Mexican health system consists of two sectors, the public and the
private; in both, nursing professionals account for more than 50%
of health professionals who have contributed to the achievement
of institutional goals in health.1
The public sector is made up of social security institutions and
the institutions that serve the population with the public health
insurance. The private sector includes insurance companies, health
institutions and health professionals who provide their services
Both sectors are committed to providing quality care to patients;
in this sense, Nursing plays a fundamental role because of its participation
in most care processes, where the reduction of adverse events in
hospitals needs emphasis.3,4
events result from several causes; in the literature, however, the
variation in the clinical practice of nursing care, as well as omissions
in care are reported as one of the main causes.3
When these omissions correspond to nursing care, this is called
missed nursing care or omission error.5
Kalisch defines it as any aspect of required patient care that is
partially or totally omitted or significantly delayed.6
nursing care affects quality; so it is a priority to perform all
patient care and increase the care safety.7
This implies having systems that permit the prevention and identification
of errors in a timely manner, learning from these errors and fostering
a safety culture.8
this study, the mid-range theory, called Kalisch's Model of Missed
Nursing Care, was used as the basis for the study, which takes up
three concepts from Donabedian' Quality Model from 1966: structure,
process and outcome.6,9
The structure refers to the characteristics of the hospital, the
patient care unit and the individual characteristics of the nursing
staff. The process refers to care in general, it is where the care
can be carried out according to the patients' needs or where the
omission of the nursing care may originate. The outcome refers to
the direct effects of care on the patients.The presence of missed
care can generate negative results, such as falls, pressure ulcers,
infections, among others, all of them with repercussions on the
quality and safety of care.
that nursing care is an action that involves four dimensions (individual
needs, discharge planning and education, basic care, and continuous
Individual needs interventions are those that address people's human
responses towards health problems; they are performed to promote
self-care and provide emotional support.11,12
Planning for discharge and education helps improve patients' participation
and make informed decisions about care.10
Basic care interventions are intended to meet basic needs, when
the patient lacks autonomy; such care is considered routine in most
Continuous evaluation care interventions involve an ongoing process
of patient monitoring, require ongoing evaluation of the care provided
with a view to making decisions when the patient's health status
the Kalisch Model, it is argued that there are structure-related
factors that have been associated with missed care, including those
related to human resources, communication and material resources.3,6
With regard to human resources, staff characteristics, such as sociodemographic
data, work schedules, staffing, work experience, level of competence
and training are relevant aspects and play a key role in patients'
evolution, as they have been linked to various patient complications
and adverse events.15,17
Ineffective communication entails repercussions for the planning
of the care the patient requires and affects the interpersonal nursing
communication required for collaborative activities in the interdisciplinary
Finally, the material resource includes the inputs needed to provide
care, such as drugs, supplies and medical equipment.13
view of the above, this study aimed to compare missed nursing care
in patients hospitalized in a public hospital and a private hospital,
as well as related factors.
study was descriptive, cross-sectional, comparative. It was performed
in a public hospital and a private hospital in San Luis Potosi,
S.L.P., Mexico, during 2013-2014. The census of the nursing staff
included the categories Registered Nurse and Auxiliary Nurse, working
at the inpatient service of both institutions; in total, 80 nurses
participated, 32 affiliated with the public hospital and 48 with
the private institution. Nursing staff members absent during the
data collection period due to disability were excluded.
MISSCARE Instrument designed by Kalisch and Williams was used to
It consists of three sections. The first addresses job data and
consists of 24 items; for the sake of this research, however, only
11 items were kept. The second part, part A, consists of 24 items
related to the care omitted, which are grouped into four dimensions:
individual needs interventions, discharge planning and patient education,
basic care interventions and continuous evaluation care interventions.
Answers are given on a Likert scale, ranging from 0 not applicable
to 1 never, 2 rarely, 3 from time to time, 4 frequently and 5 is
always lost. The option "not applicable" was included
for all nursing care questions that are not executed during night
shifts, such as patient feeding, walking, among others. According
to the authors, the response options are transformed into a dichotomous
scale. Options 1, 2 and 3 are considered as care performed; options
4 and 5 as missed care. The reliability coefficient for this part
was 0.91. The third section, part B, identifies the factors associated
with missed care and is grouped into human resources, communication
and material resources. It contains a Likert scale, ranging from
1 not a reason to 2 minor reason, 3 moderate reason and 4 significant
reason; the reliability coefficient for this section was 0.90. Prior
to the application of the instrument in Mexico, authorization was
obtained from Kalisch.19
the data collection, the inpatient service of both hospitals was
contacted and the nursing staff was invited to participate in this
study. Those who accepted received the MISSCARE survey in a yellow
envelope, with the instructions for completion. The provisions established
in General Health Law on Research in Mexico were complied with.20
Approval was obtained from the Ethics Committees of the School of
Nursing at Universidad Autonoma de San Luis Potosi and of
the participating hospitals.
were processed in SPSS version 20. The job variables were analyzed
with descriptive statistics. Overall indices were designed, ranging
from 0 to 100 for the variable missed nursing care, as well as for
the dimensions, where higher scores corresponded to higher rates
of missed care. Likewise, indices were designed for the factors
related to missed care, where higher score corresponded to higher
levels of importance for the nursing staff.
Kolmogorov Smirnov test was used to determine the distribution of
the data, which did not show normality. Therefore, non-parametric
tests, such as Kruskal-Wallis and Mann-Whitney's U, were used to
identify differences in missed care according to the service, category,
level of education, seniority in the service, work experience and
shift. Simple linear regression was performed to determine the effect
of these factors on the missed nursing care.
both institutions, the female gender predominated in more than 80%,
level of education Baccalaureate Nurse (53.1% public, 62.5% private),
followed by Registered Nurse (31.3% public, 14.6% private). The
Registered Nurse category corresponded to more than 85% of the staff.
With respect to seniority in the institution, in the public institution,
50% had 6 to 10 years of seniority and, in the private, 1 to 5 years.
As for the seniority at the service, in the public hospital, the
professionals had 7 to 8 years of seniority and, in the private,
1 to 2 years. Regarding the years of professional experience, in
the public institution, experience ranged from 6 to 10 years and,
in the private, 1 to 5 years. In relation to the shift, more than
30% of the personnel works in the morning shift, followed by the
The mean number of patients
assigned to the nursing staff of the public institution was 13.41
(SD=1.94), admitted 2.97 (SD=1.20), and discharged 1.56 (SD=1.39).
In the private institution, the average number of patients assigned
to the nursing staff was 6.71 (SD=3.69), admitted 3.1 (SD=1.91)
and discharged 2.5 (SD=2.80).
of missed nursing care. In both institutions, the greatest omission
in care corresponds to basic care interventions (M=41.52, SD=12.09,
Public; M=16.66, SD=18.83 Private); followed by discharge planning
and patient education (M=32.04, SD=9.91 Public; M=7.29, SD=20.60
Private); and almost the same proportion for individual needs interventions;
the dimension with the lowest omission of care was continuous evaluation
care interventions. In the overall care score, an average of 29.89
(SD=5.72) and 9.80 (SD=12.10) was obtained for the public and private
institution, respectively (Table 1).
for the dimensions of missed care, basic care interventions
were the most missed or omitted in both institutions.
Omission in oral care predominated (68.7% public, 35.4%
private), followed by feeding the patient when the food
is still hot (62.4% public, 25.0% private); the least
omitted care was skin and wound care (15.6% public,
to discharge planning and patient education, the most
missed element in the public institution is discharge
planning (40.5%), in the private institution, the most
missed elements is patient teaching during his hospital
In terms of
individual needs interventions, the greatest omission
was found in the public institution, to assist with
toileting needs within no more than 5 minutes after
the request and to attend interdisciplinary care evaluation
visits (both with 56.2%). In the private institution,
emotional support to the patient or family (16.7%) is
more often missed, followed by interdisciplinary care
evaluation visits (12.5%). The lowest omission in the
public institution corresponds to administration in
less than 15 minutes after requests for PRN drugs (15.6%)
and, in the private institution, evaluation of drug
1. Global and dimension indices of missed nursing
care according to hospital type. San Luis Potosi, Mexico.
2. Indices of factors influencing missed nursing
care according to hospital type. San Luis Potosi, Mexico.
continuous evaluation care interventions, the most missed element
in the public institution was the reassessment of the patient according
to his health condition (25.%); at the private institution, it was
care for the intravenous / central line injection site and solutions,
assessment according to hospital policies and complete patient documentation
with the necessary data (each with 8.3%); the least omitted element
in both institutions corresponds to fluid balance - control of inflow
and outflow (6.3% public and 2.1% private).
in missed nursing care. According to the perception of the nursing
staff of both institutions, the main factor related to missed care
was nursing human resources (public M=82.46, SD=12.94, private M=61.21,
SD=21.31). In the public institution, the next factor was material
resources (M=73.17, SD=17.92) and, in the private institution, communication
(M=55.65, SD=22.61) (Table 2).
the human resources factor, the nursing staff of the public institution
mentioned that the unexpected increase in the number of patients
or workload in the service (84.4%) is a significant reason for missed
nursing care, followed by insufficient number of staff (75%). The
nursing professionals at the private institution mentioned the insufficient
number of staff (47.9%), as well as the unexpected increase in the
number of patients or workload (41.7%), as significant reasons for
Regarding the communication
elements, the public institution's nursing staff perceived tension
or failure in communication with other auxiliary support departments
as a significant reason, in addition to other departments that did
not provide the necessary care (e.g. nutrition, laboratory, etc.,
both with 40.6%); followed by tension or failures in communication
with medical personnel (31.3%). The nursing staff of the private
institution mentioned that the nurse responsible for the patient
is not available when requested (31.3%), followed by tension or
failures in communication with the medical staff (27.1%).
regards the elements corresponding to the material resource factor,
the nursing staff of both institutions mentioned as a significant
reason that supplies and equipment are not available when needed
(public 50%, private 22.9%); followed by supplies and equipment
not working properly (public 46.9%, private 20.8%).
missed nursing care. The simple linear regression test showed
that, in the public institution, human resources account for 9%
of the total missed care, communication explains 10% and material
resources explain 15%; all three with high statistical significance
(p=0.001); in the private institution, human resources and communication
account for 6% of the total missed care, both with statistical significance
(p=0.05); the material resources do not influence the level of missed
care (Beta=0.05, R2= -0.006, p=0.40).
are elements of nursing care that are missed or overlooked in different
contexts of health care during patients' hospital stay. In both
institutions, nurses perceive greater omission in basic care interventions,
followed by discharge planning and patient education interventions.
As for the dimension of basic care interventions, it is similar
to that reported by Kalisch et al.,10
which is more in keeping with the public institution and to a lesser
extent in the private hospital. Nursing staff should understand
that the execution of interventions is fundamental during patients'
hospital stay, especially those who lack autonomy.13
The omission of these interventions can be attributed to the fact
that nurses do not prioritize them, either because of their low
complexity or because they consider that the patients can perform
them by themselves or with the support of a family member.18
The performance of these interventions is fundamental for the patients'
comfort though, and represent an elementary axis in the practice
of nursing care.21
regard to the elements of the basic care interventions dimension,
nurses from both institutions perceived a greater omission in oral
care, followed by feeding the patient when the food was still hot.
The first result is similar to those described by Kalisch et al.,10
Kalisch et al.18
and Kalisch and Lee,22
where the proportions coincide more with the public than with the
private institution. This may be due to the care demands at each
of the institutions studied.
In the discharge
planning and patient education dimension, the nursing staff of the
public institution perceived omission in discharge planning and
the nursing staff of the private institution reported little omission
in patient education during their stay. These results are similar
to those reported by Ball et al.17
however, both to a lesser extent.
lower omission can be attributed to the fact that, in the participating
institutions, there are care protocols that include patient teaching.
According to Kalisch et al.6
these aspects are important. Failure to provide education prior
to hospital discharge negatively affects hospital outcomes, such
as hospital complications and readmissions.
perceived less omission in individual needs interventions when compared
to basic care interventions and discharge planning and patient education;
the reported omission is notable though, especially since these
care actions are intended to respond to human needs rather than
to health problems.23
According to Chocarro, professional nursing practice goes beyond
physical contact and application of techniques, includes a social
dimension where the nurse-patient relationship is fundamental to
identify priorities and care needs during the hospital stay.24
elements of care for which the nursing staff of the public institution
perceives less omission were help with toileting needs within five
minutes after the request and attending to interdisciplinary care
evaluation visits, as reported by Kalisch et al.3
and Kalisch et al.;25
Instead, the nursing staff of the private institution noted higher
levels of care missed for emotional support to the patient, this
result being similar, but to a lesser extent than reported by Carter26
and Zander et al.27
Some authors point out that their omission can be attributed to
the time required for their execution, a time that nurses often
assign to other care that is considered a priority; the priority
attributed by the patient is not valued though, so it does not favor
Care is relational, that is, depending on the other, so the opinion
of the patient is fundamental.28
The omission in attending interdisciplinary visits could be due
to the high demands of work, as well as to the inadequate organization
in the dimension of care interventions with continuous evaluations,
although the staff of both institutions perceived low levels of
missed care, some elements are omitted; in the public institution,
such as patient reevaluations according to their health condition,
similar to Kalisch et al.10
In the private institution, omissions are observed for care of the
intravenous/central venous injection site and solutions, assessments
according to the hospital's policies and complete documentation
of the patient with the necessary data; these results are similar
to those reported in the literature.18-25
authors point out that the missed care can vary according to some
characteristics of the nursing staff, such as the service where
they work, level of education, their professional category, length
of service and institution, work experience and work shift.17,30
In this study, however, no difference was found in relation to these
job characteristics in any of the two institutions.
important finding is the factors attributed for the care to be missed.
The staff considered that the main factor corresponds to nursing
human resources. This finding agrees with what several authors have
Nevertheless, the agreement is higher in proportion and order with
the public than with the private institution. The order of importance
of the factors for the omission of care in the public institution
is attributed to human resources, followed by material resources
and, finally, communication; which differs from the order of importance
in the private institution (in the first place human resources,
then communication, and finally material resources). According to
Waldow, the context influences care.28
staff consider human resources as the main factor for the missed
care; in both institutions, they mentioned that the unexpected increase
in the number of patients or workload in the service and the insufficient
number of staff are the most relevant elements, in line with what
other authors have reported.3,10
In units with scarce human resources, nurses tend to omit interventions,
although that could increase the risk of negative outcomes for the
the communication factor, nurses perceive the tension or failures
in communication with other auxiliary support departments as a significant
reason, as well as the nurse responsible for the patient not being
available when requested and the stress or failures in communication
with medical personnel. This last result is similar to the findings
of other authors,3,10
but more in line with the public than with the private institution.
Kalisch and Lee mention that interdisciplinary communication favors
the continuity of care and avoids errors in health care.31
Therefore, health institutions should strengthen interdisciplinary
work and modify the system of work at the organizational level.
the material resource factor, the nurses of both institutions mentioned
as a significant reason that supplies and equipment are not available
when needed and that supplies and equipment are not functioning
properly. These results are similar to Kalischet al.3
and Kalisch et al.10
the findings of this study suggest that missed nursing care is a
widespread problem, which should be further explored in order to
have more useful information for the management of nursing services,
which is relevant for evaluating the quality of care.
nursing care prevailed in the public institution; it is a problem
present in the different contexts of health care though, and nurses
acknowledge these omissions; these include basic care, discharge
planning and patient education, which are proper nursing interventions
and need to be provided in a complete and timely manner during the
patients' hospital stay.
at public or private health institutions should have adequate, competent
and sufficient nursing staff, ensure sufficient material resources
and keep them functional and available when required; as well as
strengthen effective communication among health professionals, in
order to meet the care demandsin each of the different contexts.
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