomenon from its
69
context is frequently regarded as a mode of objective and scientific research
but in researching healthcare complex phenomena, the scientific mode of
creating novel and new information should be enhanced and made whole by
considering the context (Tomoaia-Cotisel et al., 2013). Contextual
considerations understandably characterise the pragmatic paradigm, which
has been adopted in the current research (Ruwhiu & Cone, 2010).
Pragmatism “as the philosophic partner of mixed methods research”
represents a practical resolution to complex research issues (Johnson &
Onwuegbuzie, 2004). Thus, it helps give a more in depth understanding of the
missed nursing care issue than if just a single approach (qualitative or
quantitative) were used (Shannon-Baker, 2016).
The pragmatism approach shares essential attributes with Complexity Theory
which was used as a framework in this research. These attributes comprise
contextual sensitivity, emphasis on and appreciating of various knowledge
forms for better comprehension of events and systems, creation of useful
information, repudiation of reductionism approach to research, concentrating
on applied research, viewing the research as lifelong learning process, and
appreciating the insights of various healthcare stakeholders (democratization
of knowledge) (Long, McDermott, & Meadows, 2018).
As explained in Chapter 1 in this thesis, complexity theory was used to direct
the inquiry in this PhD study. Complexity theory comprises a group of overlapping
and complimentary theories that describe complex system behaviour in several
sciences (Chaffee & McNeill, 2007). By definition, complexity is an explanatory
concept used to describe change and operations in the social systems (Baghbanian &
Torkfar, 2012). Complexity theory offers an alternative to existing paradigms,
assisting in examining the patterns and the interactions among them (Chaffee &
McNeill, 2007). Despite the reliance of healthcare provision on the interactions
between individuals and processes, the traditional healthcare management theories
do not consider these interactions (Plsek & Wilson, 2001).
Investigating healthcare systems using complexity theory is a an emerging field
in healthcare research (Holland, 2012). According to complexity theory, healthcare
organisations are Complex Adaptive Systems (CASs) (Begun et al., 2003). The CAS
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consists of several independent agents including people and processes that react
according to local circumstances (Holden, 2005; McDaniel & Driebe, 2001). The
CAS encapsulates various defining features, including sensitivity to initial conditions
(Rickles, Hawe, & Shiell, 2007), tendency of the agents to self-organise using simple
rules in a non-linear manner (Holden, 2005; McDaniel & Driebe, 2001), emergence
(Rickles et al., 2007), and dynamic interaction with multiple feedback loops
(Anderson & McDaniel Jr, 2000). In this perspective, research methods that
foreground these distinctive features, such as case studies, are well suited to examine
such level of complexity in the healthcare organisations (Anderson, Crabtree, Steele,
& McDaniel Jr, 2005).
Before addressing the research design and research strategies adopted in this
research, a background about the research setting will be presented in the next
section.
3.3 INSTITUTIONAL BACKGROUND OF RESEARCH SETTING
Clinical practice of the nursing staff can be shaped by the setting they are
working in (Harrison & Mills, 2016). The hospital chosen as a study site in this
research is a public acute secondary hospital located in Brisbane, Australia, which
has been chosen based on convenience recruitment/ collaboration of the nursing
management. The hospital inpatient bed capacity is 180 beds with a further 38 bed
alternatives. In September 2017, the average daily census recorded 90% occupancy
of the available 180 beds (i.e. a daily average of 162 patient occupancy). The number
of nursing staff employed in the study hospital is close to 767, which includes
casuals, relief staff, and assistants in nursing. The number of Full Time Equivalents
(FTEs) for Registered Nurses (RNs) and Enrolled Nurses (ENs) is close to 560
(Source: communication with the DON). The percent of Enrolled Nurses (ENs),
Registered Nurses (RNs), and Clinical Nurses (CNs) from total FTE in the hospital
in the year 2017 was about 3%, 77%, and 20% respectively.
The study hospital has an Emergency Department (ED) and endoscopy unit
which were opened in 2013. The study hospital delivers a variety of healthcare
services; both inpatient and outpatient. Inpatient services include: general medicine,
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general surgery, and other specialist services such as gynaecology, orthopaedics,
rehabilitation services, and urology (Source: communication with the DON).
In the 2016-2017 financial year, the study hospital supported:
• 31, 379 inpatient admissions;
• 155,125 outpatient appointments;
• 56, 421 emergency department presentations (Source: communication with
the DON).
According to Clinical Services Capability Framework (CSCF) version 3.2
(Queensland Health, 2014) for public hospitals in Queensland (which can be defined
as one patient safety tool used to designate the clinical and support services
according to the level of service capability), the study hospital has score level 5 in the
medical and surgical services it provides for its patients. Level 5 in CSCF has the
following criteria:
Treats the majority of extremely complicated cases and performs the highly
complicated interventions.
Performs as a referral centre for the majority of complicated services that
need a level 6 service.
Involves teaching and a robust association to university and many pledges for
research with both local centres and multi-centre research (Queensland
Health, 2014).
At the time of performing the study, the hospital was undergoing the American
Nurses Credentialing Centre’s (ANCC) Pathway to Excellence Program (ANCC,
2019). This program acts like a framework that aims to help the hospital to improve
and maintain an optimum practice environment. It also provides quality check
processes for the purpose of sustaining excellence. This program advocates six
standards, namely: shared decision making, leadership, safety, quality, well-being,
and professional development (Dans, Pabico, Tate, & Hume, 2017). The hospital in
this research study also complied with the Queensland Health mandated nurse
staffing ratios in medical and surgical wards started in 2016 (Forrester, 2016).
Therefore, the chosen research setting is a place where high quality services are
valued by the organization as they are working towards maintaining and improving
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their services and working conditions. The following section describes the research
design and research strategy followed to achieve the objectives of this research.
3.4 RESEARCH DESIGN
A study design is the route through which the researchers can gather, analyse
and deduce observations. It can also be referred to as a comprehensive model that
leads the researcher in the different research phases (Degu & Yigzaw, 2006). This
research adopted mixed methods design, particularly convergent parallel mixed
methods, also known as triangulation design (Creswell & Plano Clark, 2011).
Justification for use of mixed methods design
The complex nature of the healthcare system imposes a requirement on
healthcare researchers to apply a design that more holistically captures the
multidimensional and complex healthcare issues under investigation (Creswell &
Plano Clark, 2011). According to Pope and Mays (1995):
“because health care deals with people and people are on the whole more complex
than the subject of the natural sciences, there is a whole set of questions about
human interaction and how people interpret interaction which health professionals
may need answers to (p43)”.
As a result, mixed methods design in healthcare research became the most
accepted design approach to such research (Bowers et al., 2013). Mixed-method
design has been referred to as multi-strategy design by Bryman (2004) and it has
been considered as an alternate to performing either quantitative or qualitative
studies alone (Teddlie & Tashakkori, 2009). Mixed methods design allows the
researcher to obtain a detailed and comprehensive understanding of the studied topic
by incorporating both quantitative and qualitative data (Teddlie & Tashakkori, 2009).
Basically, quantitative research (mainly deductive) comprises the gathering and
analysis of numerical information, while qualitative research (mainly inductive)
involves storyline, descriptive or empirical data (Hayes, Bonner, & Douglas, 2013).
Quantitative data is usually gathered using methods such as tests and closed ended
surveys (Zohrabi, 2013). However, qualitative data is typically gathered using focus
groups, interviews (Creswell & Creswell, 2017), and open ended surveys (Zohrabi,
2013). Quantitative research aims to provide answers to the questions ‘how many’ or
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‘how much’. However, qualitative research aims to answer questions regarding the
‘what’, ‘how’ or ‘why’ of the studied phenomenon (McCusker & Gunaydin, 2015).
Quantitative research is said to be objective (Goertzen, 2017) while qualitative
research is seen as subjective (Percy, Kostere, & Kostere, 2015).
The researcher decided to use mixed methods design in this research for the
following reasons:
Mixed methods design can provide more holistic understanding of missed
nursing care, which is a complex and multidimensional healthcare
phenomenon. It was expected that the mixed-methods approach would yield
more comprehensive information than could be generated using just a mono-
method approach (either quantitative or qualitative) (Fawcett, 2015; Fetters,
Curry, & Creswell, 2013)
Mixing both types of data represents an advantageous point as the
weaknesses in one research approach can be counteracted by the strengths of
the other approach in mixed methods design (Kaur, 2016)
Complementarity can be employed. Complementarity means the findings
from one method are used to elucidate, augment and intricate the findings of
the other method. Thus, both data type should be viewed as complementary
rather than substitutable (Santos et al., 2017).
Triangulation of data from several sources can enhance the validity of the
findings and strengthen the research conclusion (Olsen, 2004).
Mixed methods design allows for data contextualising (Kaur, 2016).
This mixed methods study was designed to address the research questions
raised in this research. This research adopted a convergent parallel (triangulation)
mixed methods design by which the quantitative and qualitative data were collected
simultaneously and in the same phase during the research process, both data sets had
the same priority and were kept independent in the analysis stage (Creswell & Plano
Clark, 2011). The findings of both data were amalgamated in the inclusive data
interpretation (Creswell & Plano Clark, 2011), which could be called merging
(Creswell, Klassen, Plano Clark, & Smith, 2011) or integration of data (Creswell,
Fetters, & Ivankova, 2004). In doing so, the findings from qualitative and
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quantitative data were interpreted by comparing and contrasting for the purpose of
strengthening the credibility of the findings. This procedure has been regarded as an
essential feature in mixed methods research. In the absence of data interpretation and
triangulation, the generated information would correspond to results drawn from a
qualitative and a quantitative study which had been carried out separately, instead of
obtaining comprehensive findings (O’Cathain, Murphy, & Nicholl, 2010). However,
based on the centrality of the MISSCARE survey to answer the research questions
raised in the current PhD research, this study was considered as a quantitative
dominant mixed methods study. An illustration of the research design of this PhD
study is given in Figure 3.1.
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Figure 3.1. Convergent Parallel Mixed Methods Design
Adopted from Creswell (2013)
3.5 RESEARCH STRATEGY
Research strategy is one aspect of research methodology (Wedawatta, Ingirige,
& Amaratunga, 2011) Research strategy is the overall plan designed to answer the
research questions and achieve the research objectives (Saunders, 2007). Examples
of popular research strategies in management research include: experiment, survey,
action research, grounded theory, case study, ethnography, phenomenology, and
Descriptive Content Analysis Statistical Analysis
Content Analysis (Directed approach)
Descriptive Case Study (Study 3)
Quan
Qual
Data Collection Results (Data Analysis) Data Collection
Overall integration of results (Triangulation)
Secondary Data from the study hospital (Clinical
Incidents qualitative reports, Falls, Medication Incidents)
(Study 1) MISSCARE Survey (Study 2)
Patient Satisfaction Data, Nursing engagement data,
and Clinical Incidents summary data (Study 1)
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archival research (Collis & Hussey, 2013). The current research adopted three
research strategies as follows:
Study 1: Secondary Data Analysis.
Study 2: Nurses’ MISSCARE Survey.
Study 3: Descriptive Case Study.
3.5.1 Study 1: Secondary Data Analysis to provide context information about the study hospital
Study 1 in this research was a secondary analysis of routinely collected quality
and safety data from the study hospital. The aim of this study was to identify
contextual features in the study hospital so as to obtain a holistic understanding of
MNC phenomenon. Considering the contextual features is paramount in healthcare
research as it permits an in-depth comprehension of what occurred on the ground and
the reasons for it happening (Stange & Glasgow, 2013).
The data collected in this study included Patient Satisfaction Data, Nursing
Employee Engagement Data, and Clinical Incidents Data from the study hospital.
The following section provides details related to the theoretical aspects of secondary
data analysis and describes the nature of data obtained in this study, justifies the use
of this data, and defines the data collection and analysis procedures followed in this
research.
3.5.1.1 Background on Secondary Data Analysis
Secondary data analysis can be defined as “Analysis of data that was collected
by someone else for another primary purpose” (Johnston, 2017, p. 619). Population
census, government surveys, and administrative records represent examples of
numeric data that are suitable for secondary analysis (Smith & Smith Jr, 2008).
Secondary data analysis has been identified as a rich source to answer research
inquiries in the nursing field (Dunn, Arslanian-Engoren, DeKoekkoek, Jadack, &
Scott, 2015). However, secondary data analysis is a still underutilized research
strategy in nursing research due to nursing researchers having limited knowledge on
the availability of the data, access to data and insufficient skills to manipulate the
data (Aponte, 2010).
Generally, there are two strategies that can be utilized to analyse existing data:
research question driven, and data driven (Cheng & Phillips, 2014). The difference
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between them is that in the first one the researcher mines a particular dataset to
answer an a priori theory or predetermined research question. In the second one, the
data driven approach, the researcher looks through variables in a certain dataset, and
determines the types of research questions that can be answered by the existing data
(Cheng & Phillips, 2014). Both strategies can be used together and iteratively.
Generally, the researcher begins with a general concept about the theory or research
question and searches for the most suitable dataset to answer the predetermined
research question. However, if the dataset including the variables of interest can’t be
accessed, then adjustment of the research question or analysis strategy could take
place depending on the present data (Cheng & Phillips, 2014).
The use of secondary data offers several advantages. The advantages of
secondary data use in research include the following (Burns & Grove, 2003; Cheng
& Phillips, 2014; Doolan & Froelicher, 2009; Dunn et al., 2015; Goode, Crego, Cary
Jr, Thornlow, & Merwin, 2017; Hussein et al., 2011; Rew, Koniak-Griffin, Lewis,
Miles, & O'Sullivan, 2000; Tripathy, 2013; Windle, 2010):
It takes less money, time and other resources as well as ethical considerations
than primary data analysis.
It gives an opportunity for the researcher to get access to information related
to large sample populations in the cases where direct approaching of this
large sample is not possible.
It has no or minimal risk to the participants, given the data was provided in
de-identified format.
It gives crucial groundwork (context) for subsequent studies, which allows
for better elucidation of nursing events or phenomena.
Despite having advantages, secondary data analysis has several caveats. One
major caveat of the analysis of secondary data is that the people who are interpreting
the data usually are not the same people as those who collected the data. Thus, they
might be less alert toward glitches in the data collection which may be essential to
understanding particular variables interpretation (Cheng & Phillips, 2014; Johnston,
2017). Another caveat for secondary data is that due to the descriptive nature of most
secondary data sets, causality establishment cannot be always investigated (Dunn et
al., 2015).
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Despite time saving being viewed as an advantage for secondary data analysis,
in this research there were considerable obstacles encountered by the researcher in
obtaining ethics approval to get the secondary data from the study hospital in order to
achieve the objectives of this research about MNC due to the sensitive nature of the
data requested. However, the value that these data added to the overall research and
holistic understanding of MNC was well worth and outweighed these difficulties. It
was acknowledged that the research objectives would not be achieved without the
researcher having access to this dataset. Investigation of missed nursing care using
this data has not been previously undertaken by researchers in this field and thus has
been viewed as an innovative analytical approach. According to Dunn et al. (2015)
“high-quality secondary data analysis can provide valuable evidence to increase
nursing knowledge, guide evidence-based nursing care, and contribute to health care
policies (p1305)”. In doing so, secondary data analysis (combined with the objective
survey data) made a contribution to the progression of current knowledge about
MNC and provided a base that can be used to design interventions to reduce its
occurrence.
3.5.1.2 Nature of Secondary Data and Data Collection Procedures
After obtaining ethical approvals to perform the study, the researcher
approached the hospital to ask for the secondary data that was planned and approved
to be used. The Director of Nursing (DON) in the study hospital provided the
secondary data in de-identified format. The data obtained involved three
components:
1. Patient satisfaction survey data for the whole hospital for the year 2017, and patient
satisfaction survey data for medical and surgical wards (years 2016 and 2017).
Patient satisfaction survey data was provided in printed and electronic format.
The Patient Satisfaction Survey is an essential indicator for quality healthcare
(Cordeiro, Kirwan, Riklikiene, Rengel Diaz, & Pilar Fuster, 2018), used to assess
patients’ satisfaction with the overall quality of care the patients received in the
healthcare service during their most recent admission (Queensland Government,
2014). Patient satisfaction surveys give information about patient centred care
provision in the hospitals (Cordeiro et al., 2018). Patient satisfaction surveys also
permit the healthcare facility to identify aspects of care that need improvement
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(Batbaatar, Dorjdagva, Luvsannyam, Savino, & Amenta, 2017). Patient satisfaction
surveys also allow for prioritising quality healthcare enhancement strategies in the
hospitals (Government, 2017). According to Cordeiro et al. (2018), patient
satisfaction data are valuable in identifying missed care incidents in hospitals.
The patient satisfaction survey is conducted in the study hospital once per year
in the month of May by Best Practice Australia, which is an independent research
company located in Brisbane. Participants in the patient satisfaction survey are
patients who are admitted to the study hospital (Paper-based survey). The instrument
used in the patient satisfaction survey includes a blend of both quantitative and
qualitative questions (Source: Communication with Best Practice Australia).
Despite its value in evaluating the quality of healthcare provided in the hospital
and identifying missed care incidences, the findings of the patient satisfaction survey
are subject to a group of methodological limitations. Firstly, because of the
subjective nature of the patient satisfaction survey, the findings of the survey are
potentially affected by factors the healthcare service does not have control over, for
instance, individual characteristics, patients’ anticipations, and patients’ judgments
on certain care elements (Coulter, Fitzpatrick, & Cornwell, 2009; Mishra & Mishra,
2014). Patients are usually satisfied when the performance of the healthcare facility
corresponds to their expectations (Batbaatar et al., 2017). Secondly, patient
satisfaction survey findings are likely to be affected by seasonal variations. For
example, the number of patients admitted to the hospitals reduced in summer. Also,
the number of healthcare providers during summer are fewer than those in winter
times, which may impact patient perception about the provided care (Salin,
Kaunonen, & Aalto, 2012). Thirdly, patient satisfaction results are influenced by the
patient Length of Stay (LOS). Patients with different LOS might have different
perceptions regarding their disease severity, emotional wellbeing, and health status
improvement (Tokunaga & Imanaka, 2002).
2. Nursing Employee Engagement Survey data for medical and surgical wards for the
year 2015. Nursing Employee Engagement Survey data was provided in printed and
electronic format. In this context, it should be noted that staff engagement surveys
are performed for different healthcare professionals working in hospitals. In this
study we obtained staff engagement data related to the nursing cohort from the study
hospital who participated in the survey.
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Nursing employee engagement data was used in this research as it provides
information about nursing staff morale, management support to nursing staff, as well
as type of culture in the healthcare organisation that may influence missed care
incidences (Cordeiro et al., 2018). The nursing employee engagement survey is
conducted by Best Practice Australia, and all staff eligible to be included in the
survey are sent an online survey bi-annually. In the study hospital the Nursing
Employee Engagement Survey is conducted over a 2-week survey census period.
Depending on response rates this may be extended to 3 weeks and sometimes they
are extended to a maximum of 4 weeks if the response rate is deemed to be
unsatisfactory. The Nursing Employee Engagement Survey data comprises both
quantitative and qualitative questions (Source: communication with Best Practice
Australia).
3. Clinical incidents data (falls, medication incidents, and pressure injuries).
Clinical incidents data can give a background that illustrates the impact of
modifications to nurses’ factors, such as nurse staffing ratios, skill mix, and practice
environment, on patient healthcare results (Myers, Pugh, & Twigg, 2018). Also, they
help in identification of issues related to healthcare delivery (Holden & Karsh, 2007).
As MNC is an issue of healthcare delivery which has a strong link with the practice
environment and patient healthcare results, it was found important to use this data as
it enabled identification of MNC episodes in the involved hospital (Cordeiro et al.,
2018). To contextualise the findings of clinical incidents data, a contextual backdrop
to the clinical incident management system in Queensland’s healthcare is provided
next.
In the Queensland healthcare system “adverse events”, related to harm
resulting from provided healthcare, are identified as “Clinical Incidents”. The
purpose of giving adverse events this designation was to promote patient safety and
to allow for detecting systemic issues in Queensland healthcare organisations (Singh,
2015). According to the Best Practice Clinical Incident Management Guide for
health services in Queensland (Queensland Health, 2014), introducing a system to
identify and report patient safety incidents is a mandatory procedure as required by
the National Safety and Quality Health Services Standards policy and is a
requirement for hospital accreditation. Incident reporting that helps in identification
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of factors leading to incidents can result in improved understanding of practices and
recurrent risk factors in the system that, in turn, can improve the overall safety of the
healthcare system and assist in turning the hospital culture into a learning culture
(Queensland Health, 2014).
Incidents reporting is voluntary in nature. It appears that staff are motivated to
report clinical incidents in the belief that they will receive administrative and
managerial support to prevent such incidents from occurring in the future. Incident
reporting permits involvement and sharing of responsibilities between the nursing
staff and hospital nursing management and thus allows for taking remedial action.
Nurses are also likely to gain valuable feedback on their performance and expect that
the clinical incidents that they’ve reported will be resolved to prevent such cases
from occurring in the future (Paiva et al., 2014). Hence, clinical incident reporting is
a key element for patient safety improvement, because there is an opportunity for
nursing staff and their managers to learn from the various incidents reported
(Andrew, 2007). Another benefit to incident reporting is the opportunity to enhance
safety culture in the healthcare organisation (Queensland Health, 2014).
A Patient safety: From Learning to Action report published in 2012
demonstrated a substantial increase in the number of clinical incidents voluntarily
reported by the healthcare staff in Queensland. Since 2005, the rate of clinical
incidents reporting increased by 139% according to this report (Queensland Health,
2012). In the same report, increased reporting rates were found to be related to
keeping the clinical incident reporting system as a voluntary process in Queensland
(Queensland Health, 2012), which enabled the healthcare culture to move toward a
blame free culture.
Clinical Incidents reporting processes in Queensland typically include
completing an incident report form that can be done on paper or in electronic format
as soon as practical after the occurrence of an incident. Clinical incidents reports
must contain several pieces of information including: patient name, ID, patient age,
gender, time and location of the incident, witness details, brief, factual description
for incident, the resultant harm if any, action taken, and recommendations to reduce
or prevent the occurrence of similar events, and reporting person details such as
name and contact details (Queensland Health, 2014).
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However, the main limitation of clinical incidents reports data was the
possibility of missed and insufficient data about the incidents that would hinder the
identification of the actual contributing factors attributed to the occurrence of adverse
incidents (Hignett, Sands, & Griffiths, 2010).
The clinical incidents data from the study hospital included summary data that
was incorporated in the hospital management report. However, the data also included
a qualitative description of the details of the events reported, which acted as a rich
source of information on the incident and its causes. Clinical incidents data represent
the incidents that have been reported to the hospital reporting system. Clinical
incidents data had been reported by the PRIME incident reporting system which was
replaced in August 2017 with Risk Management Software System (RiskMan).
RiskMan is the most widely used clinical incident reporting software in Australia
(Lederman, Dreyfus, Matchan, Knott, & Milton, 2013).
Clinical incidents data related to Falls, medication incidents and pressure
injuries have been chosen in this research for the following reasons:
They represent the most common types of adverse incidents in the
Australian hospitals (Roughead & Semple, 2009).
They are directly affected by nursing care (nurse sensitive patient
outcomes). Thus, they can reflect nursing care quality (Armstrong,
Reale, & Federation, 2009; Myers et al., 2018).
They are among the incidents associated with the highest patient
harm rate in the Australian context (Australian Council for Safety and
Quality in Health Care, 2012).
Preventing these incidents is amongst the ten standards for National
Safety and Quality Health Service in Australia (Australian
Commission on Safety and Quality in Health Care (ACSQHC),
2011).
Clinical incidents data were provided in an anonymous electronic format and
for the following time periods:
Falls incidents: they were provided as a three-year report (1st January 2015 - 31th
July 2017).
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Medication incidents: they were provided as a two-year report covering the period
from October 2014 to November 2016 (detailed report). For the year 2017, they
were provided as a monthly report (summary and detailed report) covering the
period from January 2017 until November 2017.
Pressure injuries: they were provided as a single summary report for the period
2015-2017.
An example of the format of this data can be seen in Figure 3.2. The example
provided in figure 3.2 is related to falls incidents reports. Medication incidents
reports also have similar format.
Figure 3.2. Falls incidents report format
Source: Falls incidents data from the study hospital
3.5.1.3 Secondary Data Analysis Methods
After obtaining the data, the researcher read the dataset to familiarize herself
with the nature of the data and to identify the ways that could be used to answer the
current research questions relying on the data. Based on this, the researcher decided
to perform content analysis for the data obtained. Content analysis (also known as
analysis of documents) is a research technique that is capable of providing valid and
reliable extrapolations from data into their particular setting. Therefore, content
analysis gives the opportunity for the researcher to examine theoretical matters
(Cavanagh, 1997), and thus is a valuable method for giving information, new
perceptions, depiction of realities, and designing a practical plan to perform proper
interventions (Elo & Kyngäs, 2008). By performing content analysis, words can be
distilled into categories that have similar meanings (Cavanagh, 1997). It has been
identified that using content analysis is tremendously suited for analysing nursing
related complex and sensitive phenomena (Elo & Kyngäs, 2008).
Descriptive content analysis was used to analyse patient satisfaction data,
nursing employee engagement data, and clinical incidents summary data. The data in
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these surveys that related to the aim and objectives of this research were summarized
and reported using basic descriptive statistics such as frequencies and percentages.
However, regarding the qualitative descriptions in the clinical incidents reports,
they were analysed using directed approach to content analysis (Hsieh & Shannon,
2005). Directed approach to content analysis can also be called framework content
analysis (Gale, Heath, Cameron, Rashid, & Redwood, 2013). Directed approach to
content analysis refers to qualitative data assessment using a structured approach and
relying on previous research or previous theory (Hsieh & Shannon, 2005). Contrary
to the thematic qualitative analysis that is inductive in nature, a directed (framework)
approach to content analysis is a deductive analytic approach (Hsieh & Shannon,
2005). Deductive reasoning is an analytic process by which the investigator starts
with an established framework or theory. The concepts are condensed into variables
and then the investigator collects the data to evaluate or examine if the framework or
theory are underpinned (Burns, 2005).
The content analysis of the clinical incident textual descriptions in this research
has been guided by the Systems analysis of clinical incidents: the London Protocol
(Taylor-Adams & Vincent, 2004). This protocol represents a structured tactic which
allows one to reflect on the contributory factors (and their subcategories) that affect
the clinical practice and lead to clinical incidents occurrences (Vincent & Amalberti,
2016). According to this system, factors that result in incidents are placed in one
broad framework, which includes seven types of factors: patient factors, task and
technology factors, individual staff factors, team factors, working environmental
factors, organisational factors, and the wider institutional context factors (Taylor-
Adams & Vincent, 2004). Clinical incident analysis reveals the deficits and shortfalls
in the healthcare system they occurred in. To put it in another way, clinical incidents
perform as a window on the system (Vincent, 2004). In this research, the qualitative
data descriptions of the clinical incidents were read and were coded into clusters
based on London Protocol framework (Taylor-Adams & Vincent, 2004), which
resulted in identification of the contributory factors (and their subcategories) for the
incidents (falls and medication errors) in the study hospital. Illustrative quotes from
the incidents descriptions were also provided.
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3.5.2 Study 2: Nurses’ Attitudes toward missed nursing care
Study 2 was a quantitative survey with the nurses in the general medical and
surgical wards in the involved hospital. The aim of this study was to quantify missed
care elements and to identify reasons for missed nursing care in medical and surgical
wards in the study hospital. The survey that was used in this study was the previously
validated MISSCARE survey (Kalisch & Williams, 2009).
3.5.2.1 Background on survey research
Survey research can be described as gathering information from a group of
individuals (sample) by responding to questions (Check & Schutt, 2011). The survey
is a data collection tool that is used to perform survey research (Glasow, 2005). It is
worth noting that survey is a research strategy not a research method (Denscombe,
2007). The purpose of a survey as a data collection tool is to capture and understand
participants’ attitude, knowledge and behaviour at a point of time or to compare
variances taking place over time (Duffett et al., 2012).
There are several strengths and weaknesses of conducting survey research. In
regard to the strengths, survey research generates knowledge relying on actual world
observations; generates knowledge based on a representative sample, which enhance
the generalisability of the findings; and generates knowledge on multiple variables in
a limited period and with less expense (Mathers, Fox, & Hunn, 2007). Nevertheless,
the weaknesses of such types of research mainly relate to lack of depth as there is
there is no understanding of why people do what they do in survey research (Hox &
Boeije, 2005; Kelley, Clark, Brown, & Sitzia, 2003).
As per the finding by Badger and Werrett (2005), the mean response rate for
surveys in nursing research in Australia and New Zealand was 60% (SD =32). Thus,
the researcher adopted the survey as the quantitative data collection tool in this phase
of the current research.
3.5.2.2 Study Design
Study 2 was a cross sectional study using the MISSCARE survey tool (Kalisch
& Williams, 2009). Cross-sectional studies are used to assess the relationships or
correlations among particular events at a single point in time, which facilitated the
objective of this research (Mathers et al., 2007). They are characterized by being an
86
effective way of gathering large amounts of data related to the issue under
investigation (Polit & Beck, 2008). However, as the cross sectional studies give only
a snapshot of the studied event or phenomenon, so the findings may differ if the
same study were conducted in another time period (Levin, 2006).
3.5.2.3 Data collection instrument - MISSCARE survey
The MISSCARE Survey (Kalisch & Williams, 2009) used in this research
consists of an introductory section followed by a two-section Likert type scale
(sections A and B) (see Appendix 3 on page 281). The introductory part involves a
total of 20 questions, including demographic information, such as name of the unit
the nurse is working in, their age, gender, education level, experience in the current
role, experience in the current unit, and job title. It also includes questions about
working conditions of the nurses, such as working hours, shift length and overtime.
Furthermore, the introductory section in the survey includes questions about nurse
staffing, such as nurse perceived staffing adequacy, the number of patients cared for
in the current or last shift, and number of admissions and discharges. Finally, the last
three questions in the introductory part in the survey are about the level of nurse
satisfaction with the current position, nurse satisfaction with being a nurse, and nurse
satisfaction with the level of teamwork in the current working unit. Using a Likert
scale type, which ranges from very satisfied to very dissatisfied, nurses are asked the
following questions:
How satisfied are you in your current position?
Independent of your current job, how satisfied are you with being a nurse or a
nurse assistant?
How satisfied are you with the level of teamwork on this unit?
Section A in the survey contains 24 items related to the elements of missed
nursing care, with answers ranging from always missed (5) to never missed (1).
Examples of nursing interventions in Section A in the MISSCARE survey were:
patient ambulation, patient turning, and assessment of vital signs. In order to obtain
the final score, answers need to be re-coded, with higher scores indicating higher
levels of missed care. The total score for missed nursing care may range from 24 (no
intervention has ever been omitted) to 120 (all interventions were always omitted)
(Palese et al., 2015). Section B in the survey comprises 17 items related to the
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reasons for not providing the care, with choices ranging from significant reason (4)
to not a reason for missing care (1). The total score for the MISSCARE Survey
reasons may range from 17 (no reason is significant) to 68 (all reasons are
significant) (Palese et al., 2015). Sections A and B in the MISSCARE survey can be
used independently (Kalisch & Williams, 2009).
Construct validity, internal consistency and stability (test-retest) analysis in two
samples of professionals (including 459 subjects in the first phase and 639 in the
second) was performed for the MISSCARE survey (Kalisch & Williams, 2009). Test
results showed that the MISSCARE Survey was a valid and reliable tool to assess
missed care. Cronbach α ranges from 0.64 to 0.86 indicated the construct validity of
the MISSCARE survey. This is a very low Cronbach alpha, the reason for this being
that the nursing context is so heterogeneous and very complex. Several studies
established the Inter-rater reliability of this tool as well (r 0.87 IC 95% 0.76–0.93;
p<0.001) (Kalisch et al., 2011; Kalisch & Williams, 2009). The official permission to
utilize the survey in this study was obtained from the developer, Professor Beatrice
Kalisch (See appendix 4 on page 293 for the permission letter).
The main reason for choosing a MISSCARE survey as a measure for MNC is
the fact this speaks about the care missed by a nursing work group as compared with
care missed by an individual nurse (Smith et al., 2017). In addition, the MISSCARE
survey differs from other survey tools used in this field such as BERNCA and TU-13
as it allows for an inclusion of more comprehensive reasons that could attributed to
the nurses for missing some nursing care.
3.5.2.4 Participants
The target of the researcher in this study was to approach nurses in the medical
and surgical wards in the study hospital. To achieve this goal, purposive sampling
technique was utilized (Tongco, 2007). Purposive sampling (also called judgmental
sampling) is a non-probability sampling technique that focuses on individuals with
certain features who can help provide a better understanding of the phenomenon of
interest (Etikan, Musa, & Alkassim, 2016). While purposive sampling technique is
typically used in qualitative research, it can also be used in quantitative research
(Tongco, 2007). The target population (who had the eligibility to participate in the
survey) comprised 200 nurses: Clinical Nurses, CNs, nurse grade 6; Registered
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Nurses, RNs, nurse grade 5; and Enrolled Nurses, ENs, nurse grade 3, employed in
medical and surgical wards (six wards were involved) in the study hospital during the
study period.
The researcher chose to focus purposefully on the medical and surgical service
line nurses or, as they are called, the adult health nurses (American Nurses
Association, 1974) for the following reasons (Fernández-Garrido & Cauli, 2017;
Winsett et al., 2016):
Medical and surgical nursing is a complex specialty that concentrates on
nursing care delivery for adults and has been identified as the main
foundation for the nursing profession.
Medical and surgical divisions represent the vast majority of the units in the
hospital.
Medical and surgical nurses provide holistic care to the patients which
includes several aspects: health promotion, recuperation, and preservation, as
well as prevention of illnesses, which allows for holistic assessment of MNC.
The researcher decided to restrict the sample to bedside nurses because nurses
working in managerial positions have a distinctive practice environment. Also, the
nurse managers might not provide accurate responses to the survey items as they do
not provide care at the bedside. Of the target population, 44 nurses responded to the
MISSCARE survey (response rate: 22%).
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3.5.2.5 Data collection procedures
Pilot study
Prior to conducting the actual survey, the researcher performed a small pilot
study (Levy & Lemeshow, 2013) with a convenience sample of nurses in a general
medical ward chosen by the DON in the involved hospital (n=5). The main goal of
this pilot work was to ensure that the terms used were appropriate to the needs of the
study population (Hazzi & Maldaon, 2015). The wordings and terms in the survey
needed to fit nursing conditions in Queensland as the survey was originally
constructed in the USA. According to Fowler (1995), the question and any answer
items in the survey should be obvious for both the investigator and the informant.
Changing the terms and wordings as necessary helps in eradication of ambiguities
thus minimizing the risk of methods bias (Podsakoff, MacKenzie, & Podsakoff,
2012).
The pilot study was performed in collaboration with the DON in the involved
facility who was asked by the researcher to recruit a number of nurses to be involved
in the study. No particular criteria were chosen for the nurses involved in this study
other than being employed in the involved hospital (in medical and surgical units).
The DON recommended one of the ward managers to recruit the nurses. Five nurses
participated in the pilot, which was performed in the tea room of one of the medical
wards after confirming that the nurses’ participation did not impede their nursing
work. They were informed that this was a pilot study and their feedback and
comments on the survey tool were asked for and no identifying information was
requested from the nurses participating in the pilot study. Some wordings and terms
in the survey were altered in response to their suggestions. The alterations to the
survey were considered minimal and mainly related to the nurses’ job titles and
degree of nursing education obtained.
The responses to two questions in the original MISSCARE survey were altered
based on the pilot study. These questions were questions number 4 and 7 in the
MISSCARE survey:
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Question number 4 in the original MISSCARE survey was:
If you are a nurse, what is the highest degree? 1) LPN Diploma 2) RN Diploma 3) Associate’s degree in nursing (ADN) 4) Bachelor’s degree in nursing (BSN) 5) Bachelor’s degree outside of nursing 6) Master’s degree (MSN) or higher in nursing 7) Master’s degree or higher outside of nursing
Based on the pilot study, the responses to this question were changed to:
1) AIN certificate from a registered Vocational Education and Training provider (e.g. TAFE).
2) EN-hospital trained Certificate. 3) EN/EEN –Certificate IV or diploma in nursing from a registered Vocational
Education and Training provider (e.g. TAFE). 4) RN-hospital trained Certificate. 5) Bachelor degree in nursing. 6) Bachelor degree in nursing and bachelor degree outside nursing (double
degree). 7) Post graduate diploma in nursing. 8) Post graduate diploma outside nursing. 9) Master’s degree or higher in nursing. 10) Master’s degree or higher outside of nursing.
Question number 7 in the original MISSCARE survey was:
Job Title/Role: 1) Staff Nurse (RN) 2) Staff Nurse (LPN) 3) Nursing Assistant (e.g., nurse aides/tech) 4) Nurse manager, assistant manager (e.g. administrators on the unit) 5) Other [Please specify: ___________________________]
The responses to this question were changed to:
1) AIN (Assistant in Nursing). 2) EN/ EEN (Enrolled Nurse/Endorsed Enrolled Nurse). 3) RN (Registered Nurse). 4) CN (Clinical Nurse). 5) CNC (Clinical Nurse Consultant). 6) Nurse Unit Manager (NUM). 7) Nurse Practitioner (NP). 8) Nursing Director. 9) Executive Director of Nursing (DON).
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Changes performed to these questions based on the pilot study were discussed
with and approved by the DON in the study hospital. As noted, the changes were
performed to fit the Queensland nursing context as the original MISSCARE survey
was constructed in the USA.
To summarize, in this study the researcher aimed to ensure that the survey
would yield reliable and valid information by:
Employing a validated and reliable data gathering tool, the MISSCARE
survey.
Performing a pilot study for the data collection tool used with members of
the actual target cohort in the studied context.
Main study
This study relied on electronic (email survey) and paper based MISSCARE
surveys. The electronic survey responses were gathered using Key Survey tool
available from QUT library services. Using an electronic survey is reasonably low
priced and is also practical for a large sample (population based survey) (Check &
Schutt, 2011). In addition, an electronic survey captures the information in an
electronic form which facilitates the process of data analysis (Jones, Murphy,
Edwards, & James, 2008). However, an electronic survey is characterized by lower
response rates than a paper based survey, which could be related to the fact that
access by the nursing personnel to the intranet is unforeseeable, presumably due to
intensive workloads (Luck, Chok, & Wilkes, 2017).
All nurses (ENs, RNs, and CNs) rostered to medical and surgical wards in the
study hospital were invited to be involved in the electronic survey.
The researcher sent the link to the survey along with the invitation email to the
Director of Nursing (DON) in the study hospital. The invitation email with the online
link to the survey was sent by the DON to the Nurse Unit Managers (NUM) in the
medical and surgical wards who described the study for their nurses and requested
they complete the survey in the handover times and department meetings. The
invitation email contained information about the project and the way to fill out the
survey, the estimated time for survey filling, and a link to the survey (see Appendix 5
on page 294). Including the survey link in the invitation email text rather than as an
attachment to the email has been proved to be a key strategy to increase the
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participation rate in the electronic survey mode (McPeake, Bateson, & O'Neill,
2014). Furthermore, the invitation email had a subject that told the nurses what
specifically was required from them, which was completing the survey in this case.
This strategy was also found useful in increasing the response rate for electronic
surveys (Ganassali, 2008).
A Participant Information Sheet (PIS) was included as a cover page to the
online survey to delineate study objectives and to notify the respondents about the
voluntary nature of the survey and that completing the online survey inferred consent
of the nurses to participate in the study. No incentives were provided to any of the
nurses for participation in the study. Also, the PIS included information about the
confidentiality of the nurses’ responses to the survey questions (see Appendix 6 on
page 295). Further details about ethical considerations undertaken in this study can
be found in Section 3.8 in this chapter.
The nurses were asked to click the survey link and complete the survey. No
specification on the place of survey completion was offered. Thus, the nurses could
fill it according to their convenience by using their smartphones or any other mobile
devices. They could also use their own computers or computers in the hospital to
open the link and fill in the survey. The nurses could save their responses to the
survey and get back to it later.
Response bias in this study was reduced by sending reminders to the nurses
half the way through (after two weeks) in order to maximize the sample size.
Sending reminders to the respondents helps in increasing the response rate (McPeake
et al., 2014). However, the concern in using the reminders is that the quality of data
may have been jeopardized by participants’ irritation at getting e-mail reminders
(Wyatt, 2000).
One month after the initial invite to complete the online survey, only 15 nurse
responders were recorded. Thus, the researcher approached the DON and discussed
the slow response rate with the DON in order to find strategies that could boost
nurses’ participation rates. Based on this, it was agreed that doing a paper-based
survey could increase the response rate of the nurses to the MISSCARE survey.
After distribution of paper-based MISSCARE surveys by Nurse Unit Managers
(NUMs) to the nurses, an additional 29 surveys were obtained. Thus, the number of
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surveys obtained overall in this study was 44 surveys. The completed surveys were
collected by the researcher from the DON who acted as a data collection point for
NUMs. Data for this study were collected from January to March 2018.
Obtaining of a representative sample in this study was hoped for based on the
steps undertaken in the data collection plan to maximize participation rate for the
nurses, such as confirming that the MISSCARE survey was understandable by doing
a pilot study, sending reminders to increase the response rate, and the anonymous
nature of the survey. Added to the collaboration of the DON in the study hospital,
these procedures to some extent could reinforce the external validity of the research
findings (Richardson-Tench, Taylor, Kermode, & Roberts, 2014).
3.5.2.6 Data analysis of the MISSCARE survey
Data obtained from the 44 surveys were inputted and analysed using the
Statistical Package for the Social Sciences (SPSS) software version 25 (Field, 2013)
Data analysis in this study involved two types of analysis. The first type involved a
descriptive analysis of the data. The second type included inferential statistics,
particularly Analysis of Variance (ANOVA).
Descriptive analysis
Descriptive statistics were used to provide a descriptive summary of the data
collected from the MISSCARE survey. Descriptive statistics included: frequencies
and proportions, which were used to obtain a description of sample characteristics
and working conditions (questions in the introductory part in the survey). The reason
for using such descriptive analysis was that ordinal data (questions in the
introductory part in the survey) did not encounter assumptions of means and standard
deviations used for interval/ratio data (Blackman et al., 2015; Grimby, Tennant, &
Tesio, 2012). Tabular and graphical illustrations were provided when appropriate.
For the purpose of statistical analysis of the MISSCARE survey data, numeric
values (codes) were assigned to response options in the Likert scale items. Regarding
section A (elements of MNC), the responses were coded as follows: always
missed=5, frequently missed =4, occasionally missed=3, rarely missed=2, never
missed=1. For section B (the reasons of MNC), the responses were coded as follows:
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significant reason =4, moderate reason=3, minor reason=2, not a reason for missed
care=1).
For the purposes of understanding the Likert scale responses for nursing
attitudes toward MNC, the researcher collapsed Likert scores into three categories:
Always and frequently missed were collapsed into a single category to
signify MNC.
Occasionally missed was treated as an individual category to signify neutral
response of the nurses to MNC.
Never and rarely missed were collapsed into a single category to signify
absence of MNC.
This method of collapsing was based on the suggestion of Schaeffer and
Presser (2003) that the midpoint in the Likert scale indicates indifference or
ambivalence. Thus, the Occasionally response to the Missed Care Survey was
viewed as giving an indication that nurses were uncertain regarding missing or not
missing the nursing care intervention.
Similarly, with the reasons for MNC (section B) in the MISSCARE survey,
significant and moderate reason were collapsed into a single category to signify a
reason for MNC, while minor and not a reason were collapsed into a single category
and signify not a reason for MNC. Frequencies and percentages for every nursing
care item in the MISSCARE survey (e.g. ambulation, turning, assistance in toileting)
and the potential reasons were reported.
Inferential statistics: One-way Analysis of Variance (one-way ANOVA)
The relationship between two variables can be assessed by comparing the
means of the dependent variable between two or more groups within the independent
variable (Venkatesh, Brown, & Bala, 2013). One- way Analysis of Variance (one-
way ANOVA) (Samuel & Neil, 2010) was used to answer research question number
three in this study, that is: “What are the individual nursing characteristics and work
conditions that influence MNC in medical and surgical wards in an acute care
hospital?”. A p-value less than 0.05 was considered to be statistically significant
(Parab & Bhalerao, 2010).
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3.5.3 Study 3: Descriptive Case Study
A descriptive case study was performed in a general medical /cardiac/
telemetry ward in the involved hospital by collecting data from several sources
(hospital data, patients’ and nurses’ surveys) over a two week period (22th January
2018–4th February 2018). According to Thomas (2011) and Gustafsson (2017), a
case study performed within one specific confined time frame to investigate a
particular event is called a “snapshot case study”. The aim of the case study was to
investigate missed nursing care in a comprehensive manner and to advance the
conceptual (theoretical) understanding of the missed nursing care phenomenon in a
medical ward context. Investigation at ward level has been identified as permitting
closer assessment of the predictors associated with the care context (Twigg et al.,
2015). This case study coincided with the time of performing the main MISSCARE
survey (Study 2). The following section provides a theoretical consideration for the
case study research followed by the data sources collected for the sake of this study
as well as the practical steps pursued by the researcher to execute the case study as
per the research strategy followed in this research.
3.5.3.1 Case Study Research strategy: Theory and Definitions
Case studies have been long established in healthcare and social sciences. The
case study also has an extensive history of use in medicine, anthropology,
psychology and education research (Zainal, 2007). Case study is a research approach
that incorporates complexity (Anderson et al., 2005; Hetherington, 2013). Thus, Case
study is considered as a pivotal research strategy to investigate healthcare systems
sophistication (Anaf, Drummond, & Sheppard, 2007). As MNC is a complex
phenomenon and is affected by several variables that are specific for every context,
such as staffing levels, practice environment, communication issues and patient
factors, the case study approach was selected to perform this part of the research.
According to Simons (2009), case study should not be viewed as a method by
itself but as a research design framework which might include several methods, or as
Rowley (2002) proposed, as a research strategy. Thus, there is no particular fixed
ontological, epistemological or methodological locus under which case study can be
classified (Luck, Jackson, & Usher, 2006; Mills & Birks, 2014). Hence, case study
research design has been considered as a flexible and pragmatic research strategy
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(Harrison, Birks, Franklin, & Mills, 2017) which allows for in-depth and holistic
investigation of phenomenon of interest in its real life settings (Abma & Stake, 2014)
where there is a lack of clear frontier between the studied phenomenon and the
context (Landrigan et al., 2010), such as in clinical contexts where performing
experiments could be impractical or unethical (Payne, Field, Rolls, Hawker, & Kerr,
2007). Hence, case study is frequently called the naturalistic design because it
investigates the phenomenon in its natural context (Crowe et al., 2011). Based on
this, and as this research has been positioned under the pragmatic approach, case
study was viewed as an appropriate research strategy to perform this part of the study
(Darke, Shanks, & Broadbent, 1998).
As cited in Harrison et al. (2017), the definition by Yin (2014) of case study as
an “empirical inquiry” revealed that case study includes creating an accurate case
study protocol that describes all case study elements in an accurate manner, giving
attention to the validity of the findings and possibility of bias presence (Yin, 2011).
One of the basic strength points of case study research, particularly a single case
study, is the ability to establish theory by extending constructs and associations
within distinctive contexts (Ridder, 2017). This point will be further discussed later
in this section.
There have been several definitions for the case study research design.
According to Simons (2009, p. 21), “Case study is an in-depth exploration from
multiple perspectives of the complexity and uniqueness of a particular project,
policy, institution, program or system in a ‘real life’ context.” According to Yin
(2003), case study is an idiographic rigorous investigation of an individual case in
order to grasp a larger picture of comparable units. Another definition for case study
was proposed by Woodside and Wilson (2003) as being an inquiry that concentrates
on depicting, recognising, predicting, and/or monitoring of the studied case. In case
study, the unit of investigation ranges from an individual to an institution (Yin,
1994). In this PhD, the unit of investigation was a general medical ward in an acute
care hospital.
Case study research strategy provides answers to “How” and “Why” questions
(Yin, 2003). Case study research depends on various sources of evidence. The reason
for this is that the focus in case study research is directed toward multiple variables
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rather than data points. As such, the data collected in case study is required to
converge in a triangulating way (Landrigan et al., 2010). Accordingly, this case study
sought to use multiple data sources, namely: secondary data, which included ward
and patient profile, nurse rostering information, clinical incidents data, and primary
data, which included patient and nurses MISSCARE surveys.
Despite how using multiple evidence sources in case study research can be
viewed as an advantage for the case study approach, which can enhance the research
findings by using various and robust evidence that allows for deeper understanding
of the phenomenon of interest (Heale & Twycross, 2018; Tumele, 2015), some
researchers regard this as a methodological drawback for the case study approach
(Taylor, Bogdan, & DeVault, 2015). The large quantity of data, combined with the
limited timeframe available for some researches may impact on the depth of analysis
of the data within the available time and resources (Crowe et al., 2011).
Case study design allows the researcher to use any type of data (quantitative
and/or qualitative) (Yin, 2013). It may include quantitative data or even be
completely quantitative (Ghauri, 2004), and may be frequently used in a prospective
manner. Documentation, archival records, interviews, direct and participant
observation, and physical artefacts are considered the main data sources for case
study research strategy (Yin, 1994).
Case study has been identified as having a contribution to make at any
knowledge level, which means it can answer exploratory, descriptive, and
explanatory research questions (Anderson et al., 2005). Exploratory case study aims
to explore and determine the purposes of any subsequent research. A descriptive case
study aims to describe the phenomenon of interest. An explanatory type aims to
reveal cause–effect associations of the studied phenomena (Yin, 2011). The case
study conducted as a part of this PhD research was a descriptive case study.
From the previous discussions, it can be identified that the case study approach
has several advantages, such as flexibility, relying on manifold sources of evidence
to gain a comprehensive and holistic understanding of the researched phenomenon,
and its capability to advance an existing theory. On the other hand, there has been a
major criticism directed toward case study research, which is generalization of case
study findings into other contexts, and hence it has been regarded as having limited
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validity (Gerring, 2007; Merriam, 2009). However, this criticism should not be
viewed as being a totally correct opinion (Patton & Appelbaum, 2003). It is true and
generally agreed that case study cannot do statistical generalization, which is one
type of empirical generalisation based on calculating frequencies and concerns in
generalizing the case study results into the population which the case or cases are
derived from (Patton & Appelbaum, 2003; Tsang, 2014). On the other hand, case
study can do analytical (theoretical) generalization which concerns building a new
theory or expanding and generalizing an already existing theory (Patton &
Appelbaum, 2003; Tsang, 2014). In addition, it has been argued that case study can
give valuable knowledge to evaluate the statistical generalizability of the findings
(Tsang, 2014).
The current study relied on a single case (Mohajan, 2018). Despite how using a
single case could be regarded as a caveat that hinders the generalizability of the
findings into another context, as previously discussed, viewing it as a naturalistic
design (case study), it should not be assessed upon its generalizability but upon its
comparability and transferability with and into other settings. In other words, the
extent to which the outcome of one study can be compared and transferred into other
settings. In doing so, detailed description of the study context and the methods used
in the current case study have been provided. It also can be argued that case study
strategy fits the heterogeneous nature of nursing practices where there are significant
variations between different nursing contexts, and thus, generalisations of results are
frequently difficult.
3.5.3.2 Study setting
A nursing unit is a micro-organization in the hospital health care system, and
units of different types vary in patient care goals, clinical tasks, role expectations,
and social structures and norms (Ma, Olds, & Dunton, 2015).The unit is the smallest
organizational section where the ultimate effect of the decisions of government and
institutions about resources allocation takes place (Duffield, Roche, Diers, Catling‐
Paull, & Blay, 2010). According to Swiger et al. (2016), the unit is the immediate
setting for provision of care entrenched in the hospital system, which is larger and
more sophisticated. This study was performed in a 29- bed inpatient general medical/
Cardiology/ Telemetry ward in an acute care tertiary hospital. In this ward, there
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were ENs, RNs, and CNs of different professional experiences employed. A total
FTE cohort of 50 ENs, ENAPs, RNs, and CNs presented on this ward as possible
participants for the study. Nurse to patient ratio in the studied ward was 1:4 in the
morning and afternoon shifts, and 1:7 in the night shift.
The reason for choosing a medical ward to perform the case study was due to
the nature of patients in these wards, who were characterized by the presence of co-
morbidities and complicated conditions. Patients attending medical wards have a
higher level of dependency on nurses’ care than in other wards (Higgs et al., 2017).
Moreover, patients in medical wards are characterized by high Length of Stay (LOS).
Thus, patients are better able to recognize nursing care elements such as patient
teaching and individualized care (Kol, Arıkan, İlaslan, Akıncı, & Koçak, 2018). It
has been suggested that the LOS has a direct influence on the patients’ insights about
nursing care quality (Edvardsson, Watt, & Pearce, 2017).
3.5.3.2 Data Sources
The researcher collected both secondary and primary data for the sake of this
case study (a two week period in a general medical ward).
Secondary data
As evident from the literature about missed nursing care, a significant
association has been noticed between missing care and nursing workload and staffing
levels. Thus, the researcher decided to use data that could shed light on the workload
of nursing staff in the designated ward during the case study timeframe that could
refer to the busyness of the study ward. Also, as MNC has an association with patient
outcomes, clinical incidents data could shed light into MNC episodes (Cordeiro et
al., 2018). Within this context, the secondary data chosen to be used by the
researcher were provided by the DON in the study hospital in electronic formats and
included the following:
Ward profile: including Average Length of Stay (LOS), Patient Turnover (number of
admissions, transfers, and discharges), and Bed Occupancy rate for the case study
ward during the 2 week study period.
Patient turnover is one of the aspects of nursing workload (Jennings, 2008) that
provides an indicator to the complexity of healthcare (Spirig et al., 2014). Bed
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occupancy rate is indicative of patient flow in the healthcare setting, and thus refers
to the workload of the healthcare workers (Cordeiro et al., 2018).
Patients’ profile: including Demographic Profile (age and gender), and Clinical
Profile (Diagnosis Related Groups DRGs) for the patients admitted during the 2
weeks study period.
Nurse Rostering information.
Nurse Rostering or scheduling is defined as allocating an optimal count of
various grades of nurses to every shift (Asta, Özcan, & Curtois, 2016). Nurse
Rostering is a complex procedure that requires collaboration between several nursing
personnel in the hospital. The Nurse Rostering process involves the following stages:
1. Development of first draft of the roster by rostering portfolio nurses
(who attend roster planning workshop held by the Nurse Unit
Manager (NUM) every four weeks).
2. Check of first draft against Nursing Roster Checklist by the rostering
nurse, which allows the nurse to identify and target discrepancies
within the roster and rectify them prior to submitting the final roster
for consideration by the NUM.
3. Roster nurse submits final draft roster and completed final draft roster
checklist to NUM for review and approval.
4. Approved roster saved in completed roster file, printed and posted in
clinical unit (Queensland Government, 2016).
Report on clinical incidents data during the two weeks period.
Primary data
The primary data collected in this case were as following:
Patients’ perception regarding MNC.
Patients admitted to the study ward during the case study period were surveyed
by the researcher using MISSCARE survey- Patient (paper based).
Nurses perception regarding MNC.
Nurses rostered in the study ward during the case study period were also
surveyed about their perception about MNC. The survey used in this study was the
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same MISSCARE survey used in study 2 (paper based). Additional details about the
data collection procedures followed in the current case study are provided further in
this chapter.
3.5.3.3 Data collection
This study involved a convenience sampling for both patients and nurses
within the designated ward. All patients and nurses in the studied ward during the
data collection period who fulfilled the following inclusion criteria were invited to
participate in the research.
Patients’ inclusion criteria:
Adult (over18 years of age) patients who were conscious (did not have
cognitive impairment).
Able to read and speak English.
Able to provide a verbal consent and answer survey questions individually.
Patients had to be hospitalized for at least 48 hours in the selected medical
ward.
A paper based MISSCARE survey–Patient was used to collect data from the
patients (see Appendix 7 on page 298). This survey was a 5-point Likert scale from
never to always. Permission to use MISSCARE survey–Patient (Kalisch et al., 2014)
was obtained from Professor Beatrice Kalisch (see appendix 8 on page 302 for the
permission letter). In this survey, patients’ reports of MNC consisted of 13 elements
that were divided into three domains:
Essential care
1. Ambulation
2. Bathing
3. Mouth care
4. Getting out of the bed and sitting in the chair.
Example: On average, how often did the nursing staff help you or monitor
that you walked?
1) Never
2) Rarely
3) Sometimes
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4) Usually
5) Always
6) Check here if you could not walk.
Communication
1. Clarity of the nurse assigned to the patients.
2. Considering patients’ opinions about their care.
3. Listening to patients’ concerns about their care or illness.
4. Discussion of treatment with the patients.
Example: How often were you clear about which specific nurse was assigned
to take care of you for the shift?
1) Never
2) Rarely
3) Sometimes
4) Usually
5) Always
Timeliness
1. Response to machine beep.
2. Response to call light.
3. Providing help after call light.
Example: When a monitor or other machine beeped, how long did it usually
take the nursing staff to respond?
1) Less than 5 minutes.
2) 5 to 10 minutes.
3) 11 to 20 minutes.
4) 21 to 30 minutes.
5) More than 30 minutes.
6) No machine beeped.
The Cronbach alpha values in the validated survey for communication, basic
care, and timely responses were 0.78, 0.86, and 0.78, respectively. In the
MISSCARE Survey–Patient, patients were also asked to report if they had adverse
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events during their hospitalization period. They were asked about six kinds of
adverse events during their hospitalization period (falls, skin breakdowns or pressure
ulcers, medication administration errors, new infections, IV running dry, and IV
leaking into skin) and other problems. In addition, the demographic information of
the patients (age and gender) was included in the initial part of the MISSCARE
Survey–Patient. MISSCARE survey (paper based) used in study 2 in this research
was used to collect data from the nurses in the studied ward.
Nurse’s inclusion criteria:
Nurses providing direct patient care in the selected medical ward regardless
of gender, years of experience.
Nurses available during data collection period.
Nurses agreeing to participate in the study.
The MISSCARE survey used in study 2 in this research was used in this case
study to assess the perception toward MNC of nurses working in the study medical
ward.
Patients and Nurses data collection procedures
The researcher, with the help of the Nurse Unit Manager (NUM) of the studied
ward (who was identified through the main gatekeeper), was able to survey the
patients admitted in this ward. During the two weeks period (22th January 2018–4th
February 2018), the NUM provided the researcher with the list of patients that could
be surveyed every day based on the predetermined inclusion criteria. The researcher
visited the patients in their rooms and asked them to complete the MISSCARE
survey–Patient after explaining the research objectives and asking them to sign the
consent form (PIS and consent form for the patients can be found in Appendices 9,
10 respectively). The majority of patients who were eligible to participate and
accepted to participate were able to complete the survey by themselves. Only five
patients from those who accepted being involved were not able to do this and the
surveys were completed for them by the researcher. The researcher read the
questions and provided them with the options to choose from. Questions that were
not clear for the patient were explained by the researcher. The patient survey was
conducted during quiet times when there were no nurses present in the patient’s room
in order to preserve confidentiality and enable them to answer the questions freely.
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The survey was conducted prior to discharge day as the patients had a lot to do on the
discharge day and this could have affected their responses. The initial plan for the
patient survey was to do the survey on the discharge day. However, based on the
recommendation of the DON in the study hospital (research gatekeeper), an
amendment was performed to the ethics approval and was changed into a patient
survey prior to discharge day. The response rate to the patients’ survey was
calculated and was 81% (n=30).
Regarding the nurses, printed surveys were placed in the tearoom and the
NUM asked the nurses to complete them and post them in a locked box placed in the
tea room (PIS and consent form for nurses can be found in Appendices 11, 12
respectively). The NUM also reminded the nurses to complete the survey during shift
handover meetings. Response rate to the nurse survey was 56% (n=28).
3.5.3.4 Data analysis for the case study data
This study used descriptive statistics to summarize the secondary data collected
from the hospital databases. Ward and patient profile were tabulated and reported.
Regarding the nursing rostering information, calculations were performed to identify
the number of nurses in different shifts and were reported. Clinical incidents report
data were also summarized and reported.
The data obtained from both patients and nurse MISSCARE surveys were
inputted into SPSS V.25 (Field, 2013) for analysis. In MISSCARE Survey–Patient,
the Likert scale-based responses (Never–Always) were re-coded as a dichotomous
scale (categorical) by grouping participants; scoring Never, rarely, sometimes on the
scale were grouped into missed care and given code 1; and scoring usually, always
were grouped as not missed care and given code 2. This coding pattern was also used
by Kalisch et al. (2014).
The researcher performed descriptive statistics to summarize the demographic
information for both the nurses and the patients, as well as to summarize the
variables of interest in this study (missed care elements as extracted from both the
patients and nurses and the reasons for MNC as reported by the nurses). Descriptive
statistics performed included: proportion and frequencies for patient and nurses’
demographic features as well as missed care elements as reported by both patients
and nurses. A chi-squared test was performed to examine the association between the
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age and gender of the patients and how they perceived MNC. The chi square test is a
non-parametric test that is used to examine the relationship between two categorical
variables (Rana & Singhal, 2015). Graphical and tabular displays were provided
where appropriate.
3.6 METHODOLOGICAL LIMITATIONS
The research design of secondary data analysis (Study 1) is a limitation for this
research as the data used was not gathered in the first place to address the specific
research questions of this research. Also, the nature of the data provided in Study 1
did not allow for performing statistical tests to investigate the association between
nurse’s engagement and MNC. Another potential limitation was due to the cross-
sectional nature of the quantitative survey conducted in this research (Study 2). The
survey might have been done in a ‘quiet’ period in the hospital so the mistakes were
less frequent. Regarding Study 3, patients who were unable to read and comprehend
the Patient Information Sheet and consent forms (e.g. maybe with severe and
complicated health conditions) were excluded from the study, as well as patients who
were not proficient in reading and writing in English. The exclusion of these patients
could potentially impact the characteristics of the sample. MNC is strongly
contingent on the quality of communication between patients and nursing team, and
the exclusion of the above described patients could affect the data obtained on MNC.
Hence, the validity of the study findings may be only applicable to the English-
speaking and those patients without severe and complicated health conditions.
3.7 GATEKEEPING
Access to a research setting is one of the challenges facing the researcher that
might affect the research progress if it were to be denied (McFadyen & Rankin,
2017); that, combined with the sensitive nature of research about missed nursing
care, means gatekeeping processes have been identified as a vital issue that has a
considerable impact on achievement of such research. Gatekeeping process details
are provided in this section.
Gatekeeping is a prevalent phenomenon in education, health and social science
studies (McFadyen & Rankin, 2017). Gatekeeping is defined as the process of
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allowing or negating the access of the researcher to a chosen site. This process
necessitates that the investigator has excellent communication and social skills in
order to build a relationship with various gatekeepers met in the process of research
(Lee, 2005). The researcher, with the help of associate supervisors for this project,
strove to build a pleasant interpersonal relationship with the gatekeepers during the
research process (Baillie, 2007; Lee, 2005).
Gatekeepers could be present at two levels: organisational and professional. An
example of gatekeepers at the organisational level is the research coordinator.
However, the Director of Nursing (DON) is an example of a professional gatekeeper
in nursing (Benton & Cormack, 2000). The DON (the main professional gatekeeper)
in the study site assisted in paving the way of the researcher (Holloway & Wheeler,
2010) and recognizing other informal gatekeepers such as unit managers so that the
investigator could gain their collaboration in various research phases (Lee, 2005).
The DON stayed as the point of contact for the researcher until study completion.
It should be emphasized that the project supervisors helped the student
researcher in identifying the gatekeepers in this research as they were part of their
professional network. Supervisors contacted the DON in the target hospital and
provided her with a summary about the current research including research plan,
objectives and implications. The DON was affirmative and eager to take part and
collaborate in this research. Preliminary approval to conduct the research in the study
hospital was obtained from the DON prior to confirmation of the research proposal
for this research.
3.8 ETHICAL CONSIDERATIONS
MNC could be viewed by nursing staff as a sensitive issue (Saqer &
AbuAlRub, 2018) as it might be related to provision of substandard care to the
patients that could influence patient safety. MNC might be also viewed as sensitive
as it may cause conflict in the relationship between nurses and their management due
to neglected care, particularly if it occurred in a punitive environment. Thus, the
potential risk for nurses completing the MISSCARE survey was that their responses
might lead to punitive behaviour from their management if their responses were not
anonymous. Nurses tend to under report the issues related to meeting practice
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standards due to fear of labelling, blame, repercussions and retribution (Attree,
2007). Hence, the ethical issues were given serious consideration and the researcher
made every effort to protect the rights of the participants and to reduce any
uncomfortable feelings the participants may have experienced during the course of
this research. Ethical considerations adopted in this research are discussed in the
following section.
Ethical principles employed
According to the World Medical Association Declaration of Helsinki. Ethical
principles for medical research involving human subjects (World Medical
Association, 2001), it was acknowledged that in the case of performing any research
study that involves humans, the possible participants must be knowledgeable about
the objectives, methods, the advantages and the hazards that the study may pose to
the participants. In addition, they must be well informed about being able to
withdraw from the research study at any time and without giving any reasons
(McCully, 2011). This PhD research adopted several strategies to address the
sensitive nature of this research and to ensure the research was conducted in an
ethical manner.
Secondary data ethical considerations (Study 1 and 3)
Secondary data used in this research were provided from the study hospital in
de-identified (free of identifying information) format whether it was related to
administrative information about patients (e.g. gender, age) or health services
information, such as clinical diagnoses and procedures followed during inpatient
stays and discharge information. No identifiable information for nursing employees
was requested or obtained in this study.
Primary data ethical considerations (Study 2 and 3)
Consent was obtained from the participants prior to being involved in Studies 2
and 3 in this research. The consent included elements that indicated human rights
protection, such as anonymity of the responses, privacy and confidentiality of the
participants (Nijhawan et al., 2013).
To protect the anonymity of the participants, no identifying information was
requested from them. The email which included the survey link was distributed by
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every NUM to their nurses in Study 2 in this research, thus their identity was
protected, and they remained anonymous. As missed nursing care is a sensitive issue,
the rationale for keeping participants’ anonymity during the research process was to
protect participants’ identity, thus reducing their stress while responding to the
survey questions, as well as to protect the identity of the research location (Clark,
2006).
It was made clear to the participants in this study that participation in the study
was voluntary. No enticements or favours were presented to the participants and no
coercion (minimal to low risk) was posed. Participant Information Sheets (PIS) that
explained the purpose and the research strategy pursued were supplied to the
participants.
The researcher also reminded the nurses that they could withdraw from the
research at any time without giving any reasons and without any penalty and/or
prejudice. The participants were informed about the benefits of this work as the
findings of this study could aid in the development of quality improvement
approaches to minimize reduced care and improve patient outcomes. Basically, no
risk in participating in this research was identified more than is usually experienced
in daily life.
The researcher provided the participants with her contact information in the
PIS in case they had inquiries regarding the study and informed them that the results
would be available to them on completion of the study.
All the data collected were treated as confidential data, and remained
confidential during the data collection and after completion of the project. The data
collected were kept securely against access by people other than the researcher and
the project supervisors, according to data management plans that coincided with
QUT policy. The data were stored during the project in an encrypted personal
password protected laptop for the researcher. Upon completion of the study, and to
ensure the confidentiality of the data, all the data collected (both electronic and hard
copies) in this research will be kept confidentially at the School of Public Health and
Social Work, Queensland University of Technology, for the period of 25 years as
recommended by the HREC due to the clinical nature of the collected data.
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Although the researcher explained to the hospital management that the purpose
of this research was not to assess the performance of the involved hospital, the
facility manager requested that the hospital involved in this research not to be named
in this thesis and also not be named in any future publications arising from this
thesis.
This research project met the requirements of the National Health and Medical
Research Council's (NHMRC) National Statement on Ethical Conduct in Human
Research (2007). Ethical approval for this research was obtained from Metro North
Ethics Committee (on behalf of Qld Health) (HREC/Project Number:
HREC/16/QRBW/591), hospital approval (Approval Number: SSA/17/QPAH) and
QUT (Approval Number: 1700000980) (combined ethics approval was obtained for
all three studies involved in this research). Authority to release data under the Public
Health Act (PHA) was obtained from Queensland Health (approval number:
RD006717) (ethical approvals obtained in this research can be found in appendices
13, 14, and 15).
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3.9 CHAPTER SUMMARY
This chapter has depicted the methodical approaches and methods used to
achieve the objectives of this research. The rationale for using the selected methods
was also demonstrated. The institutional background of the research setting and
access to it, and the methodological limitations, were also described. Lastly, this
chapter has presented the ethical considerations warranted during the research
process and how they were mitigated.
The next three chapters present the findings derived from the data collected and
analysed as per this chapter.
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Chapter 4: Findings of Study One (Secondary Data Analysis)
4.1 INTRODUCTION
This research aimed to explore the issue of Missed Nursing Care (MNC) in an
acute care hospital setting, particularly in the context of the implementation of
mandated nurse staffing ratios as a new nurse staffing policy in medical and surgical
wards in public health services in Queensland, Australia (Forrester, 2016). The
minimum ratios are 1:4 on morning and afternoon shifts, and 1:7 on night shifts
(Queensland Health, 2016). The key intentions of mandated nurse to patient staffing
ratios were to promote quality and safety of healthcare and to enhance nurse
satisfaction with their work and thus nursing workforce sustainability. Prior to the
mandating legislation, the number of nurses in different health services was
determined by the nursing managers based on the guidelines from Queensland Health
Business Planning Framework: Nursing Resources (QLD Legislative Compliance
Alert, 2016).
Study One in this research involved retrospective analysis of secondary data
collected by the hospital as part of its routine quality assurance process. The aim of
this component of the research was to provide background (context) information to
the everyday working practice of nursing staff in the study hospital. The secondary
data used in the current study permitted capturing systemic local issues in the study
hospital that may contribute to MNC. According to Kaplan, Froehle, Cassedy,
Provost, and Margolis (2013), the characteristics of local contexts in healthcare
organisations affect the results of efforts aiming to improve quality healthcare.
Hence, with a better understanding of the study hospital local context, the researcher
was able to identify measures that could be implemented in the local context to
manage missed nursing care and, in turn, improve overall quality of healthcare in the
study hospital.
Secondary data used in Study One in this research were: Patient Satisfaction
Survey Data, Nursing Employee Engagement Data, and Clinical Incidents Data
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(Falls, Medication Incidents, and Pressure Injuries). It was key to the current PhD
study to identify the types and characteristics of the MNC in the setting of the study
hospital. To that end, this chapter synthesises the secondary data according to the
following research questions:
1. What is the nature of MNC in medical and surgical wards in an acute care
hospital?
2. What are the reasons for MNC in medical and surgical wards in an acute care hospital?
3. What are the individual nursing characteristics and work conditions that
influence MNC in medical and surgical wards in an acute care hospital?
This chapter presents the findings of the secondary data synthesis in the
following order: Patient Satisfaction Survey Data, Nursing Employee Engagement
Data, and Clinical Incidents Data. The chapter concludes with a summary for the key
findings.
4.2 FINDINGS OF PATIENT SATISFACTION SURVEY DATA
The study hospital provided hospital aggregated reports of patient satisfaction
survey results for the whole hospital for May 2017, as well as reports for the
Division of Medicine and Division of Surgery for 2016 and 2017 (published in May
2016 and May 2017 respectively). These thus provided a whole of hospital snapshot
view as well as a more extensive and trend view for the medical and surgical wards
that formed the focus of this research.
The surveys were distributed to a random sample of patients by the external
provider. The response rate to the patient satisfaction survey for the whole hospital
for 2017 was 89% of those sampled (number of surveys distributed was 158, number
of respondents was 141). The response rate for Division of Medicine was 77% (74
surveys distributed, number of respondents was 57) in 2016, and 92% in 2017 (76
surveys distributed, number of respondents was 70). The response rate in Surgical
Divisions was 94% (83 surveys distributed, number of respondents was 78) and 87%
(82 surveys distributed, number of respondents was 71) in 2016 and 2017
respectively. Content analysis was performed by the researcher on patient
satisfaction survey data, particularly in relation to patient satisfaction with nursing
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care provided over the survey period. The results of the content analysis on patient
satisfaction data are provided next.
Patient satisfaction survey data for the whole hospital revealed high levels
(>90%) of patient satisfaction with the hospital and nurses, and overall satisfaction in
both years (2016 and 2017) (Figure 4.1). There was no discernible long-term
significant trend. An increase in patient satisfaction across the three domains was
observed in 2017 compared to 2016, which coincided with the introduction of
mandating nursing ratios. However, there was equally a small decline in 2016
compared with 2015 and thus the observations may simply be a statistical correction.
Figure 4.1. Patient satisfaction with the hospital (trend by year)
Data from the patient satisfaction survey-Medical Divisions revealed similarly
high levels of patient satisfaction with some year on year variability (Figure 4.2). The
observed lower rates for 2016 are not immediately explicable and may represent a
statistical glitch. The increases in 2017 coincided with the introduction of mandating
nursing ratios but they may also represent a reversion to a long-term trend.
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Figure 4.2. Patient satisfaction (trend by year)-Medical Divisions
Data from the patient satisfaction survey from the study hospital also revealed
nursing care aspects rated highest against the benchmarking norms (study hospital is
benchmarked against group of hospitals; peer groups; in Queensland) (Queensland
Government, 2014). Nursing care aspects that rated highest against benchmarking
norms in the Medical Divisions in 2016 were: patient satisfaction that nurses
demonstrated attention to their requirements for rest (83% of the patients in the study
hospital were satisfied, benchmarking norm was 83%), and preparing patient for
discharge from the hospital (93% of the patients in the study hospital were satisfied,
benchmarking norm for the same care aspect was 92%). In 2017, patient preparation
for discharge was not among the highly rated care aspects against the benchmarking
norms, however, patient satisfaction with nurses’ demonstrated attention to their
requirements for rest stayed above the benchmarking norms and the level of patient
satisfaction with this nursing care element was higher than that perceived in 2016
(93%, benchmarking norm for the year 2017 was 84%). From these findings, it can
be concluded that nurses in the study hospital tend to follow patient centred
approaches to healthcare, which is the care that is provided as per patient
requirements and preferences (Martz, 1994).
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Areas for improvement in Medical Divisions identified in 2016 were found to
be primarily related to nursing care, particularly in regard to nurses’ behaviour.
Areas of improvement were calculated by quantifying the number of respondents
who responded negatively (disagree or strongly disagree) to the following questions:
nurses act in professional manner (14% respondents provided negative answers),
meeting patient expectation by the nurses in the recent visit (12% provided negative
answers), nurses honesty on any issue of concern, reassurance of patient on any issue
of concern, nurses demonstrated a friendly and approachable manner, nurses
demonstrated caring and compassionate attitude (10.5% respondents provided
negative answers for each) (2016 data). These statements were mainly related to the
emotional support provided by nurses. It may be perceived by nurses that not
prioritising these care elements might not affect patients’ physical health outcomes,
at least in the short term, and thus they prioritise clinical management over these care
elements, particularly if they do not have sufficient time to provide such care for
patients with complex conditions. . .
However, in 2017, only one area for improvement related to nursing care was
identified in medical divisions, and it was “the nurses explained things clearly so
that I could understand” (2.85% of the respondents provided negative answers),
which may reflect a potential communication issue between the nurse and the
patients. However, it could also reflect increased nursing workload. The doctors may
not provide emotional support for the patients as they do not have sufficient time
with individual patients. Thus, these issues may be left to be performed by the
nurses, which may represent an additional burden on them.
From the above findings, it can be extrapolated that the new nurse staffing
policy might improve nursing care quality by facilitating provision of compassionate
support for the patient (i.e. reducing MNC) and thus enhancing patient satisfaction.
Patient satisfaction survey data for the Surgical Divisions also showed a high
overall patient satisfaction (100% overall satisfied) in 2017, and an increase in the
patient satisfaction with the nurses in 2017 relative to the year 2016. See figure 4.3.
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Figure 4.3. Patient satisfaction (trend by year)-Surgical Divisions
Data from the patient satisfaction survey for the Surgical Divisions (2016)
showed that 92% of the patients were satisfied with the information they received
from the nurses to prevent pressure injuries (benchmarking norm was 85%).
However, an overall patient satisfaction with the same care element (100%) was
found in the survey results for the year 2017 (benchmarking norm was 86%). One
area for improvement related to nursing care had been identified in the year 2016,
which was ‘patient preparation for discharge’ (3.8% of respondents provided
negative answers), which represented an example of MNC. However, in 2017, none
of the improvement areas identified by the study hospital related to nursing care.
There seemed to be an improvement in patient education about their care by the
nurses in the surgical wards in the study hospital following the introduction of the
new staffing legislation in Queensland.
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4.3 FINDINGS OF NURSING EMPLOYEE ENGAGEMENT SURVEY
Medical and surgical divisions’ Nursing Employee Engagement Survey data
were provided for the study hospital for the year 2015. Analysis of the data from the
nursing engagement survey revealed that medical nurses perceived that there was a
shift in hospital culture from a culture of blame in 2013 toward a culture of ambition
in 2015 (Figure 4.4). The same trend was noticed in the surgical nurses’ engagement
data. According to Best Practice Australia (Best Practice Australia, 2018), a culture
of ambition indicates that nurses are ambitious about pursuing new methods for
practice improvement. The findings indicate that nurses are determined and ready to
adopt contemporary and innovative approaches to the quality of healthcare provided
in the study hospital. There is also evidence that nurses are keen to be involved in
professional development courses aimed at enhancing their knowledge and skills.
Figure 4.4. Organisational Culture in the Study Hospital–Medical Divisions
NB: the above figure was provided by the hospital in this format. It demonstrates the
increase in engagement over time and the change in culture from one of blame to one of
ambition.
Nursing employee engagement data provided by the hospital included
information about nursing perceptions regarding their engagement, administrative
support, and recognition of their performance. Content analysis was performed on
nursing engagement data and the results are summarized in Table 4.1.
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Table 4.1
Nursing Employees Engagement Data (2015)
Element Medical Divisions Surgical Divisions
Response Rate 72% (267 surveys distributed, number of respondents 192)
62% (290 surveys distributed, number of respondents 180)
Areas rated highest
Engagement Safety Values and
behaviours
Engagement Consumer
outcomes Values and
behaviours
Areas for Improvement
Trust in executive management.
Regardless of how difficult the situation, nursing managers exude a sense of confidence that nurses will get through it.
Rewards and recognition for outstanding performance.
Trust in executive management.
Meeting nurses’ expectations by the hospital management
Presence of strong sense of purpose and direction.
Rewards and recognition for outstanding performance.
Percent of respondents think that the hospital is a truly great place to work
71% 64%
Engagement is a positive job associated state of mind which is characterized by
vigour, dedication and absorption (Schaufeli & Bakker, 2004). Nursing engagement
also refers to involvement of the nurse in the decision making processes, inter
professional relationships, and obtaining opportunities for professional development
(Prybil, 2016). Nursing employee engagement data implies that nurses in the study
hospital are determined and willing to have a positive impact on their patients’
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welfare. Thus, it would be suggested that nurses progressively strive and are
committed to providing good quality and safe patient care in the study hospital.
Looked at from another perspective, the findings from this PhD study indicate
that about one third of the nurses reported that they do not enjoy their work in the
study hospital. This finding could indicate that even when nurses reported high
engagement with their place, they still didn’t think that the study hospital provided a
great work environment. This finding could be due to current environmental
influences, such as lack of trust in management and high demands from the
management on the nurses, especially in handling difficult situations. There appears
to be a lack of praise and rewards for nurses when completing their professional
practice. Such systemic factors can ultimately affect nurses’ commitment to their
work and organisation and can result in MNC. This finding is important given that
the definitive success of safety management systems implemented in hospitals relies
primarily on employees' motivation as well as their perceptions of a safety climate
within their organisations (Naveh, Katz-Navon, & Stern, 2011).
Regrettably, the nursing employee engagement data provided from the study
hospital did not allow for reflections on the associations between the new staffing
legislation in term of the impact that it might have on the level on nurses’
engagement. Also, as that nursing engagement data was provided for one year, the
researcher was not able to identify any trends concerning these data.
Thus far in this chapter, patient satisfaction survey data and nursing employee
engagement data related to the acute care hospital have been discussed. Findings of
clinical incidents data synthesis will be discussed in the next section.
4.4 FINDINGS FROM CLINICAL INCIDENTS DATA
The findings from clinical incidents data reported through the hospital incident
reporting system aimed to identify occurrence and factors of MNC. In general, a
wide range of clinical incidents get reported by healthcare staff in hospital settings.
However, this study focused on investigating MNC in the following domains: patient
falls, medication incidents, and pressure injuries in the study hospital. These
incidents were chosen as they would on face value be most likely to represent MNC.
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As background information to this PhD study, a summary with detailed clinical
incidents reports for falls and medication incidents, and a summary report for
pressure injuries for different time periods were provided by the DON in the study
hospital. This background secondary hospital data on falls and medication incidents
reports related to individual cases were de-identified prior to sharing them with the
researcher.
Summary data on these clinical incidents included metrics that tended to
describe the risk profile of the patients, and activities and locations where incidents
occurred, which helped in understanding the chain of events leading to the incident,
thus helping to identify preventative strategies. The data were analysed using a
content analysis technique. However, clinical incidents descriptions were completed
by staff who reported the incident and provided further details on the circumstances
and potential causes of the given incident. This qualitative data was analysed using a
guided (framework) approach to content analysis (Hsieh & Shannon, 2005). The
analysis was based on the Systems analysis of clinical incidents: the London protocol
(Taylor-Adams & Vincent, 2004).
As depicted in Chapter Three in this thesis, Systems analysis of clinical
incidents: the London protocol (Taylor-Adams & Vincent, 2004) is a framework that
describes and categorises the factors that contribute to the occurrence of clinical
incidents in healthcare. The factors outlined in the framework are: patient factors,
task factors, individual factors, staff factors, team factors, working conditions,
organisational factors, and institutional context (Taylor-Adams & Vincent, 2004).
Incidents analysis, which depicts contributory factors to the clinical incidents,
represents “vulnerable points” (Toffoletto & Ruiz, 2013) in the healthcare system
which principally lead to incidents happening. Systems analysis of clinical incidents:
the London protocol was used to analyse the secondary data set describing falls and
medication incidents in the study hospital, and the findings are provided next.
4.4.1 Patient Falls
As patient educators, and due to their close working relationship with patients,
nurses play a key role in patient fall prevention (Chu, 2017; Gu, Balcaen, Ni, Ampe,
& Goffin, 2016). Nurses are likely to be in the forefront when falls incidents occur
due to the nature of their job, making them an easy target for blame (King, Pecanac,
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Krupp, Liebzeit, & Mahoney, 2016). The secondary falls incidents data from the
study hospital identified that falls can occur when the nurse is present in the patient
room or when the nurse is absent, but the dynamics of those circumstances appeared
to vary. Most falls incidents took place while the nurse was not available in the
patient room. Patient falls can also take place when the nurse is available and
actively supervising the patient (guided fall) and during the nursing rounds.
Falls incidents that occur when the nurse is present may have a different
causation chain that those that occur when the nurse is not present. In these
circumstances, the nature of the missed nursing care as a contributing factor may
relate to clinical assessment, mobility assessment, or the nurses’ judgement on the
need for assistance. However, the causative chain could not be ascertained from the
secondary data set.
Content analysis was performed for the patients falls data obtained from the
study hospital and the findings are presented in the next section.
Content analysis of the falls Secondary Summary Data (Quantitative Findings)
Six hundred and seventy-seven falls incidents were reported between 1st
January 2015 and 31 July 2017 (in a single report containing the three years of data).
The number of falls incidents considerably declined in the period from January
2017–July 2017 (See Figure 4.5). It also dropped in the period from July 2016–
January 2017. Despite the reasons for these changes not being completely clear, they
may be related to the introduction of a new nurse staffing policy in the hospital,
which took place in July 2016. Thus, it can be inferred that systemic modifications
can have a measurable impact on the rate of nurse related errors and subsequently on
adverse patient outcomes including patient falls.
0
4
8
12
16
20
0
4
8
12
16
20
07/2014 -01/2015 07/2015 01/2016 07/2016 01/2017 07/2017
132 134 102 164
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24
132 135 102 165
121
24
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Figure 4.5. Number of falls incidents in the study hospital (July 2014–July 2017)
As identified from the secondary data, patient falls occurred in all age groups.
However, the highest number of falls was reported in the age groups 75-84 and 85-94
years old over the three years review period. Patients in these age groups have more
complex age-related physiologic changes. Also patients in these age groups have
psychological changes and increased risk of polypharmacy that may contribute to
patient falls (Tsai et al., 2014).All of these factors increase the patient risk for falls in
these age groups.
The number of falls reported varied at different times of the day. For example,
in the year 2015, the highest number of falls was reported in the time between 8pm to
12am (56 incidents, 21%), followed by the time between 8am to 12pm (52 incidents,
19%). These findings imply that patient falls tend to occur during the night shift
where fewer nurses are on duty than during the day shift.This confirms that the
nurse–patient ratio is extremely important for prevention of patient falls and thus
enhancing patient safety. It can also be inferred that patient falls tend to occur in the
morning shifts due to increased nursing workload in these times because of
admission and discharges procedures required to be performed by the nurses, thus
reducing the time available for them to help in patient ambulation.
The lowest number of incidents in the year 2015 was reported in the time
between 4pm to 8pm. Previous study showed that reduced number of falls in these
times may be due patient visitors in these , which may reduce patients’ attempts to
ambulation (Cox et al., 2015). The highest number of falls in the year 2016 was
reported in the times between 8am to 12pm (71 incidents, 27%). However, in the
year 2017 (post staffing legislation) the highest number of falls incidents were
reported in the time from 12 pm to 4 pm (20%). This could be related principally to
nursing staff taking breaks within these times and thus lower staffing levels (Kline,
Thom, Quashie, Brosnan, & Dowling, 2008). Also, there was a reduction in the
number of falls reported in the period 8am to 12 pm (16%). From this perspective, it
should be noted that variations in the number of patient falls according to the time of
the day could indicate there are complex interactions between several elements in the
healthcare environment.
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Most falls incidents in the review period (98%) were associated with a Severity
Assessment Code (SAC) Category 3, which means most falls incidents in the study
hospital caused no or minimal harm to patients (non-injurious falls). After reviewing
the falls incident data, it can be assumed that nurses in the study hospital performed
regular falls risk assessment for patients and executed fall prevention protocols.
Regarding the location of falls, the secondary data showed that incidents took
place in several locations within the study hospital and/or the ward. The following
were the most frequently reported locations (ordered from the most frequent to less
frequent). This order was consistent over the three years.
Bed/Bedside/trolley/treatment chair (61%-72%).
Bathroom area (25%-30%).
Corridor on their way to the toilet (1%-5%).
Dining/kitchen areas (2%).
Treatment/procedure area (1%).
Thus, most incidents occur in locations which raise particular challenges for
the provision of nursing support, such as bed/bedside/trolley/treatment chair. This is
potentially due to patients spending most of their hospital stay in this area.
This finding also implies the issue may be related to the visibility
(observability) of the patients by the nursing staff from the nursing working areas
(such as nursing stations) (Hadi & Zimring, 2016), particularly when the patients are
in the bed space and bathroom/toilet areas. Hence, hospital design may be a factor in
patient falls as patient beds are arranged as suites to protect patient privacy.
Patient falls in the hospital are associated with a wide range of activities,
particularly Activities of Daily Living (ADL). The most common activities
documented for all patients who fell during the period of the incident report (2015-
2017) were as following (in a descending order). This order remained the same for
the three years.
Toileting (including attempting to reach the toilet, during and after toileting)
(32%-42%).
Patient unable to recollect (23%-25%).
Bathing/showering (6%).
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Exercising (4.7%).
Grooming or dressing (5.3%).
Use of entertainment (2%).
Falls related to toileting activities accounted for up to 42% of all falls in the
study hospital. This finding could be related to patients attempting to do toileting
related activities independently and tending not to seek nursing assistance as they
thought they placed a further workload on the busy nurses However, the identified
activities might also reflect the quality of basic nursing interventions and possibly
MNC in the study hospital (e.g. toileting, bathing/showering and changing clothes).
Content Analysis of the falls incidents textual descriptions (Qualitative Findings)
Directed (framework) approach to content analysis (Hsieh & Shannon, 2005)
based on Systems analysis of clinical incidents: the London protocol (Taylor-Adams
& Vincent, 2004) was used to analyse the secondary data falls incidents descriptions.
Findings of content analysis for falls incidents reports are provided next.
Findings of content analysis for falls textual descriptions
Although voluntary incident reporting is subject to under-reporting, the
secondary data in this study provided adequate information to be able to identify
some of the factors that contributed to patient falls in the study hospital. Three
distinct contributory factors were associated with patient falls: patient related factors,
nursing task factors, and work environmental factors. Patient falls commonly
occurred due to a combination of these factors rather than one single factor, and thus
the definite cause of the patient fall was difficult to identify in most reported
incidents. In the following section, these three major contributing factors will be
discussed.
1) Patient related factors are responsible for most falls incidents in the study hospital. It
can be argued based on this finding that categorizing falls as "nurse sensitive outcome"
in the study warrants further investigation. The role of patient factors in falls prevention
should be further investigated. For example, there is little known about the nature of the
patients and the complexity of their condition on admission, as they are likely to be high
risk patients.
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The following two patient related categories were identified from the
secondary data:
a. Health condition factors. In this category, the patients had poor physiological
conditions or frailty. For instance, the incident reports described patients’ health
condition factors as: problems related to the patient age, acute illness, postural
hypotension, steadiness and musculoskeletal problems, urinary incontinence,
taking sedative medications. All are factors that resulted in patient falls in the
study hospital. Example descriptions of this category are:
“Patient walked 5 m became dizzy/faint unresponsive lowered to the ground.”
“Patient was sitting out of bed and tried to get back on to the bed without
assistant. Patient loss balance and fell backward on the floor. Patient did not hit
head. Nil visible injury noted.”
b. Personality and social factors were cited as precursors to patient falls in the study
hospital. Personality and social factors are related to patients’ beliefs regarding safety
issues and the role of nursing staff in healthcare delivery.
In several fall incidents concerning self-care activities, patients regularly
ignored nursing advice. For example, in one incident, the nurse provided the patient
with the directions he should follow to avoid falling but the patient did not comply
with the nurse’s advice. In another incident, the patient was taken to the toilet by her
husband, despite being told to ring the call bell and seek help from the nurses. During
transport the patient suddenly felt dizzy and fell on the floor. Similarly, another
incident happened when the patient requested help to visit the bathroom from the
nurse in charge. The nurse asked him to wait until she fetched the shower chair. The
patient disregarded the nurse’s instructions and went to the bathroom by himself and
fell over. Also, in one incident, the patient disregarded nurses’ instructions on the
proper use of assistive devices and thus fell.
However, it should be noted that lack of patient adherence to nurses’
instructions could be related to patients’ health conditions, such as being fatigued and
not able to follow the provided instructions or communication perhaps due to clinical
effects of the illness or to language differences. For example:
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“Patient had a well-known postural drop and was told by nursing staff to use
the bottle and to buzz if needing to use the toilet. Patient disregarded
nurses”.
Patients also may be aware that they should ask for nurse help in getting into
the toilet but due to their urgent need to use the bathroom which surpasses the
nurses’ directions, they do not wait to get nursing assistance. This is clearly reflected
in the following excerpt:
“Patient urgently wanted to use the bathroom. She did not wait for nursing staff for
assistance and walked herself. Patient states she lost balance and fell on her right
side.”
Also, the data suggested that patients' views of fall risk may be associated with
their perceptions of their walking capability. According to previous research, patients
without physical restrictions (clinical conditions affecting their capability to walk)
usually do not believe they have a risk for falls and often reaffirm their stability as
protection from falls (Radecki, Reynolds, & Kara, 2018). For example:
“Mentally competent patient who refused nursing assistance to transfer.” “Patient mobilising out of bed without calling nurse for assistance. Patient
aware he needs supervision when mobilising.”
“Patient was doing exercise holding the bar in the corridor. For that he
needs nursing staff with him but patient noncompliant and while staff were
attending another patient, he overbalanced and slowly sat on the floor. This
incident witnessed by OSO. The patient has been told numerous times about
falls risk and not doing exercise by himself, but patient doesn't listen to staff.”
Another factor derived from the data was the lack of patient request for
assistance. Patients are often not aware the dangers of moving by themselves.
Despite being informed by the nurses to ask for help when they need it, patients may
be still reluctant to seek nursing help, probably due to perceptions of being a burden
or not to irritate or bother the nurse.
Similarly, patients might refuse the service offered by the nurses due to their
need to protect their privacy or to preserve their dignity and/or in consideration to
other patients. The data also indicated that one patient did not want to use the light
while using the bathroom in the night due to their belief that the light would disrupt
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other patients’ sleep, which resulted in a patient fall. Some patients were also
reluctant to disclose their falls history during their hospitalization, as they “did not
want to make a fuss about the issue”, because they were concerned that if they told
the nurses about previous falls, their stay in the hospital would be prolonged.
2) Task related incidents are related to inadequacies in the procedures performed by the
nurses, such as an incomplete task with toileting assistance. In one incident, the nurse
left the bathroom to collect a specimen pot and, on her return, found the patient on the
floor.
“Patient was placed on toilet chair and taken to the toilet. After staff member
left the toilet area, a loud noise was heard from the toilet and staff found
patient on the floor and the toilet chair had fallen over.”
In another incident, the patient asked the nurses to leave the toilet to protect
their privacy. For example:
“Patient was in the bathroom attempting to urinate into a bottle. Nursing
staff left the room, as patient indicated for nursing staff to leave the room.
Nursing staff outside patient room as patient required specialling for
behavioural reason.”
Inadequate documentation of patients’ falls risk and their history of falls was
also identified as one factor leading to patient falls. For example, the nurse assessed
the patient’s falls risk but did not document it in the patient record. Thus, the nurse in
charge was not aware about the risk of falling for that patient. An example that
describes insufficient documentation was:
“Patient known falls risk not documented on admission. Staff alerted about
the patient’s fall by a neighbouring patient. Appropriate first aid attended.”
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3) Work environmental factors include nursing busyness and thus not having adequate
time to ambulate the patients, as per the description of one fall incident:
“Patient was resting in the chair and the nurse was occupied with another
task.”
It is likely that the ward was understaffed at the time of the above described
incident. However, such an incident could also potentially have occurred due to
difficulty in handling patients with complex conditions, as well as due to fluctuations
in patient requirements (increased patient acuity). The potential cause of the fall
cannot be ascertained from the study hospital’s notes.
Furthermore, work environmental factors that contribute to patient falls in the
study hospital include the circumstances and hazards in the healthcare settings. These
hazards could be related to the physical design of the hospital setting, such as uneven
floors, or to the appliances used, such as drains or catheters. For example, one patient
fell over while going to toilet due to a little bump on the floor between the toilet and
the patient’s room. Another one fell over while going to the toilet because he got
tangled in the IV lines and was stopped by the oxygen tubing. One nurse reported
that:
“Patient assisted to toilet with nurse. Left on toilet and informed to press
buzzer when finished. Patient stood independently without ringing for nurse.
Patient states he became tangled in IV Lines and NG tubing.”
Environmental factors increase the falls risk brought on by patients’ health
conditions. Therefore addressing work environmental factors that lead to falls of
especially complex patients could be an effective prevention procedure (Gu et al.,
2016). According to Luzia, Almeida, and Lucena (2014), environmental safety
management should be a key priority when aiming to reduce falls incidents in
hospitals. Nurses are the most likely healthcare professionals who through their job-
related tasks end up monitoring and reporting environmental risks and hazards in
patients’ surroundings (Ross et al., 2018), such as securing patients and ensuring that
attached devices, such as catheters, drains, and tubes do not restrict their movement
(de Goes Victor et al., 2017). Indeed, nurses should perform environmental scans to
ensure safety of the patient care environment (Watson, Salmoni, & Zecevic, 2018).
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Environmental scans comprise completing of a checklist after performing a “walk-
around” in the care environment, searching for any safety hazard and getting rid of it.
These scans should be performed regularly (Watson et al., 2018). Hence, in the
above incident, while the fall might be due to the patient being tangled by
intravenous lines and nasogastric tubes, MNC could also be a factor. It is possible
that nurses could omit checking the state and condition of medical devices whilst
doing their rounds which could lead to falls in high risk patients.
From the above discussion, it can be suggested that falls in the study hospital
might have a link to missing nursing care due to missed or inadequate assessment of
patients’ health status, patients’ surveillance, assessment of environmental safety,
and missed communication between various healthcare providers caring for patients.
Overall, it appears from the secondary data analysis that nurses perform very well in
the domain of falls risk assessment (identified in detailed descriptions of falls
incidents) in the study hospital. All reported incident data show that there was only
minimal harm to patients who fell. The falls incidence data shows that nurses indeed
play a key role in patient fall prevention by performing effective falls risk
assessments and establishing fall prevention protocols.
4.4.2 Medication Incidents
Medication incidents are the second most common reported incidents in the
Australian healthcare context (Clinical Excellence Commission, 2013). In Australia,
up to 96,000 medication incidents, which were preventable, occur every year (Hayes,
Power, Davidson, Daly, & Jackson, 2015). Medication incidents are perceived by
both patients and staff as something that may be a result of missed nursing care. The
study hospital provided a 2-year single report for the period October 2014 -
November 2016 (detailed report) then monthly reports (summary and detailed
reports) from January 2017 till July 2017 and another report (summary report) from
August - November 2017. This secondary data from the study hospital provided an
overview and a detailed textual description of the medication incidents. Content
analysis was used to analyse the medication incidents summary reports. However, a
directed approach to content analysis using Systems analysis of clinical incidents: the
London protocol (Taylor-Adams & Vincent, 2004) was used to analyse clinical
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incidents textual descriptions. The findings of content analysis for medication
incidents summary reports are presented in the next section.
Content analysis of medication incidents summary reports (Quantitative findings)
According to the medication incident reports there were 336 cases documented
in the period from January 2017 till November 2017. The number of incidents
reported in the study hospital in 2016 was 57, while in the year 2015, 41 incidents
were reported. The data showed an increase in the level of medication incidents
reporting following the new staffing legislation, which could be related to the fact
that nurses had more time to report and document incidents. Medication errors are
anticipated to be influenced by the continuity of the provided care (as medication
errors entail several stages) rather than by the number of staff. Most medication
incidents reported within the review period (86%) resulted in minimal or no harm to
the patient.
Medication incidents in the study hospital occurred at several different stages
of the therapeutic process, namely: transcribing (2.9%), prescribing/ordering
(17.6%), dispensing/supply (5.9%), monitoring (2.9%), and administration (70.6%).
Medication incidents can occur at different stages of this process, which indicates the
complexity of the medication administration procedure. Medication administration is
a multispecialty activity that requires co-operation and clear communication between
diverse healthcare providers, not just between nurses but also with doctors and
pharmacists. However, as previously discussed, often the medication administration
becomes the responsibility of nurses, hence making them eventually accountable for
medication errors. Thus, the medication administration process is vulnerable to
missed nursing care. The secondary data from the study hospital revealed that
approximately 73% of medication incidents reported prior to the new nurse staffing
legislation occurred at the administration stage. However, following the mandatory
nurse to patient ratio legislation, there was a substantial reduction in medication
incidents (43%) at the administration stage. Thus, it can be inferred that reducing
nurse-patient ratios improved the safety of patients.
Content Analysis of the medication incidents textual descriptions
Directed approach to content analysis using Systems analysis of clinical
incidents: the London protocol (Taylor-Adams & Vincent, 2004) was performed for
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the textual descriptions of medication incidents. The descriptions included details
about the medication incidents, which allowed for identification of potential
contributory factors. As the current research topic focuses on nursing care omissions
or MNC, nursing related factors that were identified as contributing factors to
medication incidents, particularly medication omissions in this study, were the focus
of the analysis. The findings of medication incidents content analysis are presented in
the next section.
Findings of the content analysis for medication incidents textual descriptions
(Qualitative findings)
The contributory factors for medication incidents, particularly medication
omissions, which can be a result of MNC, were: staff factors, task factors, work
environmental factors, and teamwork and communication factors.
1) Staff related factors outlined in the London protocol, and which have been identified
in the data set of the study hospital, were staff characteristics such as staff competency,
qualifications, being new on the ward, nurse’s fatigue, and experience in the medication
administration process.
For example, in one incident description the patient was found to have an
increased heart rate. Increased heart rate in this incident was identified in the report
as perhaps related to missing medication for the patient. The nurse team leader asked
the allocated Enrolled Nurse the reason for the medication omission. The nurse
responded that the medication was not given (missed) due to the patient vomiting. It
was explained to the Enrolled nurse that this issue should have been escalated to a
more senior nurse so appropriate management of the patient could have been
determined. The secondary data described the impact of nurse inexperience and thus
lack of familiarity with nursing medication administration procedures:
“Acute patient with many devices. Ward call, and priority to keep airways
working. Not so experienced with insulin continuous infusion management.
Insulin Order was written on other side of BSL records, not visible to access.”
Data derived from the medication incident reports that described staff related
factors in the study hospital showed that nurses must have the knowledge and the
experience (technical skills) about the clinical applications of medications with
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regards to dosages, indications, side effects, and contraindications, and
administration techniques, as well as the schedule of medication administration for
the assigned patient. Nurses new to the ward might not be familiar with ward practice
and, therefore, their actions can disrupt care continuity with a possible impact on
patient safety due to medication administration omissions. For example:
“Patient not given breakfast dose of novorapid and lantus. Nurse was new to
ward and patient.”
2) Task factors are related to omissions of duties performed by the nursing staff, such as
inaccurate or incomplete documentation, which may be considered direct examples of
missed nursing care.
The data showed that incomplete documentation of the patient’s case history
led the nurse to be confused about the type of diabetes the patient had and that led to
missing medication administration. Another nurse missed the administration of a
‘sliding scale’ for insulin (Novorapid) as the patient chart was not updated regularly.
This medication was written in the old patient chart but not transferred to the new
chart (by the doctor). This incident implies that hospital system errors, such as
communication issues, might contribute to the occurrence of medication omissions.
Similarly, an example of task factors was lack of clarity in patients’ charts,
which may result in MNC. According to the data, one patient missed out on their
insulin dose as the nurse was not able to read and understand the patient chart
(illegible handwriting). For example:
“Some evening medications were missed because one of her charts was
inadvertently filed”.
Another example of task related incident was that nurses perhaps did not have
time to read a patient’s charts in detail, or it was not written up clearly, so there was
an incident of missed diazepam 2.5 mg dose medication. However, according to the
data, no harm occurred to this patient. He was settled and slept well despite the
medication omission due to MNC.
3) Work Environmental factors are the factors that relate to nursing practice atmosphere.
There were several environmental factors identified from the data that may have
contributed to medication errors, such as increased workload.
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The nurse staffing levels may be absolute (e.g. fewer nurses than normal) or
relative to the complexity of the patients under their care. For example, the
administration of Warfarin medication was missed in one case due to fewer nursing
staff being on the ward. Nursing workload also increased due to nurses being
assigned based on patient numbers rather than on the complexity of patients’ care,
which might result in task overload for some nurses and can impact their tasks
prioritization and decision-making processes. In addition, increased nursing
workload can cause fatigue in nurses and thus might lead to missed administration of
the prescribed medication.
The following are examples derived from the secondary data that described
missed medication due to increased nursing workload:
“Targin was not given this morning. It was missed due to nursing pressures.”
“Morning insulin not given 0730 hours insulin missed due to busy patient
load.”
From the above examples, it can be derived that medications administration
was missed in the morning shift in both examples.
Interruptions and distractions in medication preparation and administration
were other environmental factors associated with medication omission. Interruptions
in this context refer to delays in the process of medication administration, when the
healthcare professional is called away to attend to another task. Nurse interruptions
and distractions could occur at the request of other nurses, patients, as well as their
families. Also, interruptions and distractions could result simply from medication not
being available. In one incident, the prescribed medication (Danaparoid) was not
immediately available, so the nurse missed the administration of this medication.
However, no harm was experienced by the patient in this case. Interruptions and
distractions also hinder the nurses from reading the patient charts thoroughly and
thus could lead to missed administration of medications.
The above discussed environmental factors derived from the incident reports
appeared to disrupt the nurses’ concentration and avert their attention during the
medication administration process, causing MNC. These incidents indicate the need
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for the nurses to have the necessary skills for delegation of the secondary tasks,
therefore reducing the risk of medication incidents.
4) Teamwork and communication factors are related to disrupted communication
between healthcare providers and between healthcare providers and patients or their
families, inadequate communication during handover, and inadequate sharing of
information.
As medication administration is carried out by a team of healthcare provides
from a multi-disciplinary background, communication and teamwork is essential in
this process. An example of teamwork and communication factors derived from the
hospital data was miscommunication between doctors and nursing staff. For
example, in one incident report, the nurse missed administration of insulin to a
diabetic patient because the doctor charted the prescription too late. Furthermore,
communication breakdown between patients’ families and nursing staff can also
contribute to missed medication. One incident was recorded as a missed medication
despite the fact that the medication was administered by the patient’s family without
informing nursing staff.
Inadequate handover also can lead to medication omission. One nurse reported:
“Patient transferred to ward 3b noted of morning doses of medications was not
given and no proper handover was given by the ward 5b staff. Patient was
transferred to ward 3b from 5b and noted that no medications was given from the
morning medication rounds. Staff from 5b was informed to come down to3b to
give a proper hand over. 5b staff came at 1700.”
Inadequate sharing of information also resulted in missing medication. For
example, any changes to care should be communicated to the nurse team leader, so
that information can be relayed to all team members involved in the care of the
patient. An example from the hospital data that described inadequate sharing of
information was:
“On checking patient. BSL AT 16:30, it was noted that the morning dose of
Lantus was not given. This was confirmed by the patient, and by contacting the
morning nurse who advised that she was unaware that the patient was diabetic.
Team contacted, and a stat, half dose of Lantus was ordered and given”.
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Thus far in this chapter, falls and medication incidents data have been
discussed. The following section illustrates the findings of pressure injuries summary
data.
4.4.3 Pressure Injuries (PIs)
Pressure injuries have been identified by the Australian Commission on
Quality and Safety Health care as one of the Healthcare Acquired Complications
(HAC) (Independent Hospital Pricing Authority, 2018). In Australia, the cost of
pressure injuries management in all states in 2012-2013 was approximately AUD
$983 million, which represents about 1.9% of all public hospitals expenditures
(Nguyen, Chaboyer, & Whitty, 2015). According to the National Health Reform
Agreement published in June 2017, it was determined that the level of funding to
acute care episodes would be diminished if any healthcare acquired complication
(including pressure injuries) existed in the hospital (Independent Hospital Pricing
Authority, 2018). The reason for this is that the health acquired complications cost
about 8.8% more than non-health acquired complications. It has been determined that
the final incremental cost for pressure injuries was 14.3% and the adopted adjustment
was 12.5% (Independent Hospital Pricing Authority, 2018). As pressure injuries are
a cause of patient harm and financial cost, their prevention needs to be prioritized
(Loikkanen & Tammi, 2016). In this perspective, financial penalties can be regarded
as a good motivator for hospitals to confirm the soundness of their safety
management systems (Shaban, 2018). For example, financial penalties motivate the
hospitals to recognize the patients who are at risk of pressure injuries and to perform
accurate evaluation of skin problems for all admitted patients, thus allowing for
preventive measures establishment (Wake, 2010).
However, implementing pressure injuries prevention measures is not as easy as
it may appear. It is a complex issue that depends on an interplay between
organisational and patient related factors. In this perspective, the hospitals should
strive to reduce the challenges nurses encounter during their daily practice, for
example, ensuring availability of supplies, equipment and other resources as well as
authentic leadership, which is essential to shape the healthcare environment to
confirm that nurses perform pressure injuries prevention measures in an effective
manner (Barakat-Johnson, Lai, Wand, & White, 2018; Wurster, 2007)
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Secondary analysis of pressure injuries data reported in the period from
January 2015-July 2017 in the study hospital revealed 1,805 reported pressure
injuries incidents in this period. The report revealed that most of the pressure injuries
incidents were reported by the nursing staff. For example, in 2017, from the 708
pressure injuries incidents reported to the hospital system, 707 incidents were
reported by the nursing staff and only one incident was reported by the medical staff.
This could indicate that most commonly nurses detect pressure injuries rather than
any other healthcare professionals. Lack of reporting by the doctors could be related
to unfamiliarity with the process of incident reporting (Grootheest, 1999).
Furthermore, it could be related to organisational issues such as lack of time and
length of the incident reporting forms (Uribe, Schweikhart, Pathak, Marsh, & Fraley,
2002). As doctors infrequently report to the hospital incident reporting system, the
incidents clearly dominating the reports were mainly related to procedures performed
by nurses or incidents witnessed by the nurses (Johnson, 2003; Neale, 2005).
Like falls incidents, pressure injuries in the study hospital occur most
frequently in the age groups 75-84 and 85-94 years old, with those deemed to be
complex patients. To this extent all of the secondary data that has been analysed
could be really useful to inform practice by exploring the interaction of MNC,
hospital systems and the needs of this patient group with their complex profiles.
According to the hospital report, the number of reported pressure injuries had
been reduced following the introduction of the new staffing policy (774 in 2016
compared to 708 in the year 2016). This finding has a financial implication on the
study hospital because it leads to reducing the fiscal burden incurred to manage these
incidents. It is also possible that the pressure injuries rate in the study hospital
reduced due to pressure injuries prevalence audits and implementation of strategic
preventive initiatives in Queensland hospitals to prevent pressure injuries. According
to a report published by Queensland Health regarding the Queensland Bedside Audit,
pressure injuries in Queensland hospitals reduced from 14% in 2003 to 3.2% in 2017
(Queensland Government, 2017). The Queensland Bedside Audit (QBA) is a clinical
patient safety audit performed yearly by Queensland Health (Queensland
Government, 2017).
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However, more simply, reduction in the number of pressure injuries could be
related to under-reporting. According to the Miles, Fulbrook, Nowicki, and Franks
(2013) study which aimed to identify trends in PIs prevalence over 10 years in public
hospitals in Queensland, Australia, “Under-reporting must always be factored into
any consideration of a hospital’s incident reports for PIs (p 152)”.
Secondary data from the study hospital when analysed by the time of day
revealed that most pressure injuries incidents were reported between 12 pm to 4 pm
pre- and post-mandatory nurse to patient ratio regulation (24.9% pre-legislation and
26.7% post legislation). These times correspond with the time of nursing staff breaks
and thus a fewer number of nurses on the ward.
Despite reporting of incidents being voluntary, the process after report may
involve acknowledgment of the results of the incidents investigation and the action
taken by the hospital management following the incident. The acknowledgment is
important because it permits for harnessing frontline workers’ knowledge and
experience of the factors leading up to various incidents that might occur in the
healthcare system and the way of addressing them by means of appropriate and
practical safety processes and procedures (Wallace, 2010). Hospital data revealed
that incidents investigation results and the actions undertaken after the incident were
communicated to healthcare staff who reported pressure injuries in most of the
incidents over the review period.
4.5 CHAPTER SUMMARY
This chapter presented the findings of the secondary data from the study
hospital which included: patient satisfaction survey data, nursing employee
engagement data, and clinical incidents data (falls, medication incidents, and
pressure injuries). Analysis of these data revealed that patient satisfaction with
nursing care was rated more highly than it was in benchmarked institutions. The
overall hospital culture reflected in the data showed the institution’s activities to
promote patient safety and this was also demonstrated in patient outcomes
improvement over the review period. Nevertheless, the data uncovered a rich array of
contextual features of the study hospital that might influence quality of nursing care
provision.
138
Key contextual features identified can be classified into three levels: facility
level – lack of management support and performance recognition; Team (knowledge
and skills) level – nurses new on the ward, communication and teamwork issues; and
at patient level – cultural and social factors. Within the context of the above
mentioned features, some nursing procedures were noted as missed (MNC) and that
may impose a risk on patient safety and overall quality of healthcare in the study
hospital. Considering these contextual elements is foundational to fostering an
understanding of MNC in the local context and to informing management approaches
to improve quality healthcare and patient safety.
The next chapter reports the results of Study Two, which was a cross sectional
survey to examine missed nursing care elements and reasons as perceived by medical
and surgical nurses using the MISSCARE survey.
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Chapter 5: Findings of Study Two (MISSCARE Survey)
5.1 INTRODUCTION
Study Two in this research aimed to examine nurses’ attitudes toward missed
care (elements and reasons). This study also aimed to examine individual nursing
characteristics and work conditions that influence MNC. A survey using the
previously validated MISSCARE survey was conducted with nurses in general
medical and surgical wards in the study hospital. The terminology related to nursing
degrees and job titles were customized to fit into the Queensland context and the
details of those customization were reported in the chapter on methodology and
methods page 91 (Permission letter to use the MISSCARE survey can be found in
Appendix 4 page 288). This chapter reports the findings of the MISSCARE survey as
well as the individual nursing characteristics and work conditions that influence
MNC in medical and surgical wards. The chapter concludes with a summary of the
findings.
To reiterate, this chapter sought to answer the following research questions:
1. What is the nature of MNC (extent and types) in medical and surgical
wards in an acute care hospital?
2. What are the reasons for MNC in medical and surgical wards in an acute
care hospital?
3. What are the individual nursing characteristics and work conditions that
influence MNC in medical and surgical wards in an acute care hospital?
5.2 SURVEY RESULTS
5.2.1 Response Rate and Respondents’ Demographic Profile
A total of 44 nurses from those who were eligible (200 nurses) completed the
MISSCARE survey (response rate: 22%). The sample of 44 respondents comprised
40 females (91 %) and 4 males (9%). The percentage of nurses working in medical
wards was 61% (n=27) compared to 39%% (n=17) working in surgical wards. As
140
shown in Table 5.1 on page 145, about one third of the respondents (36%, n=16)
were in the 25–34-years age category. The next largest age category (25%, n=11)
was 35–44 years. Only 7% % of the respondents were in the age group under 25
years old (n=3). The lowest proportion of respondents (5%%, n=2) were in the age
category over 65 years old.
More than half of the responders stated that they had bachelor’s degrees in
nursing (59%, n= 26), followed by those with master’s degree or higher in nursing
(11%, n=5). Regarding the job title, the majority of the responders were Registered
Nurses RNs (80%, n= 35). Clinical nurses (CNs) accounted for 16%% (n= 7) of the
respondents. Enrolled nurses/ Endorsed Enrolled nurses (ENs/EENs) accounted for
only 5 % (n=2) of the respondents.
Eighteen respondents (41%) had experience in the current role of more than 10
years, followed closely by respondents who stated that they had experience from 5–
10 years (34%, n=15). However, regarding the nurses’ experience in the current unit,
34% of the respondents (n= 15) had 2–5 years’ experience in the current unit. Only
2% (n=1) had up to 6 months experience in the current unit (Table 5.1). All
respondents stated some level of MNC, which was described on page 153 and for
several reasons described on page 162.
Table 5.1
Demographic profile of the respondents
Characteristic Group Frequency (n) Proportion (%) Working unit Medical
Surgical
27
17
61%
39 %
Gender Female
Male
40
4
91%
9%
Age Under 25 years old
25 to 34 years old
35 to 44 years old
45 to 54 years old
55 to 64 years old
3
16
11
7
5
7%
36%
25%
16%
11%5%
141
Over 65 years old 2
Highest nursing degree EN–hospital trained certificate
EN/EEN–Certificate IV or diploma in nursing from a registered Vocational Education and Training provider (e.g. TAFE). RN–hospital trained Certificate. Bachelor’s degree in nursing. Bachelor’s degree in nursing and bachelor’s degree outside nursing (double degree). Post graduate diploma in nursing Post graduate diploma outside nursing Master’s degree or higher in nursing Master’s degree or higher outside nursing
1
1
3
26
1
4
1
5
2
2%
2%
7%
59%
2%
9%
2%
11%
5%
Job title EN/EEN
RN
CN
2
35
7
5%
80%
16%
Experience in current role Up to 6 months
6 months–2years
2–5 years
5–10 years
1
1
9
15
2%
2%
21%
34%
142
More than 10 years
18 41%
Experience in current unit Up to 6 months
6 months–2years
2–5 years
5–10 years
More than 10 years
1
8
15
8
12
2%
18%
34%
18%
27%
Total 44 100%
5.2.2 Working conditions and nurse perceived staffing adequacy
Most of the respondents were working 30 hours or more per week (91%, n=
40). The largest proportion of the respondents stated that their working hours rotated
between days, nights, and evenings (71%, n=31). The lowest proportion of
participants reported that they were working only at night (2%, n= 1). Regarding the
shift length, it has been found that the majority of the respondents (77%, n= 34) were
working 8-hour shifts. Furthermore, of the respondents, 61% (n= 27) stated that they
had not worked overtime in the past three months. Only 2% had worked more than
12 hours overtime in the past three months. With regard to nurse staffing,
approximately one fourth of participants felt that unit staffing was adequate 100% of
the time (n=10), whereas 50% agreed that it was adequate 75% of the time (n=22)
(Table 5.2).
The mean number of patients nurses cared for in the previous or last shift was
6(SD= 4.09). The mean number of patient admissions in the current or last shift was
13 (SD= 1.23). The mean number of patient discharges in the current or last shift was
1.1 (SD= 1.53).
143
Table 5.2
Working conditions and nursing perceived staffing adequacy
Characteristic Group Frequency (n)
Proportion (%)
Number of hours worked per week Less than three hours per week
30 hours or more per week
4
40
9%
91%
Work hours Days (8 or 12 hours shift)
Evenings (8 or 12-hour shift).
Nights (8 or 12-hour shift)
Rotates between days, nights and evenings
8
4
1
31
18%
9%
2%
71%
Shift nurses most often worked in 8-hour shift
10-hour shift
8 and 12 hour rotating shift
34
3
7
77%
7%
16%
Overtime in the past three months None
1-12 hours
More than 12 hours
27
16
1
61%
36%
2%
Nurse perceived staffing adequacy 100% of the time
75% of the time
50% of the time
25% of the time
0% of the time
10
22
7
4
1
23%
50%
16%
9%
2%
Total 44 100%
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5.2.3 Missed care elements
As depicted in the methods chapter, section A in the MISSCARE survey
represents the elements of MNC. Total scoring for nursing care interventions in the
MISSCARE survey as calculated by Palese et al. (2015) gives scoring ranges from
24 (no nursing care element ever being missed by the nurses) to 120 (all nursing care
elements were always missed). In this study, the average score for missed nursing
care (total) for 44 respondents was 52.9 out of 120. The mean missed care score for
every nursing care intervention was determined to be 2.03. The value of 2.03
approaches the value of 2 assigned to the frequency category “rarely”.
Frequencies and proportion were used to identify the extent of missing
individual nursing care interventions. As reported in Table 5. 3, it was found that the
most always/frequently missed nursing care elements (which were treated in this
study as missed care) were: patient ambulation (34 %), attending interdisciplinary
care conferences whenever held (30 %), patient teaching about illness, tests, and
diagnostic studies (25%).
Regarding nursing care elements that were not frequently missed, 90% of the
participants reported that they rarely/never missed bedside glucose monitoring as
ordered. This was followed by patient bathing/skin care, patient discharge planning
and teaching, patient assessments performed each shift (84% of the participants
reported not missing of these care aspects), and vital signs assessed as ordered (82
%).
Table 5.3
Nurses perceived MNC
Missed Care Element Always /
Frequently / Missed
Occasionally Missed
Rarely / Never Missed
1. Ambulation 3 times per day or as ordered
15 (34%) 22 (50%)
7 (16%)
2. Attend interdisciplinary care conferences whenever held
13(30%) 11 (25%)
20 (45%)
3. Patient teaching about illness, tests, and diagnostic studies
11 (25%) 10 (23%)
23 (52%)
4. Full documentation of all necessary data
10 (23%) 12 (27%)
22 (50%)
5. Turning patient every 2 hours 8 (18%) 18 (41%) 18 (41%)
6. Monitoring intake/output 8 (18%) 16 (36%) 20 (46%)
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7. Mouth care 7 (16%) 12 (27%) 25 (57%) 8. Emotional support to patient and/or
family 6 (14%)
12 (27%) 26 (59%)
9. Feeding patient when the food is still warm
5 (11%) 11 (25%)
28 (64%)
10. Setting up meals for patient who feeds themselves
4 (9%) 10 (23%)
30 (77%)
11. Response to call light is initiated within 5 minutes
3 (7%) 13 30 %)
28 (63.7%)
12. Assess effectiveness of medications 3 (7%) 13 (30%) 28 (64%) 13. Medications administered within 30
minutes before or after scheduled time
3 (7%) 10 (23%)
31 (71%)
14. Skin/Wound care 3 (7%) 10 (23%) 31 (71%) 15. Patient discharge planning and
teaching 3 (7%)
4 (9%) 37 (84%)
16. PRN medication requests acted on within 15 minutes.
2(5%) 9 (21%)
43 (75%)
17. Vital signs assessed as ordered 2 (5%) 6 (14%) 36 (82%)
18. Hand washing 1 (2%) 7 (16%) 36 (82%) 19. Patient assessments performed each
shift 1 (2%)
6 (14%) 37 (84%)
20. Focused reassessments according to patient condition
0 (0%) 13 (30%)
31 (71%)
21. IV/central line site care and assessments according to hospital policy
0 (0%) 10 (23%)
34 (77%)
22. Patient bathing/skin care 0 (0%) 7 (16%) 37 (84%) 23. Bedside glucose monitoring as
ordered 0 (0%)
4 (9%) 40 (91%)
24. Assist with toileting needs within 5 minutes of request
0 (0%) 20 (46%)
24 (55%)
5.2.4 Categories of MNC
As portrayed in the Missed Nursing Care Model employed in this research,
nursing care elements in the MISSCARE survey have been classified into four
groups: interventions–basic care, interventions–individual needs, assessment, and
planning. The following section demonstrates the findings related to each of these
categories.
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Interventions–Basic care
The most frequent missed nursing procedures in the category interventions–
basic care were: ambulation (34%), turning patient every two hours (18%), and
mouth care (16%). No missed care was identified in the patient bathing/skin care
(0%) (Figure 5.1).
Figure 5.1. Interventions–basic care
Interventions–Individual needs
The most frequent interventions related to individual needs that were missed by
the nurses were: emotional support to patient and family (14%), medication
effectiveness assessment, and medications administered within 30 minutes before or
after scheduled time (7%) and PRN medication requests acted on within 5 minutes
(5%). No missed care was identified in the assistance with toileting needs within 5
minutes of request (0%) (Figure 5.2).
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Figure 5.2. Interventions–individual needs
Assessment Nursing Procedures
The most frequent assessment care procedures missed by the nurses in the
medical and surgical wards were: full documentation of all necessary data (23%),
monitoring fluid intake/output (18%), and vital sign assessment as ordered (5%). No
missed care was identified in the IV site care and assessment according to hospital
policy, bedside glucose monitoring as ordered, and focused reassessment according
to patient condition (0%) (Figure 5.3).
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Figure 5.3. Assessment nursing procedures
Planning
The most frequently missed nursing care items related to planning were:
attendance at interdisciplinary care conferences whenever held (30%), and patient
teaching about illness, tests, and diagnostic procedures (25%) (Figure 5.4).
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Figure 5.4. Planning
5.2.5 Reasons for MNC
According to the results of this PhD, reasons for MNC were labour resources,
material resources, and communication issues. The results indicated that the labour
resources were the most frequent reasons identified by the participants as reasons for
MNC (range from 77%–46%), followed by material resources (range from 34%–
25%), followed by communication/teamwork issues (range from 11%–39%) (Table
5.4).
Table 5.4
Reasons for missed care
Reason for missed care
Significant / Moderate Reason
N (proportion)
Minor / Not a
Reason N
(proportion)
Labour Resources Urgent patient situations (e.g. a patient’s condition worsening)
34 (77%) 10 (23%)
Heavy admission and discharge activity 32 (73%) 12 (27%) Unexpected rise in patient volume and/or acuity on the unit
31 (70%) 13 ( 30%)
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Inadequate number of staff 21 (48%) 23 (52%) Inadequate number of assistive and/or clerical personnel (e.g. nursing assistants, techs, unit secretaries etc.)
20 (46%) 24 (55%)
Material Resources
Medications were not available when needed 15 (34%) 29 (66%)
Supplies/ equipment not available when needed 13 (30%) 31 (70%) Supplies/ equipment not functioning properly when needed
11 (25%) 33 (75%)
Communication/Teamwork Resources
Unbalanced patient assignments 17 (39%) 27 (61%) Tension or communication breakdowns with other ancillary/support departments
12 (27%) 32 (73%)
Tension or communication breakdowns with the medical staff
11 (25%) 33 (75%)
Tension or communication breakdowns within the nursing team
11 (25%) 33 (75%)
Lack of back up support from team members 11 (25%) 33 (75%) Other departments did not provide the care needed (e.g. physical therapy did not ambulate)
11 (25%) 33 (75%)
Inadequate hand-over from previous shift or sending unit 10 (23%) 34 (77%) Nursing assistant did not communicate that care was not provided
5 (11%) 39 (89%)
Caregiver off unit or unavailable 8 (18%) 36 (82%)
5.3 INDIVIDUAL NURSING CHARACTERISTICS AND WORK
CONDITIONS AND MNC
One-way Analysis of Variance (one-way ANOVA) was used to answer
research question 3 in this research: “What are the individual nursing characteristics
and work conditions that influence MNC in medical and surgical wards in an acute
care hospital?” Individual nurse characteristics in this context involved: nurse’s job
title (question number 7 in the MISSCARE survey) and experience in the current role
(question number 10 in the MISSCARE survey). The results of ANOVA in Table 5.5
indicated that nurse's job title had no statistically significant effect on total score of
MNC F (2, 41) = 0.648, p > 0.05. Likewise, experience of nurse in the current role
had no statistically significant effect on total score of MNC F (4, 39) = 0.262, p >
0.05.
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Table 5.5
The relationship between individual nursing characteristics and MNC (ANOVA results)
Individual nursing characteristics
F df1 df2 p
Job title 0.648 2 41 0.528
Experience in the current role 0.262 4 39 0.900
Work related conditions in this context included: number of working hours per
week, type of working hours (day, evening, and night), shift length and overtime
(question numbers 8, 9, 12, 13 in the MISSCARE survey respectively). The results of
ANOVA in Table 5.6 indicated that number of hours worked per week had a
statistically significant effect on total score of MNC F (1, 42) = 8.576, p < 0.05.
However, no statistically significant effect was found between type of working hours
(day, evening, night, and rotating shift), shift length, overtime, and total score of
MNC (p > 0.05).
Table 5.6
The relationship between work related conditions and MNC (ANOVA results)
Nursing work conditions F df1 df2 p
Number of hours worked per
week
8.576 1 42 0.005
Type of working hours (day,
evening, night, rotating shift)
0.253 3 40 0. 859
Shift length 0.030 2 41 0. 970
Overtime 3.081 2 41 0. 057
5.4 CHAPTER SUMMARY
This chapter has depicted the finding of the cross-sectional study conducted using the
MISSCARE survey with nurses working in medical and surgical wards in the
hospital under study. The MISSCARE survey was completed by 44 nurses in
medical and surgical wards.
According to this study, most of the participants were females, Registered
Nurses (RNs), and were working in the medical wards. The data indicate that the
most frequently missed care elements were: ambulation, attending interdisciplinary
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care conferences, and patient teaching about illness, tests, and diagnostic studies. The
least frequently missed care elements were: patient bathing/ skin care, bedside
glucose monitoring as ordered, and toileting assistance within 5 minutes of request.
The results show that the most frequent reasons for MNC in medical and
surgical wards were related to the unpredictable nature of the complex healthcare
system, namely urgent patient situations (e.g. a patient’s condition worsening), heavy
admission and discharge activity, and unexpected rise in patient volume and/or
acuity on the unit.
The participants' perceptions about MNC have practical usefulness as they may
aid nurses and nursing managers to better understand and develop initiatives to
manage MNC in acute care contexts.
The following chapter illustrates the findings drawn from Study Three, which
was a case study conducted at a medical ward level in the study hospital.
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Chapter 6: Findings of Study Three (Descriptive Case Study)
6.1 INTRODUCTION
A detailed descriptive case study was carried out in a general medical and
cardiac telemetry ward in the study hospital. The study ward was chosen by the DON
in the study hospital as concerns about increased workload had been raised by the
nursing staff working in this ward to the hospital nursing management. This case
study aimed to provide a detailed and holistic understanding of MNC incidences as
well as the factors and circumstances impacting its occurrence in the medical care
environment. To do so, the researcher collected and analysed both primary and
secondary data from the studied ward. The case study was conducted in the period
from Monday 22th January 2018–Sunday 4th February 2018. This chapter illustrates
the findings of that case study.
Data sources used for this case study comprised the following, which were
collected for the defined case study period:
Ward profile, namely: average Length of Stay, patient turnover (number of
admissions, transfers, and discharges), and the bed occupancy rate.
Patients’ profile (demographic and clinical).
Nurse Rostering information.
Patient related incidents data reported to the hospital incident reporting
system.
Patients’ MISSCARE survey.
Nurses’ MISSCARE survey.
The case study sought to answer the following research questions:
1. What is the nature of MNC (extent and types) in medical and surgical
wards in an acute care hospital?
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2. What are the reasons for MNC in medical and surgical wards in an acute
care hospital?
6.2 CASE STUDY FINDINGS
This case study was performed in a 29-bed inpatient general medical/
Cardiology/ Telemetry ward in an acute care tertiary hospital. A total Fulltime
Equivalent (FTEs) cohort of 50 Enrolled Nurses (ENs), Enrolled Nurse Advanced
Practitioners (ENAPs), Registered Nurses (RNs) and Clinical Nurses (CNs) were
employed in this ward during the case study period. One FTE indicates the number
of hours worked and is equal to 80 hours per fortnight. In the study ward, if nurses
worked full time hours, namely 80 hours per fortnight, they got one day off in a
month called a Rostered Day off (RDO) which was on top of their 4 days a fortnight
as Days off. Nurse to patient ratio in the studied ward was 1:4 in the morning and
afternoon shifts, and 1:7 in the night shift.
6.2.1 Ward Profile
In this section, a discussion of the case study ward profile is provided. The
section describes and discusses the average LOS, patient turnover, and the bed
occupancy rate for the case study ward during the two weeks period (Table 6.1).
Table 6.1
Case study ward profile (during two-week case study period).
Metrics Metric value
Average Length of Stay 3.61 days
Admissions and transfers into the study ward 142 patients
Number of discharges 72 patients
Bed occupancy rate 88%
Average LOS and Patient Turnover (Admissions, transfers and discharges)
The Average Length of Stay (ALOS) in the case study ward (3.61 days) was
comparable to the ALOS in Australian public hospitals (AIHW, 2016). It can also be
seen that number of discharges from the case study ward (72 discharges) was less
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than number of admissions and transfers onto the case study ward (142 admissions
and transfers in) during the case study period. This was explained by patients who
were admitted in the previous five days before the case study period finished, but
who might not have been discharged at the end date of the case study. Also, some
patients might have been transferred out from the study ward to another area in the
hospital due to requirements to admit a telemetry patient or a patient who needed the
negative pressure isolation room (the study ward has the only one outside of the ED).
The data reflected a high patient turnover rate in the case study ward that led to
increases in the workload of the nursing staff
Admissions into the case study ward include admissions from the Emergency
Department (ED) and Elective (scheduled) admissions. Most admissions into the
study ward during the case study period were emergency admissions (68.95%).
Elective admissions accounted only for 21.12% of all admissions during the case
study period. High levels of emergency admissions are associated with adverse
patient events and thus might endanger patient safety (Tian, Dixon, & Gao, 2012).
Also, emergency admissions can disrupt and impose pressure on elective admissions
or even on already admitted patients (Morse, 2013) and may lead to MNC. Also, the
LOS associated with emergency admissions is considerably less than LOS for
elective admissions (Vetrano et al., 2014) thus further increasing nursing workload.
According to Bagust, Place, and Posnett (1999), the presence of spare beds in
the inpatient wards is found to be a key element to accommodate such high rates of
emergency admissions and to contain the possible risk to an extent that is satisfactory
to the patients. Hence, there is likely to be a reduction of MNC occurrence. Indeed,
healthcare resources are related to the economic status of the healthcare organisation
and leadership decisions (Dalton & Warren, 2016). As such, hospital leaders should
ensure the ward resources are readily available to provide care in light of high
demand coupled with a 60% reduction in the number of beds in the Australian public
hospitals (4.8 beds for 1,000 population in 1983 to 2.5 per 1,000 population in 2009)
(Sammut, 2009). According to Sammut (2009), the most important cause of
overcrowding in the Australian hospitals is bed shortages.
During the periods of bed shortages, there are higher levels of demand on
healthcare staff as well as increased demand for innovative technology diagnostic
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and therapeutic interventions (Madsen, Ladelund, & Linneberg, 2014) which
potentially lead to MNC. Bed shortages might not be caused only by a supply and
demand incongruity but also by other factors such as defective planning, financial
arrangements, and leadership strategies (Madsen et al., 2014). Thus, providing a
resolution to the visible issue by adding extra beds possibly would rectify this
dilemma in the first instance, however, the dilemma would emerge again in the near
future as the beds will replenish again and the problem will come back (Kuziemsky,
2016; Serafini et al., 2015). Hence, there is a need to consider the complexity of the
healthcare system in addressing this issue (Kuziemsky, 2016) is paramount.
However, it is important to recognize that reduced bed numbers do not
essentially indicate a lack of beds, but may indicate increased bed occupancy rates
and greater amounts of delayed episodes of care transfers (Richardson, 2017).
Transfers into the case study ward included patients who were transferred
from Intensive Care Unit (ICU) or patients who were transferred from another ward
(i.e. surgical wards or medical wards that did not have cardiac telemetry). Transfer
between several wards is somewhat essential to perform certain diagnostic or
therapeutic procedures. However, it undermines the continuity of care and reduces
the time available to provide patient care (Blay, Duffield, & Gallagher, 2012).
Patient transfers impose high communication requirements on the nurses (Lees,
2013). A potential outcome of frequent patient transfers is increased nursing
workload which might have implications for patient safety (Blay, 2015).
Additionally, frequent patient transfers may have a negative impact on patient safety
due to unfamiliarity with the patients and their requirements/care by the nursing staff
in the ward that the patient was transferred to (Lees, 2013). Thus ineffective
communication, missing essential health information, and increased rate of
healthcare errors may result (Friesen, Hughes, & Zorn, 2007). Also patient transfer
documentation is an essential part of the process that is sometimes missed by
nursing staff (Kulshrestha & Singh, 2016).
Transfer of a patient from ICU into a general ward represents a challenging
shift of care (Kauppi, Proos, & Olausson, 2018). This event is well known by the
name of medical outliers (Stylianou, Fackrell, & Vasilakis, 2017). Other names for
this event are: “boarders”, “Overflow” and “sleep-outs” (Goulding, Adamson, Watt,
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& Wright, 2012, 2015). It also can be called bed spacing (McAlister & Shojania,
2018). The ICU patients are high acuity patients. The ICU environments are well
equipped to handle such types of vulnerable patients. However, general wards have
limited resources to deal with them (Kauppi et al., 2018). It has been identified that
assignment of patients to wards that do not have the potential to present the care that
is needed by patients particularly may result in substandard care provision as well as
endangering continuity of care (Stylianou et al., 2017). This is not only related to
resources, but also to absence of specialised nursing staff based on the illness /health
status of the outliers (Santamaria, Tobin, Anstey, Smith, & Reid, 2014; Stylianou et
al., 2017). Further examination of the relationship between medical outliers and
MNC in a medical ward context needs to be investigated in future research.
Additionally, transfer of patient from the ICU into a general ward requires
effective and standardized communication strategies between the ICU nurse and
general ward nurses in order to preserve patient safety (James, Quirke, & McBride�
Henry, 2013). In this vein, it is important to note that providing nursing care for a
former ICU patient may be demanding for the nurses and may potentially lead to
MNC. According to Kauppi et al. (2018), the critical condition of the ICU patients
who are newly transferred into a general ward makes the general ward nurse
prioritise the care for such patients, which may affect the nursing care provided for
other stable patients in the ward. In addition, transfer of ICU patient into a general
ward can potentially lead to missing recognising early deterioration signs for
vulnerable patients by the nurses, particularly less experienced nurses, and thus
compromise patient safety (Kauppi et al., 2018). In this context, insufficient care for
patients could refer to the insufficiency of personnel skills in the “outlier” (non-
home) unit relative to the transferred patient’s needs. Hence, being an outlier patient
or “home” unit patient impacts the patient’s healthcare results (Santamaria et al.,
2014).
Furthermore, according to an observational cohort Australian study conducted
in a teaching hospital in Victoria (Santamaria et al., 2014), medical outliers were
associated with 53% increase in the number of emergency calls, and hence, increased
staff workload. Further, in the case of medical outliers, the staff might not have
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enough information about the patients. Thus, suboptimal decisions might be made
that have a negative impact on patient safety (Santamaria et al., 2014).
Also, patients who are admitted to the general ward from the ICU may have
different requirements from other patients in the ward, such as emotional support,
medication administration and medication effectiveness assessment. Hence, the
increased nursing burden necessitates additional staffing (Kauppi et al., 2018).
However, patients newly transferred from ICU into a general ward should be well
informed about variations in staffing levels between the ICU and the general ward. In
doing so, patients could anticipate that they may not receive such prompt help as they
were receiving in the ICU (Kauppi et al., 2018).
Bed occupancy rate
Bed occupancy rate represents a measure for quality healthcare and reflects the
hospital capability to provide healthcare for the patients in an appropriate and
efficient manner (Keegan, 2010). Healthcare managers generally agree on 85%
occupancy rate as a safe ideal (Scott, 2010; Stevenson et al., 2011). An occupancy
rate of 85% gives an ideal equilibrium between efficiency of the hospital and patient
safety (Green, 2002). However, according to the Australasian College of Emergency
Medicine, a bed occupancy rate of more than 85% is viewed as compromising the
safety of healthcare provision, and negatively impacting staff satisfaction, and it
might result in a bed shortages issue (Forero & Hillman, 2008). Bed occupancy rate
has a significant relationship with adverse patient outcomes (Abhicharttibutra,
Wichaikhum, Kunaviktikul, Nantsupawat, & Nantsupawat, 2018). Also, increased
bed occupancy rate is associated with reduced staff compliance with hand hygiene
protocols as a result of reduced staffing levels and increased workload (Clements et
al., 2008; Jones, 2016).
Bed occupancy rates above 85% suggest overcrowding and need for admitting
more patients urgently, which exceeds the available staffed beds (Sammut, 2009).
Bed occupancy rate in the 29-beds case study ward during the case study period was
88%. High occupancy rates refer to the system productivity (Madsen et al., 2014).
However, it might have negative influence on patient and staff outcomes as well as
perhaps leading to MNC in the study ward (e.g. missed hand washing). Increased bed
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occupancy rate in the case study ward can be explained by a high rate of emergency
(unplanned) admissions into the study ward during the case study period.
6.2.2 Patients’ Profile (Demographic and Clinical)
Demographic information for the patients admitted to the study ward during
the case study period was obtained from the hospital. The percent of male patients
was 60% and females was 40%. The average age of the patients admitted was 66
years old, which indicates a more complex patient profile.
Diagnosis Related Groups (DRGs) data, which is a system for classifying
patients into particular sets depending on their illness severity and thus the required
resources to provide care for them (Duffield, Roche, & Merrick, 2006), were
obtained for the sake of the case study and illustrated in Table 6.2 below. From the
141 patients who were in the study ward during the case study period, the largest
DRG category was in cardiovascular and cardiac diseases (n=43, 30%), followed by
respiratory and thoracic diseases (n=26, 18%), and renal and urologic diseases (n=13,
9%). No death was reported in the study ward during the case study period.
Based on the criteria of the Australian Refined Diagnosis Related Groups (AR-
DRGs) (Australian Consortium for Classification Development, 2016), it has been
found that of the admitted patients, 55% (n=78) had major complex conditions
(required highest consumption of resources, as they had catastrophic complication
and/or co-morbidity codes). However, 6% (n=9) had intermediate complexity and
38% (n=53) had minor complexity (which required lower resources consumption as
they had severe complication and/or co-morbidity codes).
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Table 6.2
DRGs for patients who were in the case study ward during the two weeks case study period (clinical
profile)
DRG category Number (n) Proportion
Neurology and cranial 8 5%
Ophthalmology 1 0.7%
Head and neck and ENT 1 0.7%
Respiratory and thoracic 26 18%
Cardiovascular and cardiac 43 30%
Gastroenterology and abdominal
6 4%
Hepatobiliary 2 1%
Orthopaedic incl. spinal surgery, soft tissue and hand injuries
7 5%
Skin, plastics, breast 7 5%
Endocrine 4 2%
Renal and urologic 13 9%
Male genital incl. prostatic 1 0.7%
Haematological incl. spleen 4 2%
Lymphoma, leukaemia, chemotherapy, radiotherapy
1 0.7%
Septicaemia, post-op infections, PUO, viral infections
12 8%
Mental health 1 0.7%
Drug and alcohol
1 0.7%
Trauma, allergic reactions, poisoning, complications
1 0.7%
Rehabilitation, diagnoses of other contacts, signs and symptoms only, post-op review
1 0.7%
Procedures unrelated to principal diagnosis
1 0.7%
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Demographic and clinical profile for patients presenting to the case study ward
informed the risk profile of the patients and thus indicated the risk factors for
occurrence of adverse incidents in the patient cohort. Hence, it permitted the nursing
staff to predict potential strategies and interventions that would enhance patient
safety and improve patient outcomes.
6.2.3 Nurse Rostering Information
Nurse rostering information reflects the actual work demands on the nurses
(Queensland Government, 2016). Thus, nurse rosters should provide a suitable skill
mix of competent and experienced nurses to meet identified service demand and to
provide appropriate care standards. The Nursing Unit Manager should provide
published roster guidelines according to the specific needs of each unit. The roster
should take into account fluctuations of demand and clinical requirement.
Furthermore, it should ensure that nurses are rostered in a fair, reasonable, and
equitable manner while balancing patient, employee and organisational needs
(Queensland Government, 2016). Further details about rostering procedures were
provided in the methodology and methods chapter.
The hospital provided the researcher with nurse roster information for the study
ward for the case study period (22th January–4th February 2018) after finishing
patients and nurses survey components of this case study. A Nursing roster is equal
to a four-week period (i.e. two payroll periods). Nurse roster information is generated
every fortnight and sent into Payroll Services for entry into the payroll roster system.
Rosters are posted at least two weeks before the starting date of the first working
period in the roster (Queensland Government, 2016). The hospital provided the
researcher with nurse roster information for the period (15 January 2018–11
February 2018) as the case study crossed two separate fortnights. The researcher
quantified and tabulated the roster information and was able to calculate the
following:
Nursing Hours per Patient Day (NHPPD) for the studied unit
Nursing Hours per Patient Day (NHPPD) is a quantifiable metric for nurse
staffing which refers to the nurses’ capability to deliver care for the patients
(Schreuders, Geelhoed, Bremner, Finn, & Twigg, 2017). NHPPD is the most
frequently used nurse staffing measures (Min & Scott, 2016), particularly in quality
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healthcare research (Kalisch et al., 2011). It is defined as the number of hours of
nursing care required to meet each patient’s care needs in a 24-hour period. NHPPD
can be calculated by dividing the number of productive hours worked by all nurses in
a day by the number of patients on a unit in the same day (Schreuders et al., 2017).
In this case study, Nursing Hours per Patient Day (NHPPD) was calculated by
dividing the number of all hours worked by the nurses over the number of patients
admitted to the unit in the same day and then taking the mean for the whole period.
The mean NHPPD for the studied ward was calculated and found to be 7.2 hours
(this value is possibly overestimated as it was not feasible to obtain only the number
of productive hours (direct patient care) to perform this calculation). Based on this,
this unit has been given category A according to guiding principles that classified the
hospital units based on their NHPPD. A Category A unit is characterized by being a
high complexity unit (Twigg & Duffield, 2009). However, it should be noted that
NHPPD does not provide enough information regarding resources used by nurses for
individual patients (Welton & Harper, 2016). Hence, it may be presumed that this
nurse staffing measure does not consider complexity of the healthcare system that
may be attributed to changes and variability in patients’ conditions.
Nurse staffing in various shifts
The nurse roster information comprised the number and skill mix of nurses in
day, evening, and night shifts. The number of bedside nurses rostered in every shift
per day for this period was calculated. The number of ENs, ENAPs, RNS, and CNs
was extracted from the roster information, and level of coverage was also calculated.
The level of coverage was defined as the average number of nurses in each shift on
the 7-week days. The coverage level on the day and evening shift was 9.6 nurses.
However, there were only 5 nurses on the night shift on average during this period.
Thus, staffing levels were lower during night shifts. Most nurses in all shifts were
RNs. Based on these numbers, the researcher attempted to answer the following
questions (Sections 6.2.6.7 and 6.2.6.8 respectively):
1. What is the level of nurse staffing adequacy reported by nurses working on
day, evening, and night shifts?
2. What are the most frequent reasons for MNC reported by nurses working on
day, evening, and night shifts?
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6.2.4 Patients related Incidents Data
Clinical incidents data for nursing sensitive outcomes (falls, medication errors
and pressure injuries) reported during the case study period were provided to the
researcher by the DON. Clinical incidents represent the incidents that have been
voluntarily reported by the nurses to the hospital reporting system. Surprisingly, from
the incidents data provided for the study period, no patient falls, medication errors
and pressure injuries were reported by the nurses in the study period in the study
ward. It was reported by the NUM of the involved ward that this was a bit strange
not to have any event reported. This could be related to the Hawthorne (observer)
effect (Chiesa & Hobbs, 2008). The nursing team might work harder or improve their
performance during the study period as a result of their awareness that their ward
was being investigated during this period.
Apart from nurse sensitive outcomes, three patient related incidents were
reported to the hospital reporting system during the case study period. These were:
1. Patient had high blood glucose level and high ketone since morning, which
was not treated accordingly.
2. Nursing concerns escalated to medical registerer and ward call with delayed
response.
3. Telemetry patient sent to X-ray—no nurse escort/no medical chart/no
documented decision in progress notes.
Thus far in this Chapter, findings from secondary data obtained from the study
hospital for the case study period have been discussed. As this case study aimed to
gain an in-depth understanding of MNC in a medical care environment, secondary
data discussed above provided a context for the case study ward. However, detailed
understanding of MNC in the study ward would not be gained without examining the
MNC perceptions of both patients and nurses who are the main individuals involved
in the health care delivery process. Hence, patients and nurses MISSCARE surveys
were performed for the two weeks case study period (details about the procedures
used by the researcher to collect the data from the patients and nurses can be found in
the Chapter on Methodology and Methods). The following section demonstrates the
findings of patients and nurses MISSCARE surveys.
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6.2.5 Patients Survey Results
The validated MISSCARE survey–Patient was used to assess patients’ attitudes
toward missed care in the study ward (permission to use the MISSCARE survey–
Patient from the author can be found in Appendix 8). The number of patients who
were eligible to complete the survey was 37. Seven patients declined to be involved
in the survey so the number of patients who participated in the case study was 30
(response rate: 81%). The majority of the patients completed the survey by
themselves (83%, n=25). The remainder asked the researcher to complete the survey
for them because they were unable to complete the survey due to their health
condition or the medical appliances attached, and they asked the researcher to read
the questions and options for them and they chose their response which was recorded
by the researcher in pen on the survey.
6.2.5.1 Demographic profile of the patients
There were slightly more males in the patients’ sample than females (56.7%%
male n=17, 43.3% female n=13).
About one third of the patients’ sample in the present study (33.3% n= 10) were over
65 years old. Patients under 25 years old category accounted for 13.3% of the
respondents (n= 4).
In the present study, of the patients over 65 years old, 70% (n=7) were males.
Males and females had equal proportions in the age groups: 25-34, 35-44, 45-54. The
only age category in which the proportion of females exceeded the proportion of
males was 55-64 years old (female 66% n= 4, male 33%, n=2). The patients
surveyed were asked about their perceptions of the nursing care they received during
their hospital stay and the results are presented in the next section.
6.2.5.2 Missed care identification by patients
Descriptive statistics were performed to assess the missed care elements as
perceived by the patients, as well as a chi square statistical test to assess the
relationship between patients’ demographic characteristics (age and gender), and
their perceptions of MNC.
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The most frequent nursing care element missed, as reported by the patients in
this study, were: oral care (53.3%), response to machine beep (50%), and response to
call light (46.7%).
Nursing care elements documented in the MISSCARE survey–Patient were
divided by the survey developer into three parts: essential care, timeliness, and
communication. Each one of these parts has a group of nursing care elements listed
and the percent of missing each particular element is presented in the next section.
However, the majority of patient-perceived missed care elements was related to
timeliness (42.5%), followed by essential care procedures (33.3%) and
communication related procedures (19.3 %).
Essential care
The operational definition for essential care was derived from the MISSCARE
survey–Patient based on four questions in the survey, namely: patient ambulation,
bathing, help getting out of the bed, and mouth care. As evident in Table 6.3 below,
the essential care item most frequently missed by the nurses as reported by the
patients was oral care (53.3%, n=16), followed by patient ambulation (33.3%, n=
10). Patient bathing was the least frequently missed care item (16.7%, n=5).
About 6.7% of the patients surveyed in the present case study (n=2) reported
that they couldn’t walk, and 10% (n=3) reported that they couldn’t get out of the bed.
Table 6.3
Essential care elements reported by patients
Essential care element Patient reported missed care proportion (Frequency)
Mouth care 53.3% (n=16)
Ambulation 33.3 (n=10)
Getting out of bed into the chair
30% (n=9)
Bathing 16.7% (n=5)
Timeliness
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The operational definition for timeliness was derived from the MISSCARE
survey–Patient based on four questions in the survey, namely: nurses’ response to
machine beep, nurses’ response to call light, receiving help after call light, and
receiving help for bathroom request.
Fifty percent of the patients perceived that the nurses’ responded to their
machine beep in less than 5 minutes. Of the patients, 46.7% reported that the nurses
responded to their call light in less than 5 minutes. About one third of the patients
(33.3%) perceived receiving nursing toileting help in less than 5 minutes (Table 6.4).
According to Kalisch et al. (2014), toileting assistance was the most frequent
timeliness care procedure missed (10.90%).
Table 6.4
Timeliness care elements missed by the patients
Timeliness care element Response in less than 5 minutes
Proportion (Frequency)
Response to machine beep 50% (n=15)
Response to call light 46.7% (n=14)
Receive the requested help after the call light 40% (n=12)
Assistance in toileting 33.3% (n=10)
Communication
The operational definition for communication was derived from the
MISSCARE survey–Patient based on five questions in the survey, namely: clarity of
nurse assigned to the patient, treatment discussion with the patient, providing
information about tests and/ or procedures, considering patient’s opinions and ideas
about their care, listening to patient’s concerns regarding care or illness. Effective
communication between patient and nurse is a key element in provision of quality
and safety in healthcare (McCabe, 2004). Thus, failure of the nurses to communicate
effectively with the patients could to lead to MNC.
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About one third of the patients (33.3%) reported that they were not clear about
which nurse was assigned to them during their hospitalization (Table 6.5). However,
Kalisch et al. (2014) found that 11.20% of the patients perceived that they were clear
about the nurse assigned.
About one fourth of the patients in the current study stated that the nurse did
not discuss their treatment with them and also the nurses did not give them
information about tests and/or procedures (26.7%). None of the patients reported that
nurses did not listen to their concerns about care or their illnesses.
Table 6.5
Communication care elements missed by the patients
Communication care element Patient perceived missed care Proportion (Frequency)
Patient is clear about nurse assigned 33.3 % (n=10)
Discussion of treatment with the patients, and nurse gives information about test and/or procedures
26.7% (n=8)
Considering patient opinion about their care
10% ( n=3)
Listening to patient concerns about care or illness
0% (n=0)
6.2.5.3 The association between patient demographic characteristics (age and gender) and MNC
No association was found between the age and gender of the patients and any
of the nursing care elements listed in the MISSCARE survey–Patient (P value >
0.05).
6.2.5.4 Patient reported adverse events
In the MISSCARE survey–Patient, the last part asked the patients if they
experienced the following problems during their hospital stay: fall, skin
breakdown/pressure ulcer, medication administration error, new infection, IV
running dry, IV leaking into skin, and other problems. No patients experienced any
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of these problems. However, in the other problems section one patient reported that
one nurse yelled at him. Another patient reported that the nurses did not respond to
his request for analgesics and did not treat him in a good way. Lack of optimal pain
management represents an example of missed care.
6.2.6 Nurses Survey Results
The Paper-based MISSCARE survey used in Study 2 in this research was used
to examine missed care as perceived by the nursing staff in the case study ward. The
number of nurses completing the survey in this study was 28 (response rate: 56%).
6.2.6.1 Demographic profile of the nurses
Most of the respondents (96%, n=27) spent considerable time on the medical
ward involved in the study. Of the respondents, 3.5% (n=1) were from the casual
pool and 3.5% (n=1) from the relief pool. A casual nurse is a nurse that has been
employed for a short and indeterminate time period upon a casual (temporary) basis.
Casual nurses are employed to encounter unanticipated conditions that happen when
the case permanent nursing staff could not meet these conditions, such as in the case
permanent staff taking sick leave (Australian Nursing and Midwifery Federation,
2016), or participating in fixed term projects or accredited study courses.
Furthermore, casualization takes place to address seasonal variations in workload and
in the periods of organisational change (Queensland Government, 2010). The relief
pool in the hospital consists of nurses who are used for leave relief or nursing roster
shortages (Queensland Government, 2016). Relief nurses are usually not familiar
with the ward environment, patients and the healthcare processes, which might
increase the workload of other nursing staff on the ward in regard to decision making
processes and supervision of inexperienced nursing staff (Verrall et al., 2015).
There were 25 females (89%) in the study. The age range was mainly 35–44
years (35.71% n= 10), followed by 25–34 years (28.57% n= 8). Only 3.6% (n=1)
were under 25 years of age. Job title was mainly RN (78.57%, n=22), followed by
CN (17.86%, n=5) and EN/EEN (3.57%, n=1). Regarding the highest nursing degree,
this was bachelor’s degree of nursing (67.86%, n= 19), RN-hospital trained
certificate, double degree (one in nursing and one outside of nursing) and post
graduate diploma in nursing had similar proportions (7.1%, n=2). Regarding the
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experience in the current role, half of the nurses had greater than 10 years’
experience (n=14), followed by greater than 5 to 10 years (17.9%, n=5).
Nurses who participated in the case study were asked about their perceptions
regarding their working features, nurse staffing adequacy, satisfaction, and MNC
elements and reasons and the results are provided in the following sections.
6.2.6.2 Work features and nurse perceived staffing adequacy
The majority of the nurses (78.6%, n=22) worked 30 hours or more in a week.
Regarding the shift, 93% of the nurses worked in 8-hour shifts (n= 26), and rotated
between days, nights or evenings shifts (82.1%, n=23). Nearly half of the nurses
(54%, n= 15) did not work overtime in the previous three months, and that was
followed by those working from 1–12 hours overtime (43%, n=12). 75% of the
nurses (n=21) had been absent due to illness, injury or other reasons in the past three
months in at least one day or shift.
Regarding nursing perceived staffing adequacy, 42% of the nurses reported
that staffing was adequate 75% of the time (n=12). That was followed by those who
reported that unit staffing was adequate 50% of the time (32.1%, n=9), and 17.9 %
who said unit staffing was adequate 100% of the time (17.9%, n=5). Only 7.1% of
the nurses reported that unit staffing was adequate 0% of time (n=2). The average
number of patients assigned to nurses per shift was 5.7 (SD = 6.6). Average numbers
of patient admitted were 1.7 per shift (SD = 1.7), and patient discharges were 1.8 (SD
=2.7).
6.2.6.3 Nurses Satisfaction
Of the nurses who completed the MISSCARE survey, 75% (n=21), 82.2%
(n=23), 85.7% (n=24) were very satisfied and satisfied with the current position, with
being a nurse (n= 23), and with teamwork level on the unit respectively.
6.2.6.4 Missed care identification by the nurses
Section A in the MISSCARE survey used in the study asked nurses about their
perceptions regarding missed care elements, such as ambulation, turning, and
toileting assistance. Table 6.6 below illustrates the percentage of care elements most
frequently missed by the nurses. The most frequently missed care items were:
ambulation (42.8 %, n=12), followed by monitoring fluid intake/output and
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attendance at interdisciplinary conferences whenever held (35.7%, n=10), followed
by mouth care (32.2%, n=9).
Table 6.6
Care elements most frequently missed by the nurses
Nursing care element Proportion (Frequency)
Ambulation three times per day or as ordered 42.8% (n=12)
Monitoring fluid intake/output 35.7% (n= 10)
Attendance at interdisciplinary conferences whenever held 35.7% (n= 10)
Mouth care 32.2% (n=9)
The least frequently missed nursing care elements as perceived by the nurses
were: hand washing, patient discharge planning and teaching, bedside glucose
monitoring as ordered, patient assessment performed each shift, focused
reassessment according to patients’ conditions, and response to call light within 5
minutes (3.6%), followed by feeding patient when the food is still warm, IV/ central
line site care and assessments according to hospital policy, and skin care (7.1%),
followed by setting up meals for patients who fed themselves and patient
bathing/skin care (7.2%) (See Table 6.7).
Table 6.7
Care elements least frequently missed by the nurses
Nursing care element Proportion (Frequency)
Hand washing, patient discharge planning and teaching, bedside glucose monitoring as ordered, patient assessment performed each shift, focused reassessment according to patients’ conditions, and response to call light within 5 minutes, and focused reassessment according to patients’ conditions
3.6% (n=1)
Feeding patient when the food is still warm, IV/ central line site care and assessments according to hospital policy, and skin care
7.1% (n= 2)
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Setting up meals for patients who fed themselves, patient bathing/skin care 7.2% (n= 2)
6.2.6.5 Comparing patients’ and nurses’ missed care perceptions
The common care elements listed in the nurse and patient MISSCARE surveys
were compared, namely: ambulation, mouth care, bathing, toileting assistance,
response to call light within 5 minutes, patient teaching about their care, and
emotional support to patients. The patients perceived higher levels of missed care
than did nurses in all these elements except for ambulation (42.8% for the nurses and
33.3% for the patients), and emotional support to the patients (10.7% for the nurses
and 0% for the patients). Mouth (oral care) was among the most frequently missed
care as perceived by both nurses and patients (32.2% for the nurses and 53.3% for
the patients) (see Table 6.8)
The results of this case study revealed variations between nurses and patients
regarding MNC perceptions. The findings indicate a mismatch in the expectations
and perceptions of nursing care priorities between nurses and patients.
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Table 6.8
Comparing nurses and patient perceptions of missed nursing care
Nursing Care element Nurses Proportion (Frequency)
Patients Proportion (Frequency)
1. Ambulation 42.8% (n=12) 33.3% (n=10)
2. Mouth care 32.2% (n=9) 53.3% (n=16)
3. Bathing 7.2% (n=2) 16.7% (n=5)
4. Assistance in toileting in less than 5 minutes 10.7% (n=3) 33.3% (n=10)
5. Response to call light within 5 minutes 3.6% (n=1) 46.7% (n=14)
6. Patient teaching about their care 17.9% (n=5) 26.7% (n=8)
7. Emotional support to patients 10.7% (n=3) 0% (n=0)
6.2.6.6 Reasons for MNC as reported by the nurses
Table 6.9 on page 151 demonstrates the most frequent and least frequent
reasons for MNC as perceived by the nurses. The most frequent reasons that nurses
reported as being moderate and significant reasons for MNC were related to human
resources, namely: urgent patient situations (85.7%, n= 24), unexpected rise in the
patient volume and heavy admission and discharge activity (82.2% for each, n=23),
and inadequate number of staff (71.4%, n=20).
As evident in Table 6.9, more than 50% of nurses perceived that they
experienced unbalanced patient assignments. This finding implicates the impact of
mandated staffing ratios on nurses’ perceptions of balanced assignment of patients.
This finding should be investigated in further research.
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The least frequent reasons given were related to communication issues,
namely: tension or communication breakdowns within the nursing team (17.8%,
n=5), caregiver off unit or unavailable (17.9% n=5), and nursing assistant did not
communicate that care was not provided (25% n=7).
Table 6.9
Reasons for missed care as perceived by the nurses
Reason for MNC Proportion (Frequency)
Urgent patient situations (e.g. a patient’s condition worsening)
85.7% (n= 24)
Unexpected rise in patient volume and/or acuity on the unit, heavy admission and discharge activity
82.2% (n= 23)
Inadequate number of staff 71.4% (n=20)
Medications not available when needed 64.3% (n=18)
Supplies/equipment not available when needed 57.1% (n=16)
Unbalanced patient assignments 50.3% (n= 14)
Inadequate number of assistive and/or clerical personnel, lack of back up support from team members
46.4% (n=13)
Supplies/equipment not functioning properly when needed 42.8% (n=12)
Other departments did not provide the care needed (physiotherapy did not ambulate patients), tension or communication breakdowns with the medical staff
39.3% (n=11)
Inadequate handover from previous shift or from sending unit
35.7% (n=10)
Tension or communication breakdowns with other ancillary/support department
32.1% (n= 9)
Nursing assistant did not communicate that care was not provided
25% (n=7)
Caregiver off unit or unavailable 17.9% (n=5)
Tension or communication breakdowns within the nursing team
17.8% (n=5)
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6.2.6.7 Level of nurse staffing adequacy as reported by nurse working on different shifts
Cross tabulation revealed that 75% (n=3) of the nurses working on the day shift
stated that nurse staffing was adequate for 75% of the time. Regarding the nurses
working the night shifts, 100% of them (n=1) reported that staffing was adequate for
50% of the time. Of the nurses working rotating shifts, 39% (n=9) perceived staffing
adequacy for 75% of the time, and only 4% (n=1) perceived that staffing was
adequate for 0% of the time.
6.2.6.8 The most frequent reasons for MNC reported by nurses working on day and night shifts
The most frequent reasons for MNC reported by nurses working in the day
shift were: urgent patient situations (patient conditions worsening) (100%, n=4),
followed by unexpected rise in patient volume and/or acuity on the unit and heavy
admission and discharge activity (75%, n=3). Of the nurses working in the night
shifts, 100% (n=1) reported that unexpected rise in patient volume and/or acuity on
the unit, and heavy admission and discharge activity were significant reasons for
missed care.
6.3 CHAPTER SUMMARY
This chapter has presented the findings of Study Three (descriptive case study)
conducted as part of the current PhD research. The case study illustrates that the
studied medical ward was not responsive enough to the complexities of the admitted
patients. Despite mandating nurse to patient ratios in the study ward, inadequate
staffing was still perceived by the nurses as being problematic and one of the most
frequent reasons leading to MNC, especially in the case of unexpected events that
reduced the time available for nurses to provide basic nursing care interventions.
These unexpected events are an innate component of the uncertain and
unpredictable nature of hospital and nursing practice. It is acknowledged that
planning and rostering of staff to adapt to these events is a challenging task (Willis et
al., 2015). Hence, handling of unpredictable events that influence MNC and have
been identified in this case study necessitates assuming an alternative non-
conventional perspective. This new perspective, informed by Complexity Theory,
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may allow for more fruitful resolutions for addressing MNC in the complex
healthcare environment.
The following Chapter: Discussion, Recommendations and Conclusion,
discusses the findings obtained from the three studies that comprise this PhD
research, proposes future research directions in this field, and provides a conclusion
for the whole thesis.
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Chapter 7: Discussion, Recommendations and Conclusion
7.1 INTRODUCTION
This research aimed to explore the concept of missed nursing care (MNC) so as
to produce an enhanced understanding of it, and to identify factors that appear to
contribute to MNC in an acute care metropolitan hospital in Queensland, Australia.
Prior research reviewed for this PhD thesis identified several organisational and
individual factors influencing MNC in different healthcare contexts. The findings of
this PhD confirmed that many of these factors are also prominent in the Queensland
healthcare context. However, the question remains: How to prevent MNC from
occurring in the local context. Indeed, the findings of this research assisted in
identifying areas for future interventions to reduce or prevent MNC in the local
context, thus reducing the burden on the organisation, staff, and patients, whilst
improving the overall quality of healthcare.
The findings of the current research will be helpful for nurses, nurses’
managers, healthcare scholars, and decision makers, as well as healthcare recipients.
More importantly, the findings of this thesis may increase awareness and
understanding about MNC by identifying barriers and challenges that influence
nursing care provision in every day practice. This enhanced understanding of MNC
was achieved by collating contextual information that helped to identify key issues
that lead to MNC in an acute care setting within the Queensland healthcare system.
Knowing the context helps to identify measures that can mitigate the possible effects
of MNC in acute care contexts.
The MNC evidence from the previous body of literature contained numerous
methodological limitations making it difficult to draw conclusions on prevention of
MNC. Traditionally, MNC has been measured by using principally quantitative
approaches: “this vision has been tempered with the realisation that the issue of
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‘quality’ is more complicated and nebulous than this model of management implies,
especially in the case of complex health systems and services” (Pope, Van Royen, &
Baker, 2002, p. 148). The current PhD study significantly contributes to the body of
research evidence because it is one of the first of its type that examined MNC by
exploring both self-reported data and contextual information so as to identify the key
contributing factors to MNC. There has been little if any literature that has examined
MNC phenomenon through the frame of Complexity Theory (Klijn, 2008). As
outlined in the introduction, methodology and methods chapters in the current PhD
thesis, complexity theory has been applied to guide this study on MNC. Hence, the
findings yielded in this thesis shed a different light on currently known findings. This
PhD study was performed to bridge a gap in knowledge that may be attributed to
previous methodological and theoretical limitations, and to offer a much more
consolidated, detailed, and focused picture of MNC in a local acute care setting.
Three studies were conducted to fulfil the objectives of this research:
retrospective analysis of secondary data, nurses’ MISSCARE survey, and a
descriptive case study in a general medical ward. Missed Nursing Care Model
(Kalisch et al., 2009) and Complexity Theory (Klijn, 2008) were used as frameworks
in this research. In this context, this chapter provides a discussion of the key findings
when compared to previously known information on MNC and interprets the
findings through the lens of complexity theory, along with limitations, implications
for nursing practice and management, future research directions, and a final
conclusion.
7.2 MISSED NURSING CARE
This section discusses the key findings of the current PhD research and places
those findings within the context of previous work in this area. The section is
structured to address the first and second research objectives as outlined in Chapter 1
in this thesis, namely: MNC elements, MNC reasons and contributory factors in a
local acute care setting.
The elements of MNC
The first research objective for the current PhD study was to identify, describe
and categorise MNC elements in an acute care hospital. Based on the Missed
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Nursing Care Model employed in the current research, MNC elements in the acute
care hospital were categorised into four groups, namely: interventions–basic care,
interventions–individual needs care, assessment, and planning procedures. In the
following section, the key findings of the current research related to each of these
groups are discussed and placed into the context of pertinent literature.
Interventions–Basic care
Ambulation
Unsurprisingly, most MNC in interventions–Basic care in the local acute care
context was ambulation (34.1%), which is consistent with the vast majority of
literature about MNC (Chapman et al., 2017; Kalisch, Landstrom, & Williams, 2009;
Papastavrou et al., 2014; Smith et al., 2017). In fact, advantages of early patient
ambulation are evident. Patient ambulation reduces the potential of patient falls
(Patey & Corbett, 2016). Patient ambulation results in strengthening of joints and
muscles, also reduced length of patient stay in the hospital (Constantin & Dahlke,
2018; Halpern, 2017). Furthermore, ambulation increases patient satisfaction
(Kalisch, Lee, & Dabney, 2014). On the other hand, patients’ immobilisation,
especially in elderly patients, results in severe unwanted consequences, such as
patient falls, Deep Vein Thrombosis (DVT), hospital-acquired pneumonia, pressure
injuries, as well as functional mobility loss (Teodoro et al., 2016), and eventually
patient dissatisfaction (Veesart & Ashcraft, 2015). Furthermore, patient immobility
in the hospital has been hypothesised as one factor that results in “Post-Hospital
Syndrome”. Post hospital syndrome is a tentative condition of increased
susceptibility of the patient to functional decline, adverse events, and increased risk
of readmission (Growdon, Shorr, & Inouye, 2017).
There are different views on this MNC, as Feo and Kitson (2016) argued that
basic patient care interventions, such as ambulation, are usually regarded as marginal
contributors to patient healthcare results. There is an inclination towards suggesting
that these procedures should be delivered by less educated staff (Danielsson et al.,
2014). Furthermore, emphasis on prevention of falls incidents may be unconsciously
leading to immobilization of patients during their hospital stay (Growdon et al.,
2017). However, there is growing evidence that one of the factors that leads to
missing ambulation is the view that ambulation is not required to be documented
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(Feo & Kitson, 2016). Hence, there is a need to increase nurses’ awareness,
knowledge and skills of this important care element for the patients, foster a culture
that encourages patient ambulation, and create ambulation care standards (King,
Steege, Winsor, VanDenbergh, & Brown, 2016). According to Zwakhalen et al.
(2018), there is a critical need to expand the knowledge of nurses on evidence-based
basic nursing care procedures, including ambulation in diverse healthcare contexts.
Another view put forward was that missing patient ambulation is greatly connected
to urgent patient situations and unexpected increases in the patient volume and/or
acuity of the unit (Sepulveda-Pacsi, Soderman, & Kertesz, 2016). This is similar to
the findings of my study, in which more than 70% of the nurses’ sample perceived
these reasons as causing MNC in the study There is also evidence from Doherty-
King and Bowers (2013) that nursing staff who considered ambulation as being a
responsibility for other personnel stated that they were waiting for physiotherapist
clearance and doctors’ orders before taking the decisions to commence in assisting
patients in walking, thus leading to MNC. The findings of the current research,
particularly the communication breakdown between nursing staff and doctors
indicate that this factor potentially influences missing ambulation in the study
hospital.
Indeed, patient confrontation was also one of the factors that led to lack of
patient ambulation according to findings by Brown, Williams, Woodby, Davis, and
Allman (2007). The findings of that research also suggested that MNC could be
related to either patients not asking for help from nurses or lack of comprehension of
nurses’ instruction by the patients, particularly patients from Non-English-speaking
backgrounds. This finding suggests that MNC is highly connected to patient values
as well as communication issues in the study hospital. As such, as Teodoro et al.
(2016) suggested, a different strategy that could be advantageous to increase
ambulation during patient stay in the hospital comprises encouraging increased
ambulation by informing patients about the importance of ambulation and the role in
avoiding immobilization.
Other reasons that increase the prevalence of missing patient ambulation could
be lack of mobility equipment (Brown et al., 2007). There was no information
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provided about equipment availability in the study hospital, therefore the
contribution of this factor could not be ascertained.
Oral Care
Notably, in the category of interventions–basic care, the results of this PhD
research revealed that oral care was perceived to be missed by patients (53.3%) more
than nurses (32.2%) in a medical ward context. This is an important finding because
there is clearly a mismatch between what is important to patients compared to what
is important to nurses. Patient-centred care improves the quality of provision in a
hospital setting (Edvardsson et al., 2017). Moreover, poor oral health is associated
with high infection risk and thus non-ventilator hospital-acquired pneumonia (Maeda
& Akagi, 2014). Especially, plaque accumulation due to poor oral health could result
in gingivitis and periodontitis. Periodontitis is associated with severe systemic
illnesses, such as atherosclerosis and stroke. Also periodontitis has a negative
influence on glycaemic control in diabetes patients (Linden, Lyons, & Scannapieco,
2013; Scannapieco & Shay, 2014). Hence, the consequences of neglecting oral care
of patients, especially in dependent elderly, could be severe, causing a systemic
decline in their well-being (Coker, Ploeg, Kaasalainen, & Carter, 2017; Salamone,
Yacoub, Mahoney, & Edward, 2013).
The reason for this MNC could be related to the high prevalence of elderly
patients in the study hospital and therefore the participant pool, and who potentially
require oral care more frequently than other age groups as they are more susceptible
to rapid decline due to systemic effects of poor oral care in the hospital (Rohr, 2012).
Undeniably, polypharmacy is also a contributor to oral care effects, as it is
common in patients within these age groups (Rohr, 2012). The impact of
polypharmacy was evident in the clinical incidents data utilised in this PhD research,
particularly the falls incidents data, which indicated that patients in these age groups
are highly vulnerable to falls due to the effect of polypharmacy, which also have a
negative impact on their oral health. Furthermore, patients in these age groups need
additional consideration when they are wearing dental prosthesis and/or complete
and partial dentures; as well, there is need for mouth washing, particularly in the case
of frail patients and patients confined to bed (Rohr, 2012).
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In this context, it should be acknowledged that patients, but especially frail
older patients admitted to medical-surgical units, necessitate increased attentiveness
to their oral care requirements (Jenson, Maddux, & Waldo, 2018). The findings from
the MISSCARE survey (Study 2) and case study that oral care is one of the most
frequently missed care items in the basic care interventions, suggested that there
might be lack of nurses’ awareness about the importance of presenting oral care to
patients, which is in line with Blackman et al. (2018) and Jenson et al. (2018)
findings. According to Gillam and Gillam (2006), nurses perceive oral care provision
as being of lesser priority. I suggest that this is hypothetically the cause of this MNC
in the study hospital given the consensus in the literature that oral care is highly
valued by patients, as it leads to enhanced perceptions of patient centred care,
helping them to retain their dignity, self-respect, and enhanced well-being whilst in
hospital (Rohr, 2012; Wiseman, 2006). Hence, targeted education to increase nurses’
attention to consequences of missed oral care, especially for vulnerable patients, is
worthwhile (Blackman et al., 2018; Jenson et al., 2018; Rohr, 2012). Furthermore, it
is essential that evidence-based oral care standards are put in place in order to help
nurses to support patients in attaining optimum oral hygiene results (Coker et al.,
2017).
According to Salamone et al. (2013, p. 3), oral care is an important aspect of
patients’ care and there is a pressing necessity to assimilate oral care within clinical
nursing practice. Nurses would benefit from education and additional training, such
as patient centred care training that will make them aware of the perceptions and
feelings of patients when missed oral care occurs. Such training would also lead to
best clinical practice and improved well-being in patients (Rohr, 2012).
Within this context, it is imperative to note that despite the significance of
education and training in promoting oral care in clinical nursing practice, it is also
important that “oral hygiene kits” be in place in hospital wards. This will help in
establishing an atmosphere more favourable for supporting clinical practice of oral
care provision (Sniehotta, Araujo Soares, & Dombrowski, 2007). Furthermore, oral
care should be included as an integral part of all nursing care documentation (Wårdh,
Hallberg, Berggren, Andersson, & Sörensen, 2000).
Interventions–Individual needs
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Similarly to the findings of Ausserhofer et al. (2014), this PhD’s data showed
that nursing care interventions related to physical conditions of the patients, such as
medication administration within 30 minutes before or after scheduled time and PRN
medication requests within 15 minutes, were well attended to in the study hospital.
However, the psychosocial (relational) nursing care interventions, such as emotional
support to patient and/or family, were less attended to by the nurses in the study
hospital based on the findings of the MISSCARE survey (page 160). Although this
finding is not unexpected or novel, its re-emergence in the current research
emphasises its importance.
Psychosocial care and patient centred care (Hodgkinson, 2008) involves
culturally sensitive presenting of emotional, social and spiritual care to patients
(Hodgkinson, 2008). Worth noting is that psychosocial care should also be extended
to patients’ families (Fan, Lin, Hsieh, & Chang, 2017). Psychosocial support is
equally important for nurses too, as it allows nurses to respond to needs of patients
more rapidly and effectively, whilst improving patients’ involvement in their own
healthcare (Conroy, Feo, Boucaut, Alderman, & Kitson, 2017). Healthcare providers
including nurses should be strongly encouraged to provide psychosocial care for the
patients. The time invested in providing psychosocial care should not viewed as a
“loss leader” (Adamson et al., 2012). According to Güner, Hiçdurmaz, Yıldırım, and
İnci (2018), provision of psychosocial care can have a positive impact on nurses’ job
satisfaction and personal growth. However, some researchers view psychosocial care
as an indirect nursing care procedure (Aryankhesal, Sheldon, Mannion, &
Mahdipour, 2015) that is frequently over looked by nursing staff (Legg, 2011).
Another qualitative study with 18 RNs in geriatric, medical, and surgical wards in an
acute care hospital indicated that hurdles to delivery of psychosocial care as
perceived by nurses encompassed lack of time, undue documentation, and language
barriers (Chen et al., 2017). Heavy workload was identified in several studies as a
barrier to providing psychosocial care for the patients (Botti et al., 2006; Fan et al.,
2017; Watts, Botti, & Hunter, 2010).
Providing psychosocial care for hospitalized patients has been shown to lead to
decreased patient length of stay in hospital and also to increased patient satisfaction
and well-being, thus helping the hospital to achieve their efficiency and productivity
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targets in light of current financial constraints (Legg, 2011). This is an important area
that needs to be strongly considered by hospital management. Based on the combined
and triangulated data yielded in this PhD, particularly nursing engagement data and
the MISSCARE survey, there seems to be reduced appreciation of provision of
psychosocial care by hospital management. This is consistent with the finding by
Jangland, Nyberg, and Yngman‐Uhlin (2017), who stated that provision of
psychosocial care, particularly in surgical wards, was less supported by nursing
leaders. Similarly, lack of institutional support was one of the barriers for provision
of psychosocial care as reported by nurses working in oncology units, where nurses
were informed by their organisation they were not to spend time providing this care
(Güner et al., 2018). It is imperative that institutional support be provided for nurses,
which will ensure a higher quality of healthcare provision and patient satisfaction.
Institutional support also will allow nurses to obtain essential training and gain
knowledge and skills for patient centred psychosocial care (Güner et al., 2018).
The principal component of psychosocial care is enhanced communication,
which helps to build good relationship between doctors, nurses and their patients
(Fan et al., 2017). Therefore, communication skills training aimed at clinicians,
patients, and their relatives is an important step towards providing excellent quality
healthcare and more favourable healthcare outcomes for patients (Fan et al., 2017;
Legg, 2011). However, providing such training and improving psycho-social care are
complex matters. To achieve such a care provision, multiple system and personnel
changes would need to happen in the study hospital. After assessing the current skills
of clinicians, patients, and their relatives, already existing communication skills
training for patient centred care could be introduced to those who would benefit
(Kenny & Allenby, 2013).
The findings from nursing engagement data suggested that that nurses made
every effort to present psychosocial care for patients, despite not being formally
required to do so. Previous work showed that these individual endeavours were not
always supported by the workplace and sometimes led to role conflict among the
healthcare team, its importance has been recognised. Indeed, it may not be
conceivable to create more time to provide psychosocial care within a busy workload
(Dilworth, Higgins, Parker, Kelly, & Turner, 2014). Hence, supporting the psycho-
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social care provision in the healthcare setting (Reid�Searl et al. (2009), required a
workplace culture which values the enhanced communication between practitioners,
patients, and their families as an essential element for creating mutually trusting
relationships.
Based on the findings of this PhD thesis, it is suggested that doctors and nurses
in the study hospital need education and training to improve communication skills
and multidisciplinary teamwork to provide better psychosocial care for patients.
Assessment Nursing Procedures
The findings of this PhD revealed that the most frequent MNC in the category
of assessment nursing procedures was full documentation of all necessary data. A
higher level of missing documentation was found in the current research compared to
Higgs et al. (2017) study that was conducted in an Australian hospital. Nursing
documentation is a tool that describes what the nurses actually do for the patient
(Hyde et al., 2005) and comprises all information regarding patient care (Akhu�
Zaheya et al., 2018). Nursing documentation represents the base for presenting
quality healthcare and is key for professional nursing practice. It provides
consistency and transparency for the purpose of planning healthcare provision
(Gunningberg, Fogelberg‐Dahm, & Ehrenberg, 2009). In fact, this MNC designates a
failure to provide care (Stewart, Doody, Bailey, & Moran, 2017).
Quality nursing documentation enhances patients’ healthcare experience by
detailing the patient healthcare status and the responses of patients to nursing care
interventions (Jefferies, Johnson, & Griffiths, 2010). Complete and timely
documentation is anticipated to make care provision seamless by conveying pertinent
information to incoming nurses at shift handovers, to patients and to significant
others (Gjevjon & Hellesø, 2010). In other words, the significance of quality nursing
documentation arises mainly from the fact that the documented information is
retrieved and utilised by other healthcare staff as a component of multidisciplinary
care provision for patients (Saranto & Kinnunen, 2009). On the other hand,
inadequate documentation leads to a high medical errors risk (Baker, 2018), such as
missed medication and medication dosage errors (Manias, Bucknall, Hutchinson,
Botti, & Allen, 2017) as well as legal accountability (Baker, 2018).
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Findings from Study 1, particularly medication incidents data (page 145)
indicate that important information from nursing documentation sometimes could not
be retrieved or was not understandable by incoming nursing staff at handover,
especially when patient records were written in the nurses’ own words rather than
using standardized medical language. According to Cheevakasemsook, Chapman,
Francis, and Davies (2006), this is called “disruption of documentation”. This is a
system issue that may indicate lack of nursing documentation standardization in the
study hospital (Cheevakasemsook et al., 2006; Keenan, Yakel, Tschannen, &
Mandeville, 2008). Insufficient standardization of documentation is often associated
with the hospital’s inability to identify clinically deteriorating patients (National
Patient Safety Agency, 2007), the implication of which can be life threatening to
patients (Collins et al., 2013).
This MNC in the study hospital could also be related to viewing the nursing
documentation as an additional task that prevents the nurses from ensuring continuity
in patient care delivery (Blair & Smith, 2012), or nurses’ perception that
documentation increases their exposure to clinical liability (Blair & Smith, 2012;
Brown, 2013). However, Kebede, Endris, and Zegeye (2017) found that barriers to
nursing care documentation were mainly due to system challenges, such as time
pressures, high workload, and unavailability of suitable space or an IT terminal for
documentation. Also, completeness of documentation could have been objected to by
the nurses in case it was required for institutional criteria rather than patients’ needs
(Henderson et al., 2016). More significantly, nursing documentation issues are often
related to the complexities of the nursing work (Cheevakasemsook et al., 2006).
According to Lavin, Harper, and Barr (2015), when nursing documentation is
found to be insufficient, system functions must be examined, such as current skill
level and IT provision. Authentic leadership is required to achieve such system
provision, and needs to establish staffing policies and adequate training that will lead
to improved quality and usability of nursing documentation (Okaisu, Kalikwani,
Wanyana, & Coetzee, 2014).
Improving hospital documentation requires sufficient cultural, educational, and
organizational support (Keenan et al., 2008; Stewart et al., 2017). Indeed,
multifaceted procedures should be put in place aiming at altering hospital systems, as
186
well as changing organisational culture, which is essential to improve nursing
documentation practice (Okaisu et al., 2014).
In the study hospital, one potential solution for improving insufficient nursing
documentation would be an introduction of an electronic health recording system.
Indeed, the study hospital in September 2018 did introduce an electronic health
recording system. It is anticipated but is outside the scope of this PhD that new
electronic recording systems will enhance the quality of nursing documentation by
enabling nurses to record patient related information precisely, completely, and in a
timely fashion. However, this depends on the range and scope of nursing procedures
included in the electronic systems. The effectiveness of any new IT system should be
guided and evaluated according to the standard guidelines and procedures (Stevens,
2017), should involve documentation audits and feedback (Wainwright, Stehly, &
Wittmann-Price, 2008) and a peer review process (Nelson, 2015). Audits and
feedback procedures should be automated so that the lack of essential documentation
is identified and nursing staff are notified at the point of care delivery by several
means, such as visual dashboards (Nielsen, Peschel, & Burgess, 2014). Without such
monitoring and evaluation, MNC data regarding nursing documentation in the study
hospital might not improve (Stevens, 2017).
Planning
Whilst this PhD’s findings from the patient satisfaction data revealed that
patients in the study hospital were not satisfied with discharge planning, nurses in the
MISSCARE survey reported that this MNC was the least frequently missed in the
planning category. Discharge planning is an interdisciplinary procedure to ensure
care continuity (Lin, Cheng, Shih, Chu, & Tjung, 2012). Discharge planning is
important for patients as it allows for smooth transition into home care (Kalisch,
2006) or into another setting (Graham, Gallagher, & Bothe, 2013). Effective
discharge planning leads to improvement of patient outcomes, such as improving
quality of life in patients with hip fractures due to falls (Huang & Liang, 2005).
Effective and timely discharge planning also has a positive impact on the level of
patient satisfaction (Lin et al., 2012).
The findings of this current research highlighted foremost that there were
variations in prioritization and perceptions for discharge requirements between
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patients and nurses. Patients could be dissatisfied with the discharge planning
process due to lack of their involvement in the process, which is similar to the
findings of Anthony and Hudson-Barr (2004). In this vein, it is essential to realize
that most patients require information about their potential length of stay in the
hospital, their care, and the likely discharge date. This is vital for the patients as it
allows them to confirm their engagement with their treatment plan. Hence, they can
make effective plans in preparation for discharge in order to be ready on the
discharge date (Morris, 2011). Nevertheless, it has been identified that patients were
not frequently informed in regard to their possible discharge date (Lees, 2008).
According to the Australian Nursing and Midwifery Council (2007), while
nurses perform all steps of the discharge planning process, assessment of patients
performed by the nurses at admission is crucial and has significant implications for
the length of stay and seamless discharge experiences for patients. It is essential to
review and plan for discharge at the time of admission of the patient. However,
according to Graham et al. (2013), only 30% of nurses in an acute care Australian
hospital were involved in discharge planning at admission time. The findings of this
PhD showed that there was a particularly heavy admission and discharge activity in
the study hospital. Hence, taking a holistic approach to patient care, and considering
the patient journey from admission to discharge, is worthwhile in this context
(Graham et al., 2013).
The literature identified several factors that lead to such MNC. For example,
this MNC could be related to nurses’ attempt to preserve care continuity in case of
medical emergency or worsening of patients’ conditions, frequent patient transfers
between hospital wards, and unplanned emergency admissions (Duffield et al., 2007;
Foust, 2007; Graham et al., 2013). From the findings of this PhD, it was evident that
there are high levels of unplanned emergency admissions combined with unexpected
increases in patients’ medical complexity, and these, as well as the unit’s acuity in
the study hospital, could have contributed to this MNC. Dealing with unpredictable
events in hospital care, which is a complex healthcare system, leads to a
recommendation from this PhD and the work of Augustinsson and Petersson (2015),
which is: training nurses to deal better with such emergencies so that they can
respond more quickly and more efficiently will help to reduce MNC.
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The findings from clinical incidents data and the MISSCARE survey of this
PhD research (pages 147, 162) also indicate that this MNC could be related to
communication issues. Communication issues could be related to poor
communication between medical and nursing staff, which is consistent with the
finding of Watts and Gardner (2005), and communication issues between nursing
staff and patients due to language barriers. This is consistent with the Graham et al.
(2013) findings. The same paper proposed a strategy to overcome this issue that
could also be useful if implemented in the study hospital, that is supporting nurses to
allow them to communicate with patients from non-English speaking backgrounds
(Graham et al., 2013).
In sum, the elements of MNC identified in this research include psychosocial
support and oral care that directly affect patients and their perceptions of their care,
as well as those that require inter-professional collaboration such as ambulation and
discharge planning. Nursing care elements that were perceived to have the most
medically related impact on the patient health status, such as medication
administration, were less likely to be missed.
Factors influencing MNC
The second objective of the current PhD research was to identify and describe
reasons and factors that contribute to MNC in an acute care hospital setting. This
section discusses the main findings of the current research in relation to this
objective.
Demand for patient care
The findings of this PhD study were consistent with Winsett et al. (2016),
whereby the main reasons for MNC were the unexpected rise of patient volume
and/or acuity on the unit, other urgent patient situations (e.g. a patient’s condition
worsening), and heavy admission and discharge activity. This means that the studied
unit could be seen as resistant to the variations in the workflow. This could be related
to the complicated nature of nursing work, as well as patient trajectories
(Fagerhaugh, 1997). Patient trajectory describes the pathophysiological progress of
patient disease as well as the involvement of different healthcare professionals in
patients’ care processes within the healthcare setting (Alexander, 2007; Goorman &
Berg, 2000)
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As patients’ trajectories are inevitable, their effects could be moderated by
enhancing teamwork and communication among care team members. According to
Weick Karl and Sutcliffe Kathleen (2007), effective communication between
healthcare providers aids the navigation of patients’ trajectory and is good practice in
challenging circumstances.
Relationships / Communication and teamwork issues
A noteworthy finding of this research is that there were communication and
teamwork failures that may contribute to MNC, particularly in some interventions
that required cooperation between several healthcare providers from multiple
disciplines, such as medication administration. Communication and teamwork issues
were highlighted in the current research as failures in the handover process and
inadequate sharing of information at change of shift or transfer of patients between
different hospital wards. In fact, handovers may result in higher levels of uncertainty
and also seem to demand a more robust relationship structure in order to be managed
in an effective manner (Leykum et al., 2014). The results from the MISSCARE
survey indicate that nurses perceived medication administration as a priority activity
and it had been less frequently missed, yet the findings from medication incidents
data ( pages 140, 142) uncovered several environmental and communication factors
that may impact on the medication administration by the nurses According to
Weller, Boyd, and Cumin (2014), inadequate sharing of information among
healthcare teams is related to three factors: educational, psychological and
organisational. This research revealed that psychological and organisational factors
were critical determinants of the communication and teamwork issues identified in
this research.
Regarding psychological factors, there was a sense that hierarchy in the
healthcare system that disrupts the communication among nursing teams or between
the nurses and doctors impacted MNC. One suggested strategy to overcome such a
perception of hierarchy is to apply structured communication approaches to
healthcare, in order to establish what is called a “democratic team” (Weller et al.,
2014).
In democratic teams, all team members have the confidence in their skills and
communication and expect that their views on the care of the patient will be attended
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to. Every member in a particular team must be permitted to share their views in a
safe culture to allow for better decision making processes for patients and the
hospital and its staff (Weller et al., 2014).
Regarding organisational factors, the findings indicated that the presence of
nurses who are not familiar with patients they are caring for, such as a new nurse on
the ward, could contribute to MNC, especially when administering medication. This
is an organisational factor in that if sharing of information among healthcare teams is
ineffective, there could be MNC consequences (Weller et al., 2014). Additionally,
nurses who have enough information about patients they care for may be unavailable
in times of crucial decision making about those patients’ care. In this case, although
the nurse is aware of the type of communication needed, they are not able to provide
it due to environmental factors, which are perceived to be threatening (Weller et al.,
2014). One way to overcome this organisational issue would be to introduce
Structured Interdisciplinary Bedside Rounds (SIBR) system (Payne, Odetoyinbo, &
Castle, 2012).
The system brings multidisciplinary teams together regularly in time and place
for rounds (Payne et al., 2012). Thus, improved sharing of information is fostered
between healthcare team members (Weller et al., 2014). Meanwhile, it has been
acknowledged that interprofessional bedside rounds also enhance nurse-doctor
communication and teamwork (Henkin et al., 2016). However, given the continuous
evolving of the healthcare system, there is a pressing need for an inclusive
recognition by senior hospital leaders and individual healthcare providers of the
significance of multidisciplinary collaboration and teamwork in providing safe
healthcare. This can be achieved by establishing an organisational culture that
supports healthcare teams in clinical and organisational practice (Weller et al., 2014).
However, it should be noted that given the complexity of the healthcare
organisations, planned cultural change of the healthcare organisation is a difficult
and uncertain task (Scott, Mannion, Davies, & Marshall, 2003). Cultural
transformation in the healthcare organisation necessitates that healthcare leaders are
capable of manifesting and endorsing behaviours essential to the required culture
(Barriere, Anson, Ording, & Rogers, 2002).
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One of the key findings in this research was MNC due to unbalanced patient
assignments, which was one of the most common communication and teamwork
failings. This finding is similar to that of Chapman et al. (2017), which was
conducted in four hospitals in Victoria, Australia that had mandated nurse to
patientratios. Similarly, in the study hospital, mandated nurse to patient ratios laws
had been implemented recently. However, as nurses reported, there was still
imbalanc in patient assignment causing MNC. This finding raises questions about the
effectiveness of the nurse to patient ratio laws in Queensland on missing nursing care
and patient outcomes. Thus, further exploration and evaluation of current practice is
needed to explain this finding. It may well be that more flexibility is still required in
staffing ratios to allow for patient acuity and complexity. Additionally, this finding
could be limited by lack of adherence to hospital policy in mandating and assigning
the nurses to patients based on other criteria (Chapman et al., 2017). According to
Lehmann (2016), one of the factors influencing implementation of healthcare
policies is the purpose they were created for, as well as the acceptance of these
policies driving the decisions of health managers as well as frontline staff. Hospital
staff may decide, based on their daily practice, that they will not implement the
mandated policies, or decide to adapt the policies to their hospital culture and
operating requirements (Lehmann, 2016).
In this context, although the study hospital uses an electronic staffing system, it
does not take into account fluctuation in patient requirements and intrinsic
variabilities in nurses’ daily workload (Verrall et al., 2015; Willis, Henderson,
Blackman, Verrall, & Hamilton, 2015)Thus, understaffing and unreasonable
workloads put the nursing personnel under increased pressure, and that could result
in increased risk of MNC (Garrett, 2008; Willis et al., 2015).
Interruptions
Interruption to the nurses’ workflow was identified as a factor that impacted on
medication administration in the study hospital. For example, interruptions by
another nurse and/or to perform another task for another patient, or conversations
with families, may occur in the time when medication administration should be a
priority. Drawing on the work of Johnson et al. (2018), interruptions in the study
hospital were both predictable and unpredictable. Nurses showed control over
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predictable interruptions, such as those caused by other nurses or patients’ families,
but they may have had little control over unpredictable interruptions, such as those
caused by critical patient situations (Johnson et al., 2018).
It is possible that interruptions in the medical and surgical wards where the
MISSCARE survey was conducted in the current research were predominantly
predictable. As the findings of this research revealed, interruptions lead in some
cases to medication omission. This is an important issue that needs to be considered
by nursing management in the study hospital as they play a key role in reducing
particular forms of predictable interruptions. Similar to the findings of the present
research, Seki and Yamazaki (2006) found that nurses missed medication most
frequently in the morning shifts. The authors of the paper justify this by increased
nursing workload post medical rounds or visits by doctors. Therefore, one solution
to reduce interruptions in the study hospital might be the modification of the time of
medication rounds (Johnson et al., 2018).
Lack of management support
The findings of this PhD show that despite nurses in the study hospital
maintaining strong commitments to the provision of patient centred care, they felt
that they still didn’t meet their managements’ expectations, which can lead to
mistrust, can affect safety culture, and can reduce the quality of healthcare provision.
According to Reis et al. (2019), lack of management support negatively influences
nurses’ capability to implement approaches that emphasize provision of safe care for
the patients. Nurses rated their ability to meet these expectations low, which may be
associated with the omission of performing essential care procedures in a situation of
restricted time and resource allocations (Schubert et al., 2008). According to the
findings of the current research, there seems to be continuous pressure from the
hospital management on the nursing staff to increase their efficiency and to adapt to
increased demands, turbulence, and exigencies in their everyday practice.
According to Harvey et al. (2018), nurses practice within two opposing
directives: the regulatory requirements that determine professional practice of the
nurses, and the demands of the employer (i.e. health service). Both directives require
definite and pre-determined but conflicting performance indicators (Harvey et al.,
2018). To put it in another way, the context that nurses practice in is virtually
193
paradoxical: nurses are required to provide patient-centred care within a productive
and standardised system (Kieft et al., 2014). Hence, a contention between
productivity standards and nurses satisfaction could take place (Ingwell-Spolan,
2018).
It has also been acknowledged that even when nurses have the capacity to
manage patients’ treatment and care, their workflow is negatively influenced by cost
constraints and by unpredictable social, cultural and clinical changes (Harvey et al.,
2018) that may lead to MNC. This has an implication for understanding that the
blame for MNC should not be directed only toward the nurses. Acknowledging the
complex interplay of multiple influencers may enhance transparency in the working
culture (e.g. climate of openness) and ensure that nurses report missed care incidents,
which will have a positive impact on patient clinical outcomes, patient satisfaction
with their care, as well as nurses’ satisfaction. This is important, as it may lead to
enhanced psychological safety thus decreasing the level of underreporting (biased
reporting) that is identified as one of the central limitations of clinical incidents data
used in the current PhD research.
Psychological safety is defined as the extent to which personnel have the belief
that they will not be punished for errors incurred whilst caring for patients, they feel
they can request help without being blamed or ask for feedback about the results of
errors investigations and the actions undertaken by the hospital management after the
incident occurrence (Edmondson, 1999; Wallace, 2010). In fact, psychological safety
allows employees to take risks and persevere in light of difficult work circumstances
(Warshawsky, Havens, & Knafl, 2012).
In this context, nursing management has the responsibility to establish and
maintain psychological safety within their healthcare organisation. This can be
accomplished by encouraging nurses to voice their concerns without any potential
harmful personal consequences for them (Gilmartin et al., 2018).
Indeed in such a safety culture, if in existence, nurses would feel safe to take
personal risks associated with reporting errors occurring whilst providing healthcare
and would speak up to improve patient safety (Gilmartin et al., 2018), thus allowing
for knowledge transfer, organisational learning and providing resolution prior to
errors occurrence, and thus improving patient safety (Gilmartin et al., 2018).
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Based on the findings of this research and given the unique challenges that
nurses encounter in the Queensland healthcare system due to increased demand on
provision of healthcare and financial restrictions, there is a need for more nursing
management support and increased attention to nurses’ challenges in everyday
practice. Nursing management support is presumed to result in improvements in
nurses’ working conditions and creating a positive workplace culture, and thus in
provision of safe patient care. Nurses value social support from colleagues and team
members at work, which is also associated with increased intention to remain in
employment in the same hospital (AbuAlRub, Omari, & Al�Zaru, 2009).
7.3 COMPLEXITY THEORY VIEW
Healthcare organisations are progressively immersed with complexity,
uncertainty, and risk as a result of patient acuity, several co-morbidities, and
increased utilisation of technology (Simmons, 2010). At the same time, healthcare
organisations must have the capability to adjust their actions based on unexpected
changes in patients’ conditions or unexpected demands without threatening the
quality of healthcare and patient safety (Ratnapalan & Uleryk, 2014). While the
Missed Nursing Care Model used in this research provides a coherent and
comprehensive framework for interpreting MNC elements and contributory factors to
MNC in the local context of an acute care setting, it underestimates the dynamic,
non-linear and emergent distinctive characteristic features of complex adaptive
systems (Anderson & McDaniel Jr, 2000; Braithwaite, Churruca, & Ellis, 2017;
Mitchell, 2009). The Missed Nursing Care Model also lacks consideration of the
contextual circumstances of MNC that are essential to allow for identification of
suitable interventions for addressing MNC in the local context of an acute care
setting. According to Gear et al. (2018), designing healthcare interventions in the
absence of a complexity theory view would adversely influence the sustainability of
the developed interventions. Hence, complexity theory has been used as a conceptual
framework in the current PhD research, and provides an alternative interpretation of
the current PhD findings. More importantly, complexity theory will be applied to
address MNC in light of the dynamic nature of the healthcare system.
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In this current research, it has been proposed that complexity theory can be
advantageous in describing and interpreting the events related to MNC in acute care
settings. Hence, the capacity of complexity theory in doing so is explored in this
section. I attempt to advance the current body of knowledge about MNC by
conceptualising MNC as a Complex Adaptive System (CAS) that operates in a
complex care environment. Complexity theory concepts identified in this research as
relevant to MNC were adaptation and self-organisation, non-linear interactions, and
history. These concepts are discussed in detail in the following section.
1. Adaptation and Self-organisation
Adaptation and self-organisation are two concepts of complexity theory that
have been applied here to demonstrate the complexity of factors influencing MNC
and to depict the nurses’ response to such complex and interrelated factors.
Adaptation means that the components of the system adjust their performance with
other components of the system and with the external environment (Agyepong,
Kodua, Adjei, & Adam, 2012). A complex adaptive system is adaptive as it reacts to
events actively, questing advantages from any condition. For instance, human beings
progressively learn from their previous experiences and respond to variations in their
surroundings. Therefore, a complex adaptive system is a “pattern seeker” that
interrelates with its environment, learns from experiences and after that, the complex
system adapts (Anish & Gupta, 2010). In fact, the adaptive feature of the CAS arises
from the ability of the complex system agents or elements to operate freely in an
unpredictable manner or without being constrained by others. As a result, creative
behaviours arise (Chaffee & McNeill, 2007).
A related concept to adaptation is self-organisation, which is defined as the
process by which the components of the system collaborate within the system (i.e.
locally) and over time (Bailey Jr et al., 2012). To put it simply, this means that
unstable system elements self-organise and evolve to adapt in reaction to
environmental events (Condorelli, 2016). Individuals self-organize not necessarily
according to hierarchy or the structure of the healthcare organization but according to
the way their duties are actually performed (Colón-Emeric et al., 2006). According to
Marchal, Van Belle, De Brouwere, Witter, and Kegels (2014), new behaviours,
indeed, may arise from self-organisation in reaction to exigencies and dynamic
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events in the working environment. New behaviours can also arise due to interaction
between healthcare providers within and outside of the organisation. These
behaviours, whether favourable or unfavourable, are principally non-predictable.
Findings of this PhD research highlighted that these concepts are potentially relevant
to the MNC issue, which will be discussed next.
Adaptation and self-organisation as related to factors influencing MNC
In the current research, several events were identified that could have led to
MNC in the local context of acute care setting, such as heavy admission and
discharge rates (patient turnover), increased unit acuity, and urgent worsening of
patient conditions. These events reflect the uncertainty of the healthcare system.
According to Han, Klein, and Arora (2011), there are three main sources for
uncertainty in the healthcare system. These are: patient healthcare condition
trajectory, scientific information restrictions, and healthcare system nature.
Uncertainty has a negative impact on decision making, quality of healthcare, as well
as management of patient conditions (Djulbegovic, Hozo, & Greenland, 2011).
Interpreting the results through the lens of complexity theory, it can be argued
that MNC (as a CAS) consists of several elements that interact in contingent and
multiple manners. Elements in this context refer to the factors and circumstances that
have been identified to influence MNC occurrence. Hence, it can be demonstrated
that MNC is a result of interactions between these elements and the dynamic
environment, as well as being a product of individual performances. Therefore, it can
be argued here that one MNC element influences other MNC elements and at the
same time that element is influenced by other elements and by the hospital
environment too. Change in one of these elements while the system is operating can
lead to instantaneous chain reactions, which then lead to changes in the remaining
MNC elements. However, it should be noted that even if these elements are
identified in the healthcare system, knowing them won’t allow for any prediction
about whether MNC will occur or not and, if it occurs, when and how.
For instance, the findings of the current research indicated that high patient
turnover influenced MNC occurrence. High patient turnover as revealed from the
findings of the case study could lead to increased unit acuity. Increased unit acuity is
potentially associated with Dynamic Patient Events (DPEs), which are defined as fast
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and unexpected alterations in clinical condition of the patients. This may lead to very
rapid alterations to nursing workload (Borowski, 2013). Unfortunately, this shift in
focus and interruption of normal workflow is not considered in the daily staffing
requirements (Borowski, 2013). In response to such events, nurses may continue to
perform their multiple responsibilities in a shorter time frame (Krichbaum et al.,
2007). Against a backdrop of scarce resources, nurses should be well prepared to
improvise and develop work practices in quick response to deal with such
unpredictable environmental events (Laustsen & Brahe, 2018; Paradiso & Sweeney,
2018), which will be discussed in detail later in this chapter.
Adaptation and self-organisation as related to nursing behaviour in response to
the complex set of MNC factors.
According to Cranley, Doran, Tourangeau, Kushniruk, and Nagle (2012),
unexpected instability in the patient healthcare condition makes the nurses feel
uncertain and as if they are “caught off-guard”. This is because they do not have
enough knowledge and experience about how to deal with complex patients.
Furthermore, there is not enough time for decision making (Cranley et al., 2012). In
the case when nurses do not have sufficient information about the patient, they are
forced to perform continuous assessment of the patient condition until there is some
certainty of health status, a procedure which interrupts prior patient care planning
(Cranley et al., 2012). One of the important findings of this PhD is that rapid
worsening of patients’ conditions was one of the most frequent reasons for MNC in
the study hospital. In this context, it appears that a ‘workaround’ phenomenon
occurs, which is defined as “the situations where one experiences a block in
workflow and, rather than complete the work process as intended, creates an
idiosyncratic solution to get around the block” (Halbesleben, Rathert, & Bennett,
2013, p. 50). In these circumstances, prioritisation of nursing procedures is one of the
approaches usually pursued by the nurses (Blackman et al., 2015; Hendry & Walker,
2004; Kalisch et al., 2009; Kalisch & Lee, 2010; Miller, 2011). Viewed through the
lens of complexity theory, this could also be viewed as self-organisation of the
nurses to adapt to the changing environment and demands and insufficient resources.
Despite heavy admission and discharge activities and increased demand on nursing
care in the study hospital, nurses tended to prioritise nursing interventions that may
have had a direct impact on patients’ healthcare results (Self-organisation).
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Indeed, Hall et al. (2018) also recognised that the prioritization of nursing care
interventions is difficult, especially when monitoring an unpredictable illness
trajectory in patients. According to Alfaro-LeFevre and Alfaro-LeFevre (2009),
nursing tasks were classified into three categories:
1. Higher priority nursing care
They are the procedures that interfere with the main complaint of a patient.
Missing these procedures could have a direct impact on patient outcomes and could
produce additional complications for the patient. For example, the procedures
include vital signs monitoring, hand washing, monitoring intravenous lines, and
timely response to alarm bells.
2. Intermediate priority nursing care
Intermediate procedures are related to the procedures that, if skipped or missed,
will not lead to or result in deterioration in patient illness status, such as ambulation,
turning, feeding and patient hygiene. These intermediate problems could result in
poorer mental condition of patients.
3. Lower priority nursing care
Lower priority nursing care includes procedures that do not have instant
measurable effects on patient outcomes, such as fluid intake and nurse
documentation at handover, patient teaching, documentation and emotional support.
The process of prioritizing is a task that comprises perceptual triage performed
by nurses in order to define care items integral to patient safety and rank them by
importance. Accordingly, nursing interventions related to physical conditions of
patients may be viewed as having higher priority than psychosocial care (Simpson,
Lyndon, & Ruhl, 2016). Considering the above situation, MNC will inadvertently
(Wakefield, 2013) and inevitably take place (Blackman et al., 2018; Buerhaus,
Auerbach, & Staiger, 2007; Sasso et al., 2017).
In practice, this means that nurses’ attempts to handle unpredictable and
uncertain situations in the work environment force them to reprioritise nursing care
interventions by rank of seriousness, such as medical interventions that cannot be left
undone being placed at the top of the list, whereas interventions that can be left
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undone will be (Willis et al., 2015). For instance, nurses adapted work practices by
listing assessment data in the nursing care plan as well as juggling their workload
and prioritizing care (Cranley, Doran, Tourangeau, Kushniruk, & Nagle, 2009; Mark,
Gonzalez, & Harris, 2005). In fact, handling of uncertainty in nursing practice results
in variations in care processes (Thompson & Yang, 2009). This is similar to the
findings of Blackman et al. (2018) who showed that Australian nurses tend to miss
lower priority nursing care. Indeed, nurses in the study hospital also tended to miss
patient education and emotional support, which are lower priority nursing care items
to adapt to unpredictable events. This could be viewed as self-organisation when
viewed through the lens of complexity theory.
Uncertainty in healthcare is a broad concept which does not involve only the
individual characteristics and experience of the employees, but also further
contextual factors (Ogden et al., 2002). One source for nurses’ uncertainty would be
unfamiliarity of the nurses with the patients they are caring for (Cranley et al., 2009).
Also, provision of care for patients with acute diseases, unusual diseases, or unusual
manifestations of disease may increase uncertainty more than dealing with more
familiar and frequently seen diseases (Leykum et al., 2014).
The findings of this research indicate that nurses new to the ward and the
presence of medical outliers as sources of uncertainty may contribute to MNC in a
local acute care context. For example, according to Dykes, Carroll, Hurley, Benoit,
and Middleton (2009), not knowing the patient and having inadequate information
about the patient at the bedside were crucial factors that reduced nurses’ ability to
prevent patient falls. In this context, it is important to indicate that high uncertainty
circumstances need adaptive strategies (Simpson et al., 2013). This is really
important considering that managing of uncertainty cannot be expected through
standardization and routines of healthcare procedures (Augustinsson & Petersson,
2015). Adaptive strategies should focus on relationships, and the methods of
fostering making sense of events by the healthcare providers (Simpson et al., 2013),
their improvising (Leykum et al., 2011), and their learning (Noël, Lanham, Palmer,
Leykum, & Parchman, 2013). It has been identified that nurse managers’ capability
to effectively teach nursing teams to think critically in the cases of time pressure and
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uncertainty characterises a crucial lever that enhances nursing self-management in
challenging situations (Clancy, 2009)
In this perspective, we can view MNC as a variation in nursing care provision
that depends on the nurses’ way of dealing with the unpredictable and uncertain
nature of the healthcare system and their work demands. However, in this study,
MNC occurrence in the healthcare system does not necessarily indicate poor nursing
care quality. According to Keshk, Qalawa, and Aly (2018), notwithstanding the
challenges nurses experience in their work, such as insufficient time and resources
and increased workload, nurses still do what can be considered a good job. High-
quality work in nursing is defined as “work that is theoretically and technically
efficient, as well as ethically and in a social context accountable. When nurses
perform high quality work and remain dedicated to quality, they experience
accomplishment as they safeguard the well-being of their patients” (Keshk et al.,
2018, p. 148). In this perspective, it is also important that the general public be
mindful about resource restrictions on nursing time, and therefore the available
nursing care (Suhonen & Scott, 2018).
Drawing on the self-organisation concept of complexity theory, it can be
inferred that there was a high level of nursing engagement in the study hospital,
despite high demands and increased nursing workload due to unexpected worsening
of patient conditions and, therefore, this could be viewed as self-organising.
Similarly, Brunetto et al. (2018) found high levels of engagement among Australian
nurses. Indeed, self-organising teams indicate highly engaged employees who are
energized, devoted, and inspired to persevere and accomplish their job (Schaufeli &
Bakker, 2004). Engagement is a useful concept and it allows nurses to find
resolutions to problems, to unpredicted features, and to problem situations they
experience in their daily work (Pradebon, Erdmann, Leite, Lima, & Prochnow,
2011). Engaged employees provide proactive resolutions to complex issues that
could influence hospital performance (Warshawsky et al., 2012).
However, it can be argued that communication issues identified in the current
research would challenge the engagement of nurses in the hospital system and it
appears that they highly contributed to MNC in the local context of the acute care
settings. According to Warshawsky et al. (2012), good quality interpersonal relations
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reinforce employees’ engagement. Both engagement and interpersonal relations are
essential to endorse proactive behaviours at the workplace thus enhancing the
performance of the organisation.
2. Nonlinear interactions
Non-linear interaction is a feature of the CAS, which affirms that small events
could escalate to major events, with enormous consequences for the system and vice
versa, such is the ripple effect (Agyepong et al., 2012). Viewed through the
complexity theory lens, it should be noted that small modifications in the complex
system, which is the hospital in this case, can have a large unexpected effect on the
occurrence of the MNC phenomenon. Hence, small modifications in some aspects
potentially generate larger than anticipated effects on reducing MNC. For example,
emphasis could be placed on the presence of a certain number of nursing staff to
provide safe care for a given number of patients in different shifts (nurse to patient
ratio) to reduce MNC. However, this formulation might not be true given several
determinants involved during episodes of care at any given moment in the hospital
units, which interact in a nonlinear manner (e.g. experience of staff members,
complexity of the patient conditions, interruptions and distractions of nursing staff,
teamwork and communication issues, and patient–nurse interactions). In this respect,
mandating nurse–patient ratios to reduce or prevent MNC occurrence and thus
improving patient safety, may be not be the full answer. From this perspective,
interventions introduced to manage MNC must acknowledge the non-linearity in the
complex healthcare system.
Another example of non-linearity from the findings of this PhD would be
prioritizing medical type care over psychosocial care by the nurses. The findings
from nursing engagement data suggested that nurses are determined to provide
patient centred care. However, given the unpredictable nature of the healthcare
system, increased demands, and insufficient resources, provision of psychosocial
care by the nurses could not be possible. In this context, nurses need to modify their
scheduled plan of care by prioritizing interventions that have a direct impact on the
patients’ health condition.
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3. History
Complex systems preserve remnants of their former history (Chandler,
Rycroft‐Malone, Hawkes, & Noyes, 2016). The power relations between various
occupations signify a form of commonplace or retained behaviour in complex
systems. For example, in hospitals, nurses are frequently not given the authority by
surgeons to take decisions on fasting of surgical patients (Chandler et al., 2016). It
can be argued that in the local acute care hospital, such historical and social
dynamics were preserved based on my findings in this PhD research. It appears that
tension or communication breakdown with the medical staff was at the top of
communication issues which led to MNC in the acute care hospital. Thus, my
findings indicate that hospital culture is hierarchical, and led by medical staff.
Similar to Iliopoulou and While (2010), nurses’ autonomy in the study hospital
seemed to be constrained by medical authority and perceptions of lack of nurses’
knowledge, which is reflected in the limited duties assigned to them. According to
Vaismoradi, Salsali, and Ahmadi (2011), the key factor that led to uncertainty in a
local healthcare environment was a lack of nurses’ authority to foster independent
practice. Nurses saw themselves as being under the shadow of the doctors’ orders
who forbad them to interfere with the care prescribed by them to the patients. While
some nurses recognised that some of the interventions exceeded their knowledge and
skills, most of the time they were qualified to provide safe care to patients, but they
disclosed that they were not permitted to perform these clinical duties, despite their
skills and experience (Vaismoradi et al., 2011). In this context, it is essential to
establish collegiate relationships between nurses and doctors, which are essential
requirements to improve the nursing practice environment and nurse job
satisfaction(McClure & Hinshaw, 2002; Zangaro & Soeken, 2007). Mrayyan (2004)
suggested that to provide optimal patient care, collaboration between nurses and
doctors is required. This collaboration should be based on respect, trust and mutual
provision of professional knowledge and skills as well as morals.
Additionally, as a result of the traditional role delineation between medical and
nursing staff, there may be a tendency of staff to prioritise the medical aspects of
care over the social and emotional aspects. This reflects the biomedical model that
has dominated healthcare. It may also reflect the informed task focused care provided
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traditionally by nurses who may adapt and self-organise within the dominant
biomedical model of care, thus certain tasks are missed.
To recap, as previously noted, the current study proposed that complexity
theory could provide a deeper understanding of the circumstances influencing MNC
occurrence in acute care settings. It was also proposed that information generated by
complexity theory could complement an already established MNC theory. The
findings of the current research uncovered that investigation of MNC should depart
from a conventional reductionist approach and move toward a complex systems
approach. Application of a complex systems approach to interpret and broaden the
understanding of the current research findings provides a better reflection of the
complexity of the MNC phenomenon and is helpful in addressing MNC in the local
context of acute care settings. Complexity theory offers additional, innovative and
sustainable approaches to prevent some MNC and should be the key focus of nursing
care quality research in the imminent future.
7.4 LIMITATIONS
The current research was subject to a number of limitations inherent in the
design of the research. Thus, findings of this PhD study should be interpreted with
caution considering these limitations. Five main limitations identified for the current
research are discussed next.
Firstly, the exploratory nature of this PhD study and it being conducted within
one hospital in Queensland, Australia, which impacts the generalisability of the
results.
However, given the contextual and thus complex nature of the MNC problem,
my aim in this PhD was not to generate results generalisable to every context, but to
understand a very local aspect of MNC, which might differ when compared to study
findings conducted in the USA and other countries. It is envisaged though that the
findings of this PhD should in principle be applicable to other similar hospital
settings in the Queensland healthcare context.
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Secondly, as this study relied on self-reporting of MNC, there could be an
overestimation or underestimation of the occurrence of MNC. Also, the response of
the nurses to the MNC items might have been affected by the way they wanted their
management to view the quality of their work (Papastavrou et al., 2016), which can
be referred to as social desirability bias (Gittelman et al., 2015; Van de Mortel,
2008). Despite assuring the nurses that the findings would be de-identified,
anonymous, and confidential, a group of nurses may have decided to provide precise
answers for the MISSCARE survey questions. The reason for this could be lack of
confidence, not wanting to discredit the nursing profession’s reputation, and/or legal
concerns. Furthermore, owing to nurses’ very high workload and wards crowding,
not all nurses who were eligible took part in this research, which may affect the
overall perceptions and reporting of MNC. Also, using self-report to assess nursing
care undone can assume that bedside nurses know all items of essential care required
by patients and can recognise when some of this care is not provided, and that they
can also remember precisely which care items have been missed (Vanfosson, 2017).
Thirdly, the data in the case study of this PhD thesis could have a different
interpretation; despite the data collection occurring from different sources within the
“same temporal bracket”, no associations were made between the patients and their
healthcare results with the nursing care delivered to them. There is thus a possibility
that patients who had the same clinical diagnosis and were managed in the same unit
received very different healthcare by the nurses and other healthcare professionals
involved in their care (Dubois et al., 2013), which could have also influenced
patients’ perceptions about MNC.
Finally, in the design stage of the current PhD research, I was aware that I
would not be able to ascertain the precise number of nurses who would be
approached (receive the invitation) to participate in the MISSCARE survey. The
number of nurses involved in patients’ care within any health service can be highly
variable, particularly with the use of short-term casual staff to fill unexpected
vacancies. The DON estimated a total of 200 nurses would be eligible to be involved
at any one time. The DON at the study hospital approached nurses in the medical and
surgical wards and a total of forty-four nurses agreed to participate. In this
perspective, the MISSCARE survey findings were reliant on a sample that was
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approximately 22% of those potentially eligible to participate. The response rate may
have been influenced by the fact that the study hospital was undergoing the
American Nurses Credentialing Centre’s (ANCC) Pathway to Excellence Program
(ANCC, 2019) during the study period. This program requires the nurses to fill in a
number of surveys, which may have affected the response rate. This phenomenon is
called ‘survey saturation’ (McPeake et al., 2014). Thus healthcare professionals may
be inclined to focus on the surveys that are highly necessary, avoiding or overlooking
the elective ones (McPeake et al., 2014). This phenomenon can be also referred to as
‘survey fatigue’ (Cooper & Brown, 2017).
Nevertheless, it can be considered that the sample in this study would be
reasonably representative of nurses working in the medical and surgical units where
the new legislation ratios have been implemented. I was not able to characterize the
actual population of staff eligible to participate because of privacy and other
considerations. However, the characteristics of the sample were consistent with those
of the general nursing population in Australia, as reported in Nurses and Midwives
NHWDS 2016 Fact Sheet (Department of Health, 2016). In 2016, 89.1% of the
nursing workforce in Australia were female and the average age of the total nursing
workforce was 44.3 years (Department of Health, 2016).
However, it is important to acknowledge the many strengths of this PhD
research. There is a significant contribution to the broader scientific understanding of
MNC arising from this PhD. This PhD work is one of the few that has employed a
mixed-method design, enriching the understanding of MNC. Previous studies mainly
used quantitative designs. Another major strength of this PhD is that all stakeholders
who had been identified as having an effect on MNC were participants in the studies,
namely nurses and patients, enabling a more comprehensive and holistic
interpretation of the MNC issue in the local context in acute care settings. Another
strength of the current research was the utilisation of secondary data about the
various indices relating to the everyday workings of the wards under investigation.
Despite the data that was used not being gathered in the first place to address the
specific questions of this research, they enabled the researcher to contextualise the
study findings and draw meaningful and locally relevant MNC research conclusions.
The secondary data provided an insightful background to the current research,
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highlighting contextual and systemic issues nurses encounter in their routine clinical
practice that might lead to MNC. It can thus be argued that the use of such secondary
data can provide hospitals with effective means for identification of circumstances
that might lead to MNC and permit strategic framing of action plans to mitigate
MNC occurrence.
As qualitative data (clinical incidents data in this research) have limitations
related to dependability of the results (Lincoln & Guba, 1985), direct quotes from
clinical incidents data have been used to enhance dependability of the results in the
present research. The qualitative analysis of the secondary data revealed some very
useful and interesting insights to staff and patient behaviours when MNC occurred.
Such rich data should be further explored both in research and in the practical
hospital setting, given that learnings from this data can predict and therefore prevent
MNC from occurring.
The secondary data also highlighted that there is a need to have more frequent
surveys of patients and nurses where the study took place, especially given the
constantly changing hospital environments. To accurately describe patient
satisfaction and nursing employee engagement, data collection must take place more
frequently and at different seasons of the year, which would better reflect the
working conditions where MNC takes place.
7.5 IMPLICATIONS FOR NURSING PRACTICE, LEADERSHIP AND
MANAGEMENT
The aim of this PhD study was to examine the MNC phenomenon and
contributing factors to MNC in the local context of an acute care setting. The
findings of this research revealed several important considerations for nursing
practice and nursing management and leadership. These implications will be
discussed in detail in this section.
Implications for Nursing Practice
While the current PhD study revealed that individual nursing characteristics do
not play a role in MNC occurrence in the local context of acute care settings, it can
be argued based on the complex nature of MNC and the hospital environment, that
potential effects of nurses on managing MNC at the micro level is still a valid line of
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enquiry. As per Provost, Lanham, Leykum, McDaniel Jr, and Pugh (2015), and the
findings of this PhD thesis, handling complexity in healthcare can be performed
through conversation, relationships, and culture. One particular practice
improvement, such as enhancing reflective practice in nursing, might be effective in
reducing MNC in the local context of acute care settings.
Reflective practice is a professional obligation in nursing (Jacobs, 2016), and
can be defined as the process of making sense of events, conditions and activities in
the working environment (Oluwatoyin, 2015, p. 33). However, reflective practice is
only effective if there is a safety culture present in the care setting (Sherwood &
Zomorodi, 2014; Wilshaw & Trodden, 2015), and such a culture has also been
shown to enhance nurse autonomy in the workplace (Tashiro, Shimpuku, Naruse, &
Matsutani, 2013).
According to Aiken and Patrician (2000), having control over the working
environment is one of the most important aspects of organisational culture and is
greatly appreciated by the nurses. Based on the findings of this PhD, it is paramount
that nurse managers support nurses’ autonomy, both locally and more widely in the
healthcare organisation. Healthcare staff, including nurses, would benefit from being
accountable to provide and role model patient centred care in their organisation
(Kenny & Allenby, 2013). If instead of safety culture there is a blame culture
present, all staff are more likely to look for someone to blame for MNC, rather than
focusing on how to find solutions to problems and antecedents of MNC (Kenny &
Allenby, 2013).
Reflective practice allows nurses to escape impulsive, repetitive, and
condemnatory assumptions about different work conditions, colleagues, and patients
(Freire & Freire, 2004). It has been identified that when nurses have the chance to
reflect on their daily practice, this leads to improved nursing care and thus improved
patient outcomes (Oluwatoyin, 2015). Reflective practice is important for the nurses
and other healthcare providers because it allows them to identify the methods of
interaction and communication with their colleagues that are most conducive to
preventing MNC or medical errors. Although reflective practice allows nurses and
other healthcare staff to become self-aware, self-directing learners, and be in touch
with their environment (Dubé & Ducharme, 2014; Oluwatoyin, 2015), it alone is not
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enough to prevent MNC. The system needs to be listening to these reflections, acting
upon them, and evaluating the solutions that work when addressing the problems
raised in this process (Koshy, Limb, Gundogan, Whitehurst, & Jafree, 2017).
Also, reflective practice allows the healthcare staff to identify their ability to
meet patients’ needs and demands. Reflective practice could enhance care
personalisation for both patients and their families (Dubé & Ducharme, 2014). It
could also allow nurses to identify their personal strengths and areas that need future
development and training. Engaging in daily and or weekly reflections on one’s own
practice have also been shown to improve critical reasoning and results in faster
decision-making processes (Oluwatoyin, 2015).
Reflective practice can be performed individually and in groups (Oluwatoyin,
2015). Reflective practice can be verbal and/or written. For example, a verbal
approach could include discussion of nursing issues in a small workshop enabled by
a facilitator. Written approaches could include, but not be limited to, portfolios and
reflective journals (Dubé & Ducharme, 2015).
Performing reflective practice in a group allows nurses to make a plan for
effective nursing interventions, agreed by consensus from the group, and to assess
the effectiveness of these interventions (Oluwatoyin, 2015). Actions and
interventions identified through reflective practice can be sustainable and drive
future managerial decisions around MNC prevention (Nicol & Dosser, 2016). In fact,
more reflection and evaluation of current practice aids preparation of nurses to meet
uncertain circumstances, which with practice will reduce the undesirable effects of
rapid responses when under pressure during work times (Vaismoradi et al., 2011).
Moreover, creating a supportive working culture and enabling healthcare
workers to provide and receive meaningful social support in the workplace will free
the sharing of good practice and also tangible and often scarce resources (Cox et al.,
2015).
Tailored nursing educational opportunities can also be effective in helping
nurses to address and manage uncertainty in their practice environment (Cranley et
al., 2009). Also, including highly experienced clinical nurses who have excellent
practical and research knowledge will help nurses to improve their practical and
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research skills, such as reflective practice (Cranley et al., 2012), thus enhancing
nurses’ perceptions of autonomy and competence in their practice (Cranley et al.,
2012). Hence, nurses can react appropriately to the increased demands and
encountered uncertainties during interaction with the healthcare consumers (Melo et
al., 2016).
Drawing on previous discussion about reflective nursing practice, it can be
argued that MNC can be reduced by increasing the nurses’ capacity to adapt to their
increasing demands. This can be achieved by increased nursing awareness about the
available personal and workplace resources, as well as how to best access them. As
the current study findings indicate, there was no significant association between
nurses’ job title, their clinical experience, and MNC occurrence. Hence, in the study
hospital, introducing interventions to reduce the occurrence of MNC, such as
reflective practice, should be directed to all nursing staff regardless of their level of
experience.
Implications for Nursing Leadership and Management.
According to Lin, Chaboyer, and Wallis (2009), the leadership of the
healthcare organisations bears the entire accountability for ensuring patient safety. In
this persepective, nursing leaders are required to vigilantly observe and monitor the
healthcare systems’ structural components to prevent occurrence of MNC, and make
this practice a social norm in the hospital system (Duffy, Culp, & Padrutt, 2018).
Examples on the role of nursing leadership in this context are: creating clear
expectations of various nursing job titles, leading the development of processes,
systems and policies on how nursing work should be accomplished, continuous
observing of established measures for evaluating nursing performance, and
enhancing excellent employee recognitions and teamwork (Tye & Dent, 2017).
Henceforth, ultimately the nurse leaders are responsible for confirming nursing care
standards are being met and for initiating and implementing modifications to the
practice setting in order to improve delivery of healthcare in a complete and
consistent manner (Duffy et al., 2018).
However, a consequence of uncertainty in a dynamic healthcare system,
together with the historical-social influence of the complex healthcare system,
requires hospital managers to be flexible and progressive decision makers in order to
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provide appropriate and safe patient care (Naveh et al., 2011; Pradebon et al., 2011).
The responsibility of nursing leadership does not stop at focusing on the
environmental impact on the work organisation. It should also include tackling tasks
within the organization to meet daily challenges (Pradebon et al., 2011). In the
remaining part of this section, I propose three approaches that could contribute to
managing the MNC phenomenon more effectively in the local context of an acute
care setting, namely: Minimum Specification (MS) approach, organisational
learning, and feedback loops.
1. Minimum Specification (MS) approach
Part of the nursing management responsibity is nurse education. Nurse
managers must establish practice environments which empower nurses so they can
use their own agency and feel in control of their work and practice (Laschinger &
Havens, 1996). In this respect, for the nursing management to allow for such change
to take place in healthcare organisations, it is essential to permit these changes to
occur spontaneously and as a result of the interactions between different staff from
various services involved in the healthcare of patients, rather than managing these
changes using a top down approach (Tuffin, 2016). One way to accomplish this goal
is employing the Minimum Specification Approach (MS) (Wilson, 2001).
MS is a management approach that concentrates on setting the direction and
approach to reduce and/or prevent adverse healthcare outcomes and directs resources
to where healthcare provision needs to be improved. The MS approach also
motivates staff to take responsibility for their own actions and decisions, which in
turn allows them to come up with their own innovative and creative solutions to the
problems they are facing at work. Finally, the MS approach has been seen to allow
system changes that lead to unique and local resolution of problems associated with
healthcare in general (Tuffin, 2016). Predominantly in complex conditions, to the
extent that nursing management collaborates with the nursing team in order to look
for resolutions, so will the outcomes be better (Lindberg, Nash, & Lindberg, 2008).
The findings of the triangulated data from this PhD indicate that the MS
approach is important, especially empowering of staff, which should co-exist with
the other safety management systems that will lead to continuous patient safety
improvements in healthcare organisations (Naveh et al., 2011). Indeed, the findings
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of this PhD support the fact that nurses who act autonomously make high quality
decisions significantly more often than less autonomous nurses (Bakalis, Bowman, &
Porock, 2003). Furthermore, a perception of having autonomy is a principal factor
that leads to nurses’ job satisfaction (Keshk et al., 2018) and is also one of the most
important organisational attributes valued by the nurses (Aiken & Patrician, 2000).
Furthermore, having access to organisational resources also has been shown to have
a positive impact on employee engagement level (Boamah & Laschinger, 2015).
Nurses’ autonomy is also associated with improved patient outcomes
(Papathanassoglou et al., 2005). However, the absence of an accurate definition of
clinical autonomy and the frustration in trying to differentiate between institutional
autonomy and clinical autonomy can lead to avoidance of using a clinical autonomy
approach by hospital leadership and management (Keshk et al., 2018).
Applying the principles of an MS approach, nursing management could work
together in partnership with nursing staff to identify any recurring events and factors
that influence MNC. They could jointly explore and develop the best solutions to
eliminate and/or moderate the effects of MNC. Any solutions generated by such
collaboration then would then be shared with the whole organisation. It can be
argued that the findings of this PhD study point to this approach being effective if
used, given the high level of engagement reported by the nurses in the study hospital.
If nurses observe favourable effects of their own decision makings others might
follow, the knock-on effect of which will be establishing and sustaining work
behavioural patterns that will become an integrated part of the organisational culture.
Such bottom-up driven cultural change with top-down managerial directives can
create a more autonomous nursing workforce in the study hospital, leading to
effective cooperation and interaction as a team of healthcare providers rather than
fostering isolated individual performance improvements (Martínez-García &
Hernández-Lemus, 2013). The resolutions created through this process are likely to
lead to more acceptance, adherence and valuing of the new practices that are
sustainable and can be upscaled within the whole hospital. According to Braithwaite
(2018), change in the complex healthcare system is more likely to be accepted in the
case of individuals being involved in the actions and decisions influencing them and
in the case where these activities are based on their logic. However, the change is
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more likely to be rejected in the cases where the change is levied from others
(Braithwaite, 2018).
2. Organisational Learning
Given the complex and dynamic nature of unfolding events in the healthcare
system, an effective solution would be the fostering of learning environments in the
healthcare organisation, which was also identified in the literature as being one of the
main cultural elements that needs to be addressed by hospital leaders and boards
(Edmondson, 2003; Mannion et al., 2017). Organisational learning allows for
translation of knowledge into action and for the appraisal of those actions for
effectiveness that generates the collective information within the healthcare
organisation (Ratnapalan & Uleryk, 2014). Crucially, it is necessary to reinforce the
notion that organisational learning in healthcare organisations is not a “one-time
intervention”, but an ongoing process, which happens by means of formal and
informal learning that has a reciprocal relationship with organizational change
(Ratnapalan & Uleryk, 2014).
3. Feedback loops
Complex systems develop in such a manner that information related to the
system is disseminated through the system (Cilliers, 2002). In this sense, every agent
in the system will only have an incomplete image of the whole system (Chandler,
2018). Thus, effective feedback mechanisms should be put in place to improve the
whole system learning within the healthcare organisation and to permit the sharing of
collectively generated solutions across the whole system (Tuffin, 2016). Nursing
management is responsible for providing nurses with real-time feedback so that they
can observe the associations between their nursing interventions and patients’
outcomes. This practice is important for nurses, as using this approach will provide
valuable information to the nurses at the point of care, and therefore reduce
uncertainty in the nursing practice environment (Cranley et al., 2009; Doran et al.,
2007). In fact, both positive and negative feedback loops play a role in managing
unpredictable emergent behaviours in the complex systems, including hospitals
(Marchal et al., 2014).
213
Finally, in this context, it is imperative to acknowledge that nurse managers
need to be well-informed with regards to organizational and behaviour change
theories and also to possess managerial skills that inspire their workforce through
coaching and mentoring activities, which will foster autonomy and enable their staff
to be more effective in the workplace (Stefancyk, Hancock, & Meadows, 2013).
7.6 RECOMMENDATIONS FOR FUTURE RESEARCH
Drawing on the findings of this thesis, the following recommendations are
made to reduce and/or moderate the effects of MNC, both in practice and
theoretically:
1. There is a lack of clarity on the relationship between MNC and patient
outcomes. Further research is needed to explore this association in more
detail.
2. It has been found in the current research that examining the emerging data
through the lens of complexity theory did give better insights to MNC in the
local context of an acute care setting. Future research into MNC using a
complex systems approach is needed to investigate and explain why MNC
occurs, and to try to isolate key system predictors of MNC that lead to the
biggest outcome change to reduce MNC in the healthcare setting. Using such
a new view, implementation scientists can be directed to concentrate on these
predictors to improve healthcare outcomes. There should be more mixed
methods research and also pure qualitative studies to explore MNC in much
more detail. The MNC field of study could also benefit from conducting
ethnographic studies focusing on MNC in acute care settings. Ethnography
research has been recognized as a robust tool for comprehension of context in
quality improvement healthcare research (Leslie, Paradis, Gropper, Reeves,
& Kitto, 2014). Ethnographic research could also provide detailed insight into
the organisational, environmental, social, and political influences on MNC
(Waring & Jones, 2016). There is a plethora of literature on elements of MNC
derived from various large-scale quantitative studies, but there is a distinct
lack of micro and detailed understanding of MNC. Also, there is little
214
information on how MNC varies within a hospital locally, within the same
city, and across states and nations.
3. There should be further exploration and research on what, when, for whom,
and why suggested nurse interventions discussed in this PhD work are
effective and to assess their impact on the level of MNC in the local context
of acute care settings. Also, different intervention designs should test the
effectiveness of such interventions (pre and post interventions studies).
4. The findings of the current PhD revealed that the ‘number of hours worked
per week’ was the only work environment related factor that had a significant
association with MNC in medical and surgical wards in the study hospital.
Therefore, it is recommended that nurse and hospital managers review and
work with nurses to reduce such system-related MNC issues, which will lead
to higher quality of healthcare provision.
5. Multisite research is required to further explore factors associated with MNC
in the Queensland healthcare context.
7.7 CONCLUSION
The aim of this PhD study was to explore the concept of MNC in the local
context of an acute care tertiary hospital setting in Queensland, Australia. This PhD
work consisted of a series of studies as described in Chapters 4, 5 and 6 to achieve
the aims and objectives of the research. All study objectives were related to and
investigated MNC elements, reasons and contributory factors in the local context of
an acute care hospital setting.
This research employed a convergent parallel mixed methods research design
to investigate MNC and contributory factors and used complexity theory as an
explanatory framework. The research design, methods, and frameworks applied to
this research were complementary to each other, as well as useful in their own right,
215
which permitted a holistic interpretation of MNC in the local setting, potentially
ensuring a robust, focused and consolidated results set.
This research yielded important findings that both support and add to previous
research findings on MNC. This research showed that there are multiple factors that
characterise MNC and that influence its rate and significance. Despite the complexity
of the context, this PhD work highlighted some important considerations at each
level of the system and reflected on the interactions between individuals and systems
and their effect on MNC.
This research showed that the relationships between MNC factors are complex
and not necessarily linear in nature. The solutions to reducing the rate of MNC
require detailed understanding of underlying concepts and their relationships, or else
simplistic technical solutions will be preferred. A comprehensive approach to quality
should be based on this detailed understanding. In fact, for the purpose of obtaining
an effective change, there is a pressing requirement to consider the knowledge
regarding the system’s complexity rather than continuing to apply in a blunt manner
the present improvement paradigms that are based on linear thinking (Braithwaite,
2018). In this context, to think that changing staffing ratios will resolve complex
issues without a detailed understanding of how other factors intervene may result in
disappointing outcomes. For example, increases in staff without appropriate
leadership, feedback loops, and enhancing nursing reflective practice is likely to
generate inadvertent consequences and sub-optimal results. Failure by policy makers
to identify such matters can potentially impact the attempts to resolve complex issues
in the complex healthcare system, resulting in ‘policy resistance’ (Atun, 2012).
Hence, the findings of this research revealed that the dynamic, adaptive and
unpredictable nature of the healthcare system should be fully comprehended by
healthcare policy makers when attempting to formulate solutions to address complex
problems such as MNC. Considering the dynamic complexity of the healthcare
system is a way to recognise leverage areas within the system, thus enhancing system
performance (Lebcir, 2006).
It was concluded that elimination of MNC is hard to achieve, but the findings
showed that reducing the rate of MNC occurrence and moderating of the patient and
staff outcomes from MNC is achievable, precisely by accepting the complexity of the
216
system in which it occurs. Given the pragmatic stance adopted in the current
research, modification of the overall hospital culture is best placed as a means to
address the MNC phenomenon in the local hospital under study in the acute care
setting.
The MISSCARE survey (Kalisch & Williams, 2009) used to examine MNC in
the current research is the standard instrument used to evaluate the MNC
phenomenon in most of the literature. However, the findings of this thesis suggest
that some important MNC elements, such as the importance of environmental scans,
were not considered in the MISSCARE survey and therefore are not measured, and
their influences are unknown on MNC, especially across different hospitals and
healthcare settings. For example, in this research patients’ falls could be related to
lack of environmental scans to remove safety hazards from the patient’s room by the
nurses. This could be an example of MNC that should be investigated thoroughly so
that it can be targeted and remedied by hospital management. It can be concluded
that although the MISSCARE survey is an excellent standardised instrument, the
findings yielded from it when used across different healthcare contexts might not be
fully informative of what interventions designs would be most effective when trying
to address MNC. The current research has highlighted how the local context of MNC
really matters and there should therefore be additional exploration of elements and
factors influencing MNC locally, using qualitative and quantitative methods. Thus, it
may be of significant value to develop context-specific surveys to assess MNC for
every hospital, or at least for every group of hospitals that share similar features
within the same healthcare system (or similar district).
Prior literature on MNC documented a link between MNC and insufficient
labour and material resources, as well as communication issues (Chapman et al.,
2017; Duffy et al., 2018; Kalisch & Lee, 2012; Kalisch et al., 2011). However,
previous literature on MNC prominently neglected the local context and thus
provided decontextualised simple solutions to MNC management. For example,
previous literature on MNC recommended that healthcare organisation should
establish, execute and assess particular approaches to handle increased nursing
workloads, ensure staffing adequacy and enhance teamwork to best address MNC
(Chapman et al., 2017; Kalisch & Lee, 2010; Marguet & Ogaz, 2018). It also
217
suggested that health services ensure adequacy of resources (Aiken et al., 2018; Kim
et al., 2018). The MISSCARE survey can be used to assess points requiring
improvement and thus identify the most appropriate strategies to mitigate them
(Kalisch et al., 2011), which is in line of this PhD work.
There is an emphasis in most of the MNC literature on modifications of the
structural components of nursing practice environment to address MNC (Duffy et
al., 2018). However, focusing on modifications to the overall organizational culture
to address MNC, may be a better solution for the local hospital. While conventional
approaches that address MNC are critical, integration and consideration of the local
aspects of the hospital’s safety culture will have a positive impact on MNC in that
healthcare institution, for their patients and nursing staff (Maloney et al., 2015).
According to Van Beuzekom, Boer, Akerboom, and Hudson (2010), “Ideally, safety
should be embodied throughout the institution, part of the culture, and minimizing
possible latent causes that might accidentally combine to produce injury (p 57)”.
Indeed, organizational culture controls the way systemic elements are treated (Van
Beuzekom et al., 2010).
On the whole, it can be argued that assessing the everyday struggles that
nursing staff face in their clinical practice contributes to an in depth comprehension
of the MNC phenomenon and represents a novel finding in the current research.
Indeed, the findings from the case study in this PhD allow for better identification of
emergent and unpredictable nursing work related events, that are typical of complex
systems (Marchal et al., 2014).
Clearly, there is a need to start addressing the area of MNC across the
healthcare system, because it significantly contributes to the safety culture in
hospitals and the quality of healthcare provision. This thesis provides timely
information for decision makers, healthcare scholars, nurse managers, and nurses to
expand their knowledge of MNC and to assist them with addressing this
phenomenon in the hospital environment. It may also be useful in the governance of
complex healthcare organisations, thereby contributing to improved healthcare
quality and promoting patient safety.
It is essential that nursing management devote more effort to ensure that
strategies recommended in the current research are considered for implementation. It
218
is anticipated that these strategies would empower nurses to handle the complex web
of factors that influence MNC. This also necessitates the mentoring skills of nurse
managers be enhanced through appropriate professional development and training
programmes. Hence, providing them with the ability to inspire nurses to effectively
manage dynamic events associated with MNC in the modern complex healthcare
system.
219
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Appendices
APPENDIX 1: QUANTITATIVE STUDIES ABOUT ELEMENTS AND REASONS OF MNC
Author/Year Methods MNC elements frequently missed MNC elements less frequently missed Reasons of MNC
1. Kalisch et al. (2009) Cross sectional MISSCARE survey. Three hospitals in the US. Response rate (RR): 38.6% (n=459)
1. Ambulation (84%). 2. Assessing of the effectiveness of medications (83%). 3. Turning and mouth care (82%).
1. Patient assessments performed each shift (17%). 2. Bedside glucose monitoring as ordered (26%). 3. Hand washing (30%).
1. Labour resources (85%). 2. Material resources (56%). 3. Communication (38%).
2. Kalisch et al. (2011) Cross sectional MISSCARE survey Ten hospitals in the US RR: 59.8% (n=4,086).
1. Ambulation (32.7%). 2. Attendance at care conferences (31.8%). 3. Mouth care (25.5%).
1. Patient assessments (2.3%). 2. Glucose monitoring (2.4%). 3. Vital signs monitoring (4.2%).
1. Labour resources (93.1%) 2. Material resources (89.6%). 3. Communication (81.7%).
3. Kalisch and Lee (2012)
Cross sectional MISSCARE survey 11 hospitals in the US (both magnet and non‐magnet). RR: 57.3% (n=4,412)
Non‐magnet hospitals reported higher rate of MNC, particularly in turning, feeding, meal set up, full documentation, patient teaching, mouth care, IV/central line site care, call‐light response, medication effectiveness assessment and skin/wound care. Missing ambulation, timely administration of medications and psychological assurance similar in two hospital types (percentages not reported, only the mean).
In both organisations are similar: 1. Vital signs and glucose monitoring 2. Assessment each shift. 3. Discharge planning. (mean only reported)
Non‐magnet hospitals have more communication and labour forces issues. Material resources issues are similar in both hospitals types. Only mean reported.
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4. Kalisch et al. (2012)
Cross sectional MISSCARE survey Four acute care Hospitals in USA and four acute care hospital in Turkey. RR: 67.2% in turkey and 53.4% in the USA (n= 1,098).
1.Ambulation, 2. Posture changes 3. Feeding patients’ meals while they are warm. Percentages not reported
1.Handwashing 2.Monitoring of vital signs Percentages not reported
1. Labour resources. 2. Material resources. 3. Communication. Percentages not reported.
5. Friese et al. (2013) Secondary analysis MISSCARE survey Nurses and NAs in oncology units in 9 hospitals in the US. RR not reported. N= 352 nurses.
1. Ambulation (39.1%). 2. Attendance of care conferences (31.3%). 3. Mouth care (23. 9%).
1. Patient teaching (12.5%). 2. Response to call light within 5 minutes (14.8%). 3. Documentation (14.9%).
Not reported.
6. Maloney et al. (2015)
Cross sectional MISSCARE survey Three hospitals in North Carolina. RR: 27.3% (n=205 nurses).
1. Ambulation (77.7%) 2. Patient turning (73%). 3. Timely medication administration (67%). 4. Mouth care (62%).
1. Glucose monitoring (7.9%). 2. Assessment of patient each shift (9.9%). 3. Hand washing (15.5%)
1. Unexpected rise in patient volume (87.4%). 2. Inadequate number of staff (84.9%). 3. Inadequate number of assistive and/or clerical personnel (81%).
7. Palese et al. (2015) Mixed methods (two phases: Longitudinal observation (to measure nursing workload) then cross sectional survey). MISSCARE survey RNs and NAs in 12 medical units in 12 Italian hospitals. RR: 75.2% (n= 314).
1. Ambulation (91.4%). 2. Turning the patient every 2 hours (74.2%). 3. Timely medication administration (64.6%).
1. Patient bathing/skin care (25.5%) 2. Handwashing (29.3%). 3. Glucose monitoring (30.3%).
1. Unexpected rise in patient volume (95.2%) 2. Inadequate number of staff (94.9%). 3. Heavy admission and discharge activity (93.3%).
8. Willis et al. (2015) Cross sectional Online MISSCARE survey 10 % of the Nurses and midwives registered in Nursing and Midwifery
1. interdisciplinary care conferences 2. Ambulation 2. Mouth care Means were reported.
1.Blood glucose monitoring 2.Hand washing 3. IV/central line care 4. Providing PRN medication within 15 minutes. Means were reported.
1. Sudden and unexpected rises in patient volume and/or unit acuity (54.2%).
2. Heavy admissions and discharges (44.8%).
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Federation‐South Australian Branch. (289 nurses and midwives) RR: 22% (n= 354 RNs and ENs).
3. Inadequate numbers of staff (43.4%).
9. Blackman et al. (2015)
Cross sectional Online MISSCARE survey Nurses and midwives in various healthcare settings in NSW (n=4431).
Immediate (treatment) priority care, such as ambulation
Low priority care such as discharge planning.
Quantitative findings: Moderate reasons: inadequate number of staff, urgent patient situations (which require staff attention) and Unexpected rises in patient numbers or acuity. Minor reasons: communication problems with ancillary staff, poor communication regarding whether or not care was completed and absence of rostered staff from the clinical area. Qualitative findings: 1. Work intensification due to high patient acuity. 2. Staffing issues. 3. Lack of managerial support. 4.Lack of access to equipment and resources
10. Willis et al. (2015) Cross sectional Online MISSCARE survey Nursing staff personnel and midwives in the public and private sector in Victoria, Australia.
Skin and wound care, glucose monitoring
Turning patients, oral care, timely medication administration and patient education
Unexpected increase in patient volume, urgent patients’ conditions. Unexpected increases in workloads such as increased admissions and discharges In staffing inadequacy.
11. Orique et al. (2016) Cross sectional MISSCARE survey Acute care hospital in California
1. Ambulation (78.8%). 2. Timely medication administration (63.4%). 3. Mouth care (63.3%).
1. Bedside glucose monitoring as ordered and Patient assessments performed each shift (8%). 2. Vital signs assessment (16%).
1. Labour resource issues (90.9%) 2. Materials resources (89.2%) 3. Communication (81.3%).
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N= 169 3. Focused reassessment according to patients conditions (21%).
12. Winsett et al. (2016)
Cross sectional MISSCARE survey 18 Medical and surgical units in four hospital systems in USA. RR: 29% (n=168).
1. Ambulation (53%). 2. Oral care (35.7%). 3. Medication administration within 30 minutes (31.6%).
1. Blood glucose monitoring (81.6% reported rarely missed). 2. Patient assessment each shift (67.9% rarely missed). 3. Focused reassessment (53.6% rarely missed).
1. Unexpected rise in volume/acuity (76.2%), 2. Heavy admissions/discharges (72%). 3. Inadequate assistants (59.5%),
13. Papastavrou et al. (2016)
Cross sectional correlational, descriptive MISSCARE survey RNs in 6 oncology and haematology units in the Republic of Cyprus, RR: 91.8% (n=157)
1. Attending interdisciplinary events (87.9%). 2. Turning every two hours (66.9%). 3. Mouth care (61.1%).
1. PRN medication requests acted on within 15 min and bedside glucose monitoring as ordered (1.9%) 2. IV/central line site care and assessment (2.5%). 3. Setting up meals for patient who feeds themselves (2.6%).
1. Unexpected rises in patient volume and unit acuity (77.1%). 2. Inadequate number of staff (76.4%). 3. Urgent patient situations (74.5%).
14. Hernández‐Cruz et al. (2017)
Cross sectional MISSCARE survey Private hospital in Mexico N= 71 nurses
1. Basic care (mouth care) (28.2%). 2. Ambulation and patient feeding when the food still warm (19.7%). 3. Emotional support for patient and family (14.1%).
1. Assessment of medication effectiveness (0%). 2. Wound care and fluid balance control (1.4%). 3. Discharge planning (4.2%).
1. Labour resources (insufficient staff (40%)). 2. Communication (nurses unavailable (22.5%). 3. Material resources (medications not available (21.1%).
15. Smith et al. (2017)
Cross sectional MISSCARE survey Five hospitals in the US RR: 8.1 (n= 233).
1. Mouth care (36%). 2. Ambulation (35.3%). 3. Turning (29.6%).
1. Glucose monitoring (9.1%). 2. Hand washing (9.2%). 3. Vital signs monitoring (9.4%).
Not reported
16. Chapman et al. (2017)
Cross sectional descriptive Paper based MISSCARE survey RNs and ENs in four public hospitals in Victoria (medical, surgical, ICU, specialists units). RR: 90% (n=334).
1. Ambulation (43.3%). 2. Turning patient every two hours (29%). 3. Mouth care (27∙7%).
1. Bedside glucose monitoring as ordered (1.18%) 2. Patient assessments performed each shift 2.37%). 3. Focused reassessments according to patient condition (3.58%).
1. Inadequate labour resources (range 69∙8–52∙7%). 2. Material resources (range 59∙3–33∙3%) 3. Communication (range 39∙3–27∙2%).
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17. Higgs et al. (2017) Cross sectional Paper based adapted MISSCARE survey RNs in medical, surgical and critical care units in acute care hospital in Sydney (n=249)
Medical units 1. PRN medication request acted on within 15 min (79.1%). 2. Assist with toileting needs within 5 min of request (61.6%). 3. Skin/wound care (57.7%). Surgical units 1. Patient bathing/skin care (61.2%). 2. Patient teaching about illness, tests, and diagnostic studies (57.4%). 3. Skin/wound care (56.7%). Critical care /emergency 1. Attend interdisciplinary care conferences whenever held (73.7%). 2. Turning patient every 2 h (69.5%). 3. Falls risk assessment conducted within 24 h of admission (62.8%).
Medical units 1. Vital signs assessed as ordered (7%). 2. Hand washing (8.1%). 3. Full documentation of all necessary data (15.5%). Surgical units 1. Vital signs assessed as ordered (4.2%). 2. Hand washing (4.4%). 3. Full documentation of all necessary data (10.1%). Critical care/emergency 1. Vital signs assessed as ordered (12.9%). 2. Bedside glucose monitoring as ordered (13.3%). 3. Focused reassessments according to patient condition (15.5%).
Reasons not reported.
18. Villamin et al. (2018)
Descriptive repeated measures design. Online MISSCARE survey Nursing staff (n= 286) in cancer care centre (6 units)
1. Ambulation. 2. Turning every two hours. 3.Care conferences attendance Percentages were not reported.
Not reported 1. Inadequate number of assistive and/or clerical personnel.
2. Inadequate number of staff 3. Heavy admission and discharge
activity.
19. Saqer and AbuAlRub (2018)
Cross sectional Paper based MISSCARE survey N=362
1. Ambulation three times. 2. Feeding the patient on time. 3.Mouth care Percentages were not reported.
1.Vital signs assessed as ordered 2. Full documentation of all necessary data. 3.Bedside glucose monitoring as ordered
1.Labour resources 2. Material resources. 3. Communication.
20. Duffy et al. (2018) Cross sectional MISSCARE survey and Practice Environment Scale Nursing Work Index (PES‐NWI) (paper based).
1.Ambulation (46.9%). 2.Attend interdisciplinary
conferences (40.3%).
3.Oral care (33.8%).
1.Hand washing (3.6%). 2.Bedside glucose monitoring (2.2%).
3.Patient assessment performed each
shift (1.5%).
Resources availability , satisfaction with current position, and collegial nurse‐physician relationships
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N= 138, one community hospital in mid‐Atlantic region
21. Schubert et al. (2013)
Cross sectional (part from RN4CAST study) BERNCA Medical and surgical RNs in 35 acute cate hospitals in Switzerland N= 1633 nurses
1. Set up care plans (12.3%). 2. Newly admitted patients’ evaluation (11.5%). 3. Emotional support (10.6%)
1. Change of the bed linen, and preparation for tests and therapies (0.4%). 2. Changes of wound dressing (0.8%). 3. Partial sponge bath (1%).
Not reported.
22. Papastavrou et al. (2014)
Cross sectional correlational BERNCA RNs in medical and internal medicine unit in public hospitals in Cyprus
1. Oral hygiene (31.5 %(. 2. Documentation review (31/2%). 3. Coping with the delayed response of physicians and emotional support (30%).
Activities of daily living: 1. Eating (13.4%) 2. Skin care and bathing (13.9%). 3. Managing body waste (14.2%).
Not reported
23. Jones (2015) Cross sectional PIRNCA 3529 medical surgical RNs, LPNs, and NMs in Texas.
1. Timely response to patient requirements. 2. Document review. 3. Regular hygiene provision.
1. Medication and enteral nutrition administration. 2. Following infection control procedures. 3. Wound care and dressing changes.
Time scarcity
24. Al‐Kandari and Thomas (2009)
Cross sectional exploratory Questionnaire adapted from IHOC survey Five public hospitals in Kuwait (medical and surgical wards).
1. Comfort talking with patient and family. 2. Documentation of nursing care. 3. Mouth care. 4. Catheter care
1. Medication administration. 2. Patient condition assessment. 3. Updating nursing care plans. 4. Patient monitoring and teaching.
1.Increased patient load 2.Performing non‐nursing tasks
25. Ball et al. (2014)
Cross sectional RN4CAST study survey (TU‐13) RNs in general medical and surgical nurses in 46 NHS in the UK
1. Comfort talking with patients. 2. Educating patients. 3. Updating the plans of care for the patients
1. Pain management. 2. Performing treatment/procedures.
Not examined.
26. Scott et al. (2013) Cross sectional TU‐13 Medical and surgical RNs in
1. Comfort talking to the patients. 2. Patient education
Not reported Not examined.
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30 acute care hospitals in Ireland
27. Ausserhofer et al. (2014)
Cross sectional TU‐13 European countries participating in RN4CAST study.
1. Comfort talking with patients. 2. Educating patients. 3. Updating the plans of care for the patients.
1.Mouth care 2. Documentation of nursing activities. 3. Patient surveillance.
Performing non nursing tasks
28. Zander et al. (2014) Cross sectional TU‐13 RNs in medical and surgical units in 49 acute care hospitals in German
Comfort talking with the patients Undertaking treatment/procedures.
29. Bekker et al. (2015) Cross sectional TU‐13 (paper based). Medical and surgical nurses in 7 public hospitals and 55 private hospitals in South Africa.
1. Comfort talking with patients. 2. Educating patients. 3. Updating the plans of care for the patients.
1. Pain management. 2. Performing treatment/procedures
Performing non‐nursing tasks.
30. Ball et al. (2016) Cross sectional TU‐13 (web survey and postal survey) 79 acute care hospitals in Sweden. Medical and surgical RNS. RR 70% (n = 23,087).
1. Comfort talking with patients (46%). 2. Developing or updating nursing care plans/care (34%). 3. Oral hygiene (31%).
Undertaking treatment/procedures and pain management (6%).
1.Staffing levels (RN staffing of less than four patients per RN reduced the odds of care being left undone by 85% (OR 0∙148, P < 0∙001)). 2. Time of the shift: nurse‐staffing levels is different across various shifts, for example, it was 5.5 patients per RN in day shift, whereas in the night shift, it was 11.4 patients per one RN. The occasions of MNC were higher in the day shifts than in the night shifts.
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APPENDIX 2: QUANTITATIVE STUDIES INVESTIGATING THE RELATIONSHIP BETWEEN MNC AND STAFFING LEVELS
Author/year Setting Design Significant findings
1. Kalisch et al. (2011).
110 patient care units with 4288 nursing
staff (RNs, LPNs, NAs) 10 hospitals in the
US.
Cross sectional
descriptive.
1. Negative association between MNC and HPPD, and RN HPPD.
2. High case mix index associated with lower levels of MNC.
2. Friese et al. (2013) 62 Medical and surgical unit in 9
hospitals in the US (n=352)
Secondary data
analysis. The data
was collected using
MISSCARE survey
from nurses and
nursing assistants
Increase one patient per one nurse lead to 2.1 increase in MNC.
3. Ball et al. (2014) 401 medical surgical units in 46 acute
care hospitals in the UK, (n=2917)
Cross sectional RR:
62%, TU13
As the patient to nurse ratio decreased, odds of MNC were
reduced as well
4. Ausserhofer et al. (2014) 488 hospitals across 12 European
countries, (n=33 659 nurses)
Cross sectional
multisite study.
(RN4CAST
questionnaire)
Nurses reports of nursing care left undone were lower in
hospitals having pleasant practice atmosphere (p<0.0001),
lower patient to nurse ratios (p<0.0001), and reduced number
of nurses carrying out non‐nursing duties (p<0.0001).
5. Cho et al. (2015) 4 units that have high staffing and 9 unit
have low staffing ratios. (n=115 in high
staffing units and 117 in low staffing
units)
Cross sectional
(MISSCARE survey)
The mean score of MNC was lower for the nurses in the case of
high staffing ratios (M=.1.39 versus 1.51 in units with low
staffing ratios)
6. Cho et al. (2016) 51 acute care hospitals in South Korea
(n= 3037)
Cross sectional
(Survey tool adapted
from BERNCA)
For every additional patient nurse cared for, there was 3%
higher odds of nursing care left undone (OR = 1.03, 95%
CI = 1.01–1.05).
7. Palese et al. (2015) 12 medical units in Italy (n=314) Mixed methods
(MISSCARE survey)
Higher number of patients per one nurse is associated with
more missed care (OR=0.91; p 0.001).
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Provision of more care by support workers is associated with
higher levels of missed care as perceived by nurses
8. Ball et al. (2016)
Medical –surgical wards, in 79 acute
Swedish hospitals. (N=10,174 RNs).
Cross sectional 1.Odds of MNC decreased by 85% with RN staffing levels of one
RN caring for less than four patients (OR 0.148, P < 0.001).
2. No benefit from increasing support employees in reducing
the occasions of incomplete care.
9. Orique et al. (2016) 581 bed acute care hospital in
California (n=169)
Cross sectional
(MISSCARE survey)
1. MNC is associated with nurse patient ratio; as the number of
the patients increase, the missed care score increases.
2. No significant association between nurse workload at the unit
level (patient turnover rate) and MNC.
10. Dabney and Kalisch (2015) 729 patients on 20 units in 2 hospitals Cross sectional
MISSCARE survey–
patient
A significant correlation between staffing variables and missed
timeliness of nursing care interventions, 2.Basic care and
communication were not associated with RNHPPD and HPPD.
11. Kalisch et al. (2013) One teaching hospital in US (n=633
RNs). One teaching hospital in Lebanon
(114 RN).
Cross sectional
(MISSCARE survey)
The mean number of patients per one nurse has no effect on
the MNC in both countries
12. Schubert et al. (2013) 35 acute hospitals in Germany, France
and Switzerland (n=1633)
Cross sectional
BERNCA
Strong association between nursing care rationing and nurse
perceived staffing adequacy at unit level (p0.042 but not with
the number of patient per one nurse ((p0.144)
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APPENDIX 3: MISSCARE SURVEY (STUDY 2 AND 3) (MODIFIED)
MISSED NURSING CARE (The MISSCARE Survey)
Beatrice J. Kalisch
1. Name of the unit you work on: _________________________________
2. I spend the majority of my working time on this unit: ______ yes ______ no
3. Highest education level:
1) ______ Grade school
2) ______ High School Graduate (or GED)
3) ______ Associate degree graduate
4) ______ Bachelor’s degree graduate
5) ______ Graduate degree
4. If you are a nurse, what is the highest degree?
1) ______ AIN certificate from a registered Vocational Education and
Training provider (e.g. TAFE).
2) ______ EN‐hospital trained Certificate.
3) ______ EN/EEN –Certificate IV or diploma in nursing from a registered
Vocational Education and Training provider (e.g. TAFE).
4) ______ RN‐hospital trained Certificate.
5) ______ Bachelor degree in nursing.
6) ______ Bachelor degree in nursing and bachelor degree outside nursing (double degree).
7) ______ Post graduate diploma in nursing.
8) ______ Post graduate diploma outside nursing.
9) ______ Master’s degree or higher in nursing.
10) ______ Master’s degree or higher outside of nursing.
5. Gender: ______ Female ______ Male
6. Age:
1) ______ Under 25 years old (<25)
2) ______ 25 to 34 years old (25‐34)
3) ______ 35 to 44 years old (35‐44)
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4) ______ 45 to 54 years old (45‐54)
5) ______ 55 to 64 years old (55‐64)
6) ______ Over 65 years old (65+)
7. Job Title/Role:
1) ______ AIN (Assistant in Nursing).
2) ______ EN/ EEN (Enrolled Nurse/Endorsed Enrolled Nurse).
3) ______ RN (Registered Nurse).
4) ______ CN (Clinical Nurse).
5) ______ CNC (Clinical Nurse Consultant).
6) ______ Nurse Unit Manager (NUM).
7) ______ Nurse Practitioner (NP).
8) ______ Nursing Director.
9) ______ Executive Director of Nursing (DON).
8. Number of hours usually worked per week (check only one)
1) ______ less than 30 hours per week
2) ______ 30 hours or more per week
9. Work hours (check the one that is most descriptive of the hours you work)
1) ______ Days (8 or 12 hour shift)
2) ______ Evenings (8 or12 hour shift)
3) ______ Nights (8 or 12 hour shift)
4) ______ Rotates between days, nights or evenings
10. Experience in your role:
1) ______ Up to 6 months
2) ______ Greater than 6 months to 2 years
3) ______ Greater than 2 years to 5 years
4) ______ Greater than 5 year to 10 years
5) ______ Greater than 10 years
11. Experience on your current patient care unit:
1) ______ Up to 6 months
2) ______ Greater than 6 months to 2 years
3) ______ Greater than 2 years to 5 years
273
4) ______ Greater than 5 year to 10 years
5) ______ Greater than 10 years
12. Which shift do you most often work?
1) ______ 8 hour shift
2) ______ 10 hour shift
3) ______ 12 hour shift
4) ______ 8 hour and 12 hour rotating shift
5) ______ Other [Please specify: ___________________________ ]
13. In the past 3 month, how many hours of overtime did you work?
1) _____ None
2) _____ 1‐12 hours
3) _____ More than 12 hours
14. In the past 3 months, how many days or shifts did you miss work due to illness,
injury, extra rest etc. (exclusive of approved days off)?
1) _____ None
2) _____ 1 day or shift
3) _____ 2‐3 days or shifts
4) _____ 4‐6 days or shifts
5) _____ over 6 days or shifts
15. Do you plan to leave your current position?
1) _____ in the next 6 months
2) _____ in the next year
3) _____ no plans to leave
16. How often do you feel the unit staffing is adequate?
1) ______ 100% of the time
2) ______ 75% of the time
3) ______ 50% of the time
4) ______ 25% of the time
5) ______ 0% of the time
17. On the current or last shift you worked, how many patients did you care for?
_______________
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17‐a. how many patient‐admissions did you have (i.e. includes transfers into the
unit)? _______________
17‐b. how many patient‐discharges did you have (i.e. includes transfers out of the
unit)? _______________
Please check one response for each question.
Very
satisfied Satisfied Neutral Dissatisfied
Very
dissatisfied
18. How satisfied are you
in your current position?
19. Independent of your
current job, how satisfied
are you with being a
nurse or a nurse
assistant?
20. How satisfied are you
with the level of
teamwork on this
unit?
275
Section A — Missed Nursing Care
Nurses frequently encounter multiple demands on their time, requiring them to
reset priorities, and not accomplish all the care needed by their patients. To the
best of your knowledge, how frequently are the following elements of nursing care
MISSED by the nursing staff (including you) on your unit? Check only one box for
each item.
Always
missed
Frequently
missed
Occasionally
missed
Rarely
missed
Never
missed
1) Ambulation three times per day or
as ordered
2) Turning patient every 2 hours
3) Feeding patient when the food is
still warm
4) Setting up meals for patient who
feeds themselves
5) Medications administered within 30
minutes before or after scheduled
time
6) Vital signs assessed as ordered
7) Monitoring intake/output
8) Full documentation of all necessary
data
9) Patient teaching about illness, tests,
and diagnostic studies
10) Emotional support to patient
and/or family
11) Patient bathing/skin care
12) Mouth care
13) Hand washing
14) Patient discharge planning and
teaching
15) Bedside glucose monitoring as
ordered
16) Patient assessments performed
each shift
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Always
missed
Frequently
missed
Occasionally
missed
Rarely
missed
Never
missed
17) Focused reassessments according to patient
condition
18) IV/central line site care and assessments
according to hospital policy
19) Response to call light is initiated within 5 minutes
20) PRN medication requests acted on within 15
minutes
21) Assess effectiveness of medications
22) Attend interdisciplinary care conferences
whenever held
23) Assist with toileting needs within 5 minutes of
request
24) Skin/Wound care
Section B—Reasons for Missed Nursing Care
Thinking about the missed nursing care on your unit by all of the staff (as you
indicated on Part 1 of this survey), indicate the REASONS nursing care is MISSED on
your unit. Check only one box for each item.
Significant
reason
Moderate
reason
Minor
reason
NOT a reason
for missed care
1) Inadequate number of staff
2) Urgent patient situations (e.g. a patient’s
condition worsening)
3) Unexpected rise in patient volume and/or acuity
on the unit
4) Inadequate number of assistive and/or clerical
personnel (e.g. nursing assistants, techs, unit
secretaries etc.)
5) Unbalanced patient assignments
277
Significant
reason
Moderate
reason
Minor
reason
NOT a reason
for missed care
6) Medications were not available when needed
7) Inadequate hand‐off from previous shift or
sending unit
8) Other departments did not provide the care
needed (e.g. physical therapy did not ambulate)
9) Supplies/ equipment not available when
needed
10) Supplies/ equipment not functioning
properly when needed
11) Lack of back up support from team members
12) Tension or communication breakdowns with
other ANCILLARY/SUPPORT DEPARTMENTS
13) Tension or communication breakdowns
within the NURSING TEAM
14) Tension or communication breakdowns with
the MEDICAL STAFF
15) Nursing assistant did not communicate that
care was not provided
16) Caregiver off unit or unavailable
17) Heavy admission and discharge activity
THANK YOU FOR YOUR PARTICIPATION!
278
APPENDIX 4: PERMISSION LETTER TO USE MISSCARE SURVEY
Subject: RE: Permission to use MISSCARE survey
From: kalisch, Beatrice ([email protected])
To: [email protected];
Date: Saturday, May 14, 2016 5:03 AM
Dear Rania
Thank you for your interest in the MISSCARE Survey. You have permission to use it if you are willing to send the results (data) so that I can continue to monitor the psychometric properties of the tool. Let me know if you have questions.
Sincerely,
Bea
Beatrice J. Kalisch, RN, PhD, FAAN
Titus Distinguished Professor of Nursing University of Michigan School of Nursing 2703 White Oak Drive Ann Arbor, Michigan 48103 [email protected]
7342555998 or 7342220920
From: Rania AlBsoul [mailto:[email protected]] Sent: Thursday, May 12, 2016 10:03 PM To: [email protected]
Subject: Permission to use MISSCARE survey Dear Beatrice.
My name is Rania, and I'm a PhD student at Queensland University of Technology, Brisbane, Australia. I'm intending to study the nature and factors influencing missed nursing care, and its impact on patient outcomes in an Australian teaching hospital. Upon reviewing the literature I noticed your significant contribution into this topic. Hence, Could I utilise your MISSCARE survey in my study. My principal supervisor is Professor Gerrard Fitzgerald, and my associate supervisor is Miss Paula Bowman.
Kind Regards
Rania
Electronic Mail is not secure, may not be read every day, and should not be used for urgent or sensitive issues
279
APPENDIX 5: INVITATION EMAIL (STUDY 2)
My name is Rania Albsoul. I am a postgraduate student currently pursuing a PhD in
Health Services Management at Queensland University of Technology (QUT). My
PhD research is about:
The Nature and Factors of Missed Nursing Care in an Acute Care
Hospital Missed nursing care is defined as any type of nursing care required by the patients
but is omitted or delayed (partially or totally) by the nurses.
I am conducting this research to get nursing personnel perceptions about missed
nursing care in the units they are working in and possible contributing factors, and
so would like to ask of you to take just 20 minutes of your time at the most to
answer the survey and be part of my research study.
If you choose to participate in this project, please answer all the questions as
honestly as possible. Participation is strictly voluntary and you may refuse to
undertake it at any time.
Thank you for taking the time to assist me in my educational endeavours. The data
collected will provide useful information regarding level, nature and factors of
missed nursing care, and will help in providing possible interventions to reduce the
rate of missed care, which will enhance patient outcomes and nurses’ satisfaction
with their occupations. I would very much welcome you to add comments or
suggestions that would be useful for my research. Completion of the survey will
indicate your participation and your contribution to my research and will be deeply
appreciated. If you require additional information or have questions, please contact
me at the email or phone number listed below.
Please click on the link below to access the survey:
Survey Link (once the survey items inserted into electronic survey software, the link
will be provided).
Sincerely,
Rania Ali Albsoul
PhD researcher
Ph. Ph. 04 13718072
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APPENDIX 6: PARTICIPANT INFORMATION SHEET FOR NURSES (STUDY 2)
Research Team Contact
Rania Albsoul, PhD Researcher School of Public Health and Social work, Queensland University of Technology
(QUT) [email protected]
Ph. 04 13718072
Prof Gerard FitzGerald, Principal supervisor School of Public Health and Social work, Queensland University of Technology
(QUT) [email protected]
Ph. 731383935
Description
I’m writing to invite you to participate in my research, which is being performed as
part of my PhD study at Queensland University of Technology (QUT).
Missed nursing care is defined as any type of nursing care required by the patients
but is omitted or delayed (partially or totally) by the nurses.
The purpose of this study is to identify the level and factors of Missed Nursing Care
in medical, surgical and rehabilitation wards in QEII. This study will help to advance
the conceptual understanding of Missed Nursing Care.
Participation
Your participation in this project will involve completion of the survey which is
estimated to take about 20 minutes. This survey asks nursing staff about their
PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT
“MISSED NURSING CARE IN ACUTE CARE HOSPITAL”
281
perceptions regarding the frequency of nursing care being missed in their units and
possible contributing factors.
Completion of the survey is voluntary and your decision of whether to participate or
not will in no way impact upon your current or future relationship with QUT and
QEII. If you do agree to participate and change your mind later, you can withdraw
from participation any time without comment or penalty prior to completing the
survey by closing the browser. However, as the survey is anonymous, it is not
possible to withdraw once your survey has been submitted. Your decision to
withdraw will in no way impact upon your current or future relationship with QUT.
Expected Benefits
It is expected that this project will not benefit you personally, but it is hoped that
this research will inform those people within the health care system who are
responsible for implementing the change. The findings of this study can aid in the
development of quality improvement approaches to minimize reduced care and
improve patient outcomes.
Risks
As this study will seek participant’s opinion about provision of substandard care, the participant may feel that some of the questions we ask are stressful. If you do not wish to answer a question, you may skip it and go to the next question, or you may stop immediately.
Privacy and Confidentiality
All responses are anonymous and will be treated confidentially. The names of
individual persons are not required in any of the responses. Results will be reported
within the PhD thesis, and elements of it will be reported at presentations in
conferences and in journals. Data and results of this research will also be shared
with BJ Kalisch (The author of Missed Nursing Care survey). In all of these situations,
neither individuals nor organisations will be identified, and the level of information
provided about participants will not allow for identification.
Any data collected as part of this project will be stored securely as per QUT’s
Management of research data policy.
Questions/further information about the project
Please contact the researchers named above if you have any questions or if you
require further information about the project.
The researcher will be bringing a summary of study findings to the hospital, and you
will be able to discuss any issues relating to those results.
282
APPENDIX 7: MISSCARE SURVEY- PATIENT
MISSCARE Survey-Patient
To the extent you can remember, please answer the following questions, if you cannot remember, leave the answer blank.
1. How often were you clear about which specific nurse was assigned to take care of you for the shift? 1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
2. How often did your nursing staff discuss your treatment with you?
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
3. How often did your nursing staff give you information about tests
(e.g. x‐ray, MRI, CT scan) and/or procedures you received during
this hospitalization (timing, what would be involved, etc.)?
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
4. When you had a question or concern about your care or illness,
did your nursing staff listen to you?
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
283
5. When you had an opinion about what needed to be done relative
to your care, did the nursing staff consider your opinions and
ideas?
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
6. How often did the nursing staff check with you to make sure your teeth were brushed and mouth rinsed (or provide the care if you could not do it yourself)? 1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
7. How often did the nursing staff check with you to make sure you
had a bath or were kept clean throughout your hospitalization?
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS
8. On average, how often did the nursing staff help you or monitor
that you got out of bed and sat in a chair?
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS 6) _____CHECK HERE IF YOU WERE UNABLE TO GET
OUT OF BED
9. On average, how often did the nursing staff help you or monitor
that you walked?
284
1) _____NEVER 2) _____RARELY 3) _____SOMETIMES 4) _____USUALLY 5) _____ALWAYS 6) _____CHECK HERE IF YOU COULD NOT WALK
10. When a monitor or other machine beeped, how long did it usually take the nursing staff to respond?
1) _____LESS THAN 5 MINUTES
2) _____5 TO 10 MINUTES
3) _____11 TO 20 MINUTES 4) _____21 TO 30 MINUTES 5) _____MORE THAN 30 MINUTES
6) _____NO MACHINE BEEPED
11. When you pushed your call light, how long on average did it take
the nursing staff to answer?
1) _____LESS THAN 5 MINUTES
2) _____5 TO 10 MINUTES
3) _____11 TO 20 MINUTES
4) _____21 TO 30 MINUTES
5) _____MORE THAN 30 MINUTES
6) _____I NEVER PUSHED MY CALL LIGHT
12. Once your call light was answered, how long on average did it
take for you to receive the help you requested? 1) _____LESS THAN 5 MINUTES
2) _____5 TO 10 MINUTES
3) _____11 TO 20 MINUTES
4) _____21 TO 30 MINUTES
5) _____MORE THAN 30 MINUTES
6) _____I NEVER PUSHED MY CALL LIGHT
285
+13. If you needed help to go to the bathroom, how long did it
take the nursing staff to get into your room to help you?
1) _____LESS THAN 5 MINUTES
2) _____5 TO 10 MINUTES
3) _____11 TO 20 MINUTES
4) _____21 TO 30 MINUTES
5) _____MORE THAN 30 MINUTES
6) _____I DID NOT REQUEST OR NEED HELP
. Did you experience any of the following problems during this
hospitalization?
Yes No Unsure
Fall
Skin
breakdown/Pressure
ulcer
Medication
Administration Error
New Infection
IV running dry
IV leaking into your
skin
Other problem
Explain:______
THANK YOU FOR YOUR PARTICIPATION!!
286
APPENDIX 8: PERMISSION LETTER TO USE MISSCARE SURVEY-PATIENT IN STUDY 3 FROM PROFESSOR BEATRICE KALISCH
Subject: RE: MISSCARE survey PATIENT
From: kalisch, Beatrice ([email protected])
To: [email protected];
Date: Monday, October 24, 2016 2:48 PM
Thank you for your interest in the MISSCARE Survey, patient. You have permission to use it if you are willing to send the results (data) so that I can continue to monitor the psychometric properties of the tool. Let me know if you have questions.
Sincerely,
Bea
Beatrice J. Kalisch, RN, PhD, FAAN
Titus Distinguished Professor of Nursing
University of Michigan
School of Nursing
2703 White Oak Drive Ann Arbor,
Michigan 48103 [email protected]
7342555998 or 7342220920
From: Rania AlBsoul [mailto:[email protected]] Sent: Monday, October 24, 2016 12:12 AM To: [email protected] Subject: MISSCARE survey PATIENT Dear Beatrice,I'm a PhD student in Queensland University of Technology in Brisbane, Australia. My research is about missed nursing care and its impact on patient outcomes in an acute care hospital. Please can I have the permission to use MISSCARE survey PATIENT in my research?
Kind Regards
Rania
287
APPENDIX 9: PARTICIPANT INFORMATION SHEET FOR PATIENT (STUDY 3)
Research Team Contact
Rania Albsoul, PhD Researcher School of Public Health and Social work, Queensland University of Technology
(QUT) [email protected]
Ph. 04 13718072
Prof Gerard FitzGerald, Principal supervisor School of Public Health and Social work, Queensland University of Technology
(QUT) [email protected]
Ph. 731383935
Description
I’m writing to invite you to participate in this research looking at Missed Nursing
Care in acute care hospital, which is being performed as part of my PhD study at
Queensland University of Technology (QUT).
Missed nursing care is defined as any type of nursing care required by the patients
but is omitted or delayed (partially or totally) by the nurses.
The purpose of this study is to explore the relationships between missed nursing
care and patient outcomes such as pressure ulcers, falls and hospital acquired
infections in the selected medical ward.
“MISSED NURSING CARE IN ACUTE CARE HOSPITAL”
PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT
288
Hospital unit can be considered as a micro‐organization in the hospital health care
system; and units of different types varied in patient care goals, clinical tasks, role
expectations, and social structures and norms. This part of research project is
innovative as case study at selected medical ward level to assess Missed Nursing
Care phenomenon deeply, and to identify its impact on the patients will be
performed. This study addresses a notable gap in the evidence linking missed
nursing care to the patient care experience utilizing a case study methodology.
Without clinically relevant evidence, the myriad incentives to improve quality of
health care may prompt policymakers and hospital managers to implement
misguided programmes or policies, potentially leading to negative consequences for
nurses and patients.
This case study will involve:
1. Survey for the nurses working at direct bedside in this medical ward during
the period of this case study (2 weeks).
2. Survey for the patients hospitalized for at least 48 hours in this ward during
the period of this case study.
Additionally, this case study will include operational data for the involved ward, and
report of adverse events in this ward for the period of data collection of this study
(2 weeks).
You have been asked to participate because you are 18 years age and older, and
have been hospitalized in this ward for more than 48 hours.
Participation
Your participation in this project will involve completion of the survey which is
estimated to take 20 minutes. This survey asks participants about their perceptions
regarding some nursing care services they have received during their hospitalization
period.
Completion of the survey is voluntary and your decision of whether to participate or
not will in no way impact upon your current or future relationship with QUT and
QEII. If you do agree to participate and change your mind later, you can withdraw
from participation prior to submitting the survey without any comment or penalty.
However, as the survey is anonymous, it is not possible to withdraw once your
survey has been submitted. Your decision to withdraw will in no way impact upon
your current or future relationship with QUT.
Expected Benefits
It is expected that this project will not benefit you personally but it is hoped that
this research will inform those people within the health care system who are
responsible for implementing the change. The findings of this study can aid in the
development of quality improvement approaches to minimize reduced care and
improve patient outcomes.
289
Risks
The risks and discomfort associated with participation in this study are no greater
than those ordinarily encountered in daily life.
Privacy and Confidentiality
All responses are anonymous and will be treated confidentially. The names of
individual persons are not required in any of the responses. Results will be reported
within the PhD thesis, and elements of it will be reported at presentations in
conferences and in journals. Data and results of this research will also be shared
with BJ Kalisch (The author of Missed Nursing Care survey). In all of these situations,
neither individuals nor organisations will be identified, and the level of information
provided about participants will not allow for identification.
Any data collected as part of this project will be stored securely as per QUT’s
Management of research data policy.
Consent to participate
The return of the completed survey is accepted as an indication of your consent to
participate in this project.
Questions/further information about the project
Please contact the researchers named above if you have any questions or if you
require further information about the project.
Report of the findings will be available on the QUT website (www.qut.edu.au) and
in the QUT library, Kelvin Grove campus, and you will be able to discuss any issues
relating to those results.
Please feel free to contact me on email
[email protected] or Ph. 04 13718072 if you have any
concerns regarding missed nursing care.
Concerns/Complaints regarding the conduct of the project
QUT is committed to research integrity and the ethical conduct of research projects.
However, if you do have any concerns or complaints about the ethical conduct of
the project you may contact the QUT Research Ethics Advisory Team on 07 3138
5123 or email [email protected] . The QUT Research Ethics Advisory Team
is not connected with the research project and can facilitate a resolution to your
concern in an impartial manner.
This study has been reviewed and approved by the Royal Brisbane & Women’s
Hospital Human Research Ethics Committee (EC00172). Should you wish to discuss
the study in relation to your rights as a participant, or should you wish to make an
independent complaint, you may contact the Coordinator or Chairperson, Human
Research Ethics Committee, Royal Brisbane & Women’s Hospital, Herston, Qld,
4029 or telephone (07) 3646 5490, email: RBWH‐[email protected].
290
APPENDIX 10: CONSENT FORM FOR PATIENT (STUDY 3)
Title: The nature and factors influencing Missed Nursing Care in an
acute care hospital.
Protocol Number: HREC/16/QRBW/591
Principal Investigator: Rania Ali Albsoul
Location: Queen Elizabeth II Jubilee Hospital (QEII).
Declaration by Participant
I have read the Participant Information Sheet.
I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.
I freely agree to participate in this research project as described and understand that I am free to withdraw at any time during the project without affecting my future care.
I understand that I will be given a signed copy of this document to keep.
Name of Participant
Signature Date
Declaration by Researcher
I have given a verbal explanation of the research project, its procedures and risks and I believe that the participant has understood that explanation.
Name of Researcher
Signature Date
CONSENT FORM
291
APPENDIX 11: PARTICIPANT INFORMATION SHEET FOR NURSES (STUDY 3)
Research Team Contact
Rania Albsoul, PhD Researcher School of Public Health and Social work, Queensland University of Technology
(QUT) [email protected]
Ph. 04 13718072
Prof Gerard FitzGerald, Principal supervisor School of Public Health and Social work, Queensland University of Technology
(QUT) [email protected]
Ph. 731383935
Description
PARTICIPANT INFORMATION FOR QUT RESEARCH
“MISSED NURSING CARE IN ACUTE CARE HOSPITAL”
292
I’m writing to invite you to participate in this research looking at Missed Nursing
Care in acute care hospital, which is being performed as part of my PhD study at
Queensland University of Technology (QUT).
Missed nursing care is defined as any type of nursing care required by the patients
but is omitted or delayed (partially or totally) by the nurses.
The purpose of this study is to explore the relationships between missed nursing
care and patient outcomes such as pressure ulcers, falls and hospital acquired
infections in the selected medical ward.
Hospital unit can be considered as a micro‐organization in the hospital health care
system; and units of different types varied in patient care goals, clinical tasks, role
expectations, and social structures and norms. This part of research project is
innovative as case study at selected medical ward level to assess Missed Nursing
Care phenomenon deeply, and to identify its impact on the patients will be
performed. This study addresses a notable gap in the evidence linking missed
nursing care to the patient care experience utilizing a case study methodology.
Without clinically relevant evidence, the myriad incentives to improve quality of
health care may prompt policymakers and hospital managers to implement
misguided programmes or policies, potentially leading to negative consequences for
nurses and patients.
This case study will involve:
1. Survey for the nurses working at direct bedside in this medical ward during
the period of this case study (2 weeks).
2. Survey for the patients hospitalized for at least 48 hours in this ward during
the period of this case study.
Additionally, this study will include operational data for the involved ward, and
report of adverse events in this ward for the period of data collection of this study
(2 weeks).
You have been asked to participate because you are working on the direct bedside
in this ward during the period of data collection for this study.
Participation
Your participation in this case study will involve completion of the survey which is
estimated to take about 20 minutes. This survey asks nursing staff about their
perceptions regarding the frequency of nursing care being missed in their units and
possible contributing factors.
Completion of the survey is voluntary and your decision of whether to participate or
not will in no way impact upon your current or future relationship with QUT and
QEII. If you do agree to participate and change your mind later, you can withdraw
293
from participation any time without comment or penalty prior to submitting the
survey. However, as the survey is anonymous, it is not possible to withdraw once
your survey has been submitted. Your decision to withdraw will in no way impact
upon your current or future relationship with QUT.
Expected Benefits
It is expected that this project will not benefit the participant personally, but it is
hoped that this research will inform those people within the health care system
who are responsible for implementing the change. The findings of this study can aid
in the development of quality improvement approaches to minimize reduced care
and improve patient outcomes.
Risks
As this study will seek participant’s opinion about provision of substandard care, the participant may feel that some of the questions we ask are stressful. If you do not wish to answer a question, you may skip it and go to the next question, or you may stop immediately.
Privacy and Confidentiality
All responses are anonymous and will be treated confidentially. The names of
individual persons are not required in any of the responses. Results will be reported
within the PhD thesis, and elements of it will be reported at presentations in
conferences and in journals. Data and results of this research will also be shared
with BJ Kalisch (The author of Missed Nursing Care survey). In all of these situations,
neither individuals nor organisations will be identified, and the level of information
provided about participants will not allow for identification.
Any data collected as part of this project will be stored securely as per QUT’s
Management of research data policy.
Consent to participate
The return of the completed survey is accepted as an indication of your consent to
participate in this project.
Questions/further information about the project
Please contact the researchers named above if you have any questions or if you
require further information about the project.
The researcher will be bringing a summary of study findings to the hospital, and you
will be able to discuss any issues relating to those results.
Concerns/Complaints regarding the conduct of the project
294
QUT is committed to research integrity and the ethical conduct of research projects.
However, if you do have any concerns or complaints about the ethical conduct of
the project you may contact the QUT Research Ethics Advisory Team on 07 3138
5123 or email [email protected] . The QUT Research Ethics Advisory Team
is not connected with the research project and can facilitate a resolution to your
concern in an impartial manner.
This study has been reviewed and approved by the Royal Brisbane & Women’s
Hospital Human Research Ethics Committee (EC00172). Should you wish to discuss
the study in relation to your rights as a participant, or should you wish to make an
independent complaint, you may contact the Coordinator or Chairperson, Human
Research Ethics Committee, Royal Brisbane & Women’s Hospital, Herston, Qld,
4029 or telephone (07) 3646 5490, email: RBWH‐[email protected].
295
APPENDIX 12: CONSENT FORM FOR NURSES (STUDY 3)
Title: The nature and factors influencing Missed Nursing Care in an
acute care hospital.
Protocol Number: HREC/16/QRBW/591
Principal Investigator: Rania Ali Albsoul
Location: Queen Elizabeth II Jubilee Hospital (QEII).
Declaration by Participant
I have read the Participant Information Sheet.
I understand the purposes, procedures and risks of the research described in the project.
I have had an opportunity to ask questions and I am satisfied with the answers I have received.
I freely agree to participate in this research project as described and understand that I am free to withdraw at any time during the project without any comment or penalty.
I understand that I will be given a signed copy of this document to keep.
Name of Participant
Signature Date
Declaration by Researcher
I have given a verbal explanation of the research project, its procedures and risks and I believe that the participant has understood that explanation.
Name of Researcher
Signature Date
CONSENT FORM
296
APPENDIX 13: ETHICAL APPROVAL
Queensland Government
Metro North Royal Brisbane & Women's Hospital Human Research Ethics Committee
Enquiries to: Ann-Maree Gordon Coordinator
Telephone: 07 3646 5490
Facisimilc: 07 3646 5849 File Ref: HREC/16/QRBW/591 Email: [email protected]
Hospital and Health
Service
Ms Rania Ali Mohammad Albsoul 621 / 20 Montague Road South Brisbane QId 4101
Dear Ms Albsoul,
Re: RefN0: HREC/16/QRBW/591; The Nature and Factors ofMissed Nursing care (MNC) in an Acute Care Hospital
Thank you for submitting the above research project for single ethical review. This project was considered by the Royal Brisbane & Women's Hospital Human Research Ethics Committee (RBWH HREC) (EC00172) at its meeting held on 12 December 2016. The research project meets the requirements of the National Health and Medical Research Council's (NHMRC) National Statement on Ethical Conduct in Human Research (2007).
I am pleased to advise that the RBWH Human Research Ethics Committee has granted ethical approval of this research project.
The waiver of consent and breach of the Australian Privacy Principles were considered justified in accordance with National Statement 2.3.10 and are approved.
For information on submitting a Public Health Act (PHA) application for the release of confidential health information for research purposes, please visit the Health and Medical Research website at: http://www.health.qld.gov.au/ollnw/html/regu/aces conf hth info.asp
The nominated participating site for this project is:
Queen Elizabeth Il Jubilee Hospital
297
This letter constitutes ethical approval only. This project cannot proceed until separate research governance authorisation has been obtained from the CEO or Delegate of Queen Elizabeth Il Jubilee Hospital under whose auspices the research will be conducted.
Royal Brisbane & Women's Hospital Telephone +61 7 3646 5490 Level 7 Block 7 Facsimile +61 7 3646 5849 Butterfield Street, Herston QId 4029 www.health.qld.gov.au/metronorth/research/ Australia ethics‐governance/default.asp Royal Brisbane & Women 's Hospital TIREC 2 RefNo: HREC/16/QRBW/591 18.01.2017
The approved documents include: Document Version Date
Covering Letter 22 November 2016
Application: NEAF (Submission Code: A U/1/7EF9218) 2.2 (2014)
09 November 2016
Research Protocol 1.0 21 November 2016
Peer Review: PhD Confirmation Seminar - Panel Report 21 September 2016
Letter of Suppolt from Ms Julie Finucane, Nursing Director - Medical, QEII Jubilee Hospital
1.0 18 November 2016
Permission to use MISSCARE Sutvey- Patient (Study 3) 24 October 2016
Permission to use MISSCARE Survey (Study 2 and Study 3)
14 May2016
Invitation Email for Nurses (Study 2) 1.0 20 November 2016
MISSCARE survey - Patient (Study 3) 1.0 20 November 2016
MISSCARE Survey for Nurses (Study 2 and Study 3) 1.0 20 November 2016
Curriculum Vitae of Rania Ali Mohammad Albsoul
Response to Request for Further Information Received on 2017
Information Sheet for Nurses (Study 2) 1.1 15 January 2017
Information Sheet for Nurses (Study 3) 1.1 15 Januaty 2017
Infommation Sheet for Patients (Study 3) 1.1 15 January 2017
Approval of this project from the RBWH HREC is valid from 18.01.2017 to 18.01.2020 subject to the following conditions being met:
The Coordinating Principal Investigator will immediately repolt anything 'that might warrant review of ethical approval ofthe project.
298
The Coordinating Principal Investigator will notify the RBWH HREC of any event that requires a modification to the protocol or other project documents and submit any required amendments in accordance with the instructions provided by the HREC. These insttuctions can be found at https:/hvww.health.qld.gov.au/metronorth/research/ethicsgovernance/hrec-approval/default.asp,
The Coordinating Principal Investigator will submit any necessary reports related to the safety of research participants in accordance with the RBWH HREC policy and procedures. These instructions can be found at htt s://www.health. Id. ov.au/metronolth/research/ethics- overnance/ ost-a rovalreputing/default.asp.
Royal Brisbane Women 's Hospital HREC 3 RefNo: HREC/16/QRBW/591 18.01.2017
In accordance with Section 3.3.22 (b) of the National Statement the Coordinating Principal Investigator will repolt to the RBWH HREC annually in the specified format, the first report being due on 18.01.2018 and a final report is to be submitted on completion of the study. These instructions can be found at https://www.health.qld.gov.au/mefronolth/research/ethicsgovernance/post-approval-repolting/clefault_asp.
The Coordinating Principal Investigator will notify the RBWH I-IREC if the project is discontinued before the expected completion date, with reasons provided.
The Coordinating Principal Investigator will notify the RBWH HREC of any plan to extend the duration of the project past the approval period listed above and will submit any associated required documentation. Instructions for obtaining an extension of approval can be found at https://www.health.qld.gov.au/metronorth/research/ethics-governance/hreca roval/defaulteas
The Coordinating Principal Investigator will notify the RBWH HREC of his or her inability to continue as Coordinating Principal Investigator including the name of and contact information for a replacement.
A copy of this ethical approval letter together with completed Site Specific Assessment (SSA) and any other requirements must be submitted by the Coordinating Principal Investigator to the Research Govemance Office of Queen Elizabeth Il Jubilee Hospital in a timely manner to enable the institution to authorise the commencement of the project at its site.
Should you have any queries about the RBWH HREC's consideration of your project please contact the HREC Coordinator on 07 3646 5490. The RBWH HREC's Terms of Reference, Standard Operating Procedures, membership and standard forms are available from https://www.health.qld.gov.au/metronolth/research/ethics-governance/hrecapproval/membership/default.asp.
299
The RBWH HREC wishes you every success in your research.
Yours sincerely,
D Conor Brophy Chairperson RBWH Human Research Ethics Committee Metro North Hospital and Health Service 18.012017 This HREC is constituted and operates in accordance with the National Health and Medical Research CounciPs (NHMRC) National Statement on Ethical Conduct in Hutnan Research (2007). The processes used by this HREC to review research proposals have been certified by the National Health and Medical Research Council.
300
APPENDIX 14: PHA APPROVAL
Queensland Government
Department of Health Enquiries to: Claudine Wilson
Health Innovation, Investment
and Research Office Office of the Director‐General
Telephone: (07) 3199 3175
Ref QCOS/029817/RD006717
Ms Rania Ali Mohammad
AlBsoul c/‐ QUT School of
Public Health and Social Work
Victoria Park Road KELVIN GROVE QLD 4059
Dear Ms AlBsoul
Research Title: The Nature and Factors of Missed Nursing
Care (MNC) in an Acute Care Hospital
HREC / Project Number: HREC/16/QRBW/591
I am writing to inform you that your request for access to confidential health information for the above project has been approved under the delegation of the Director‐General. In accordance with Section 284 of the Public Health Act 2005 the researchers listed in your application, which we received on 25 January 2017, can access and use the specified confidential information for the duration of the research, as specified in your application, providing they act within the limits specified in your application and subject to compliance with the conditions of this approval and Chapter 6, Pad 4 of the Public Health Act 2005.
This approval (RD006717) commences on the date of this letter.
This approval allows information to be given for the period from 1
January 2015 to 20 November 2017 from the following repositories at
Queen Elizabeth Il Jubilee Hospital: Casemix
Staff establishment by organisation Nurse roster information Admitted patients (number)
301
Admitted patients (episode of admitted patient care) o Nursing sensitivity indicators Clinical incident data (PRIME)
Patient satisfaction survey (May 2016) Staff satisfaction survey (2015)
The following researchers may be given the information as noted in the
above application: Ms Rania Ali Mohammad AIBsoul o Professor Gerry FitzGeraId
Ms Paula Bowman
Office Postal Phone HIIRO, ODG HilRO, ODG 61 7 3199 3175 Department of Health Department of Health Level 3, 146‐160 Mary Street GPO Box 48 Brisbane Qid 4000 Brisbane QId 4001 1
This approval means that you must undertake the responsibilities and obligations of confidentiality of the information under the provisions of the Public Health Act 2005. You must take all reasonable steps necessary to ensure that the confidential information is kept confidential, including storing or disposing of all data, information, documents and associated correspondence in a secure manner. Unauthorised use or disclosure of confidential information may incur a penalty under the laws of the Queensland Government. These obligations include providing notification of any change in the names of persons who will be given the information for the research.
When conducting research within the Queensland public health system, a copy of this Approval Letter must be provided to the relevant Research Governance Officer as part of your research governance application.
Please note: This letter constitutes Public Health Act 2005 approval only. The project cannot proceed until separate Research Governance authorisation has been obtained from the relevant authority.
Please display this letter and a copy of your application when requesting the confidential information from the relevant data custodian.
You are required to provide an annual progress report and a final report at the completion of your project, to Health Innovation, Investment and Research Office, Office of the DirectorGeneral. Templates can be found on the web page http://www.health.qld.qov.au/ohmr/html/requ/aces conf hth info.asp
Should you wish to extend your research project beyond this time or amend the study protocol, you will need to seek approval of these amendments from the approving HREC and re‐apply for approval of the release of confidential data. This includes disclosing this information to and recruiting additional people to this project. Please provide a copy of your HREC approval of the amendments when re‐applying
Please contact Health Innovation, Investment and Research Office, Office of the DirectorGeneral on email [email protected] or phone 07 3199 3175 if you have any queries on this matter.
302
Yours sincerely
Sue Hooper PhD Director
Health Innovation, Investment and Research Office
Office o e Director‐General
/2017
RD006717 Rania Ali Mohammad AlBsoul ‐ I‐IREC/16/QRBW/591
303
APPENDIX 15: QUT APPROVAL
Subject: Ethics application ‐ approved ‐ 1700000980 Dear Prof Gerard Fitzgerald and Rania Albsoul Ethics category: Human - Administrative Review Lead HREC: As per As per Royal Brisbane and Women Hospital (RBWH) HREC Lead HREC approval number: HREC/16/QRBW/591 QUT approval number: 1700000980 Approved until: 18/01/2020 Project title: The nature and factors influencing Missed nursing care in an acute care hospital in Australia Thank you for submitting the above research project for administrative review. We are pleased to advise that your application has been administratively approved. QUT's Office of Research Ethics and Integrity (OREI) is satisfied that your research project meets the following requirements for administrative approval: > Another HREC has granted ethics approval. > The approving HREC will remain the responsible Committee. > The approved application fully encompasses the QUT research component. > The QUT researchers are named on the approved application. Approval of this project from OREI is valid as per the dates above, subject to the following conditions being met: > Researchers must immediately notify OREI if there is a complaint regarding the conduct of a QUT researcher. Please be aware that in the event QUT is notified of any concerns regarding the conduct of a QUT researcher, it may be investigated according to QUT MoPP D2.7 Procedures for handling allegations of research misconduct. > All variations and adverse events must be submitted to the lead approving HREC for approval. Researchers are not required to submit post-approval documentation to QUT, except for TGA-regulated clinical trials. If your project is a TGA-regulated clinical trial you must also lodge all post approval documentation (including variations and adverse events) with OREI. > The Chief Investigator (CI) / Project Supervisor (PS) will report to the OREI annually in the specified format and notify the HREC when the project is completed at all sites (the CI/PS will receive an email on the anniversary of the approval). > The CI/PS will notify OREI of his or her inability to continue as CI/PS including the name of and contact information for a replacement. Should you have any queries about OREI'S consideration of your project please contact the Research Ethics Advisory Team on 07 3138 5123 or email [email protected]. We wish you every success in your research.
304
Janette Lamb and Debbie Smith Research Ethics Advisory Team, Office of Research Ethics & Integrity Level 4 | 88 Musk Avenue | Kelvin Grove +61 7 3138 5123 [email protected]
