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Cuidado de enfermería perdido en pacientes hospitalizados en una institución pública y una privada

Raúl Hernández Cruz,1 María Guadalupe Moreno Monsiváis,2 Sofía Cheverría Rivera,1 Martha Landeros López,1 Ma. Guadalupe Interial Guzmán2
1Facultad de Enfermería, Universidad Autónoma de San Luis Potosí, San Luis Potosí. México. 2Facultad de Enfermería, Universidad Autónoma de Nuevo León, Nuevo León. México

Manuscript received by 16.4.2016
Manuscript accepted by 20.8.2016

Index de Enfermería [Index Enferm] 2017; 26(3): 142-146








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Hernández Cruz, Raúl; Moreno Monsiváis, María Guadalupe; Cheverría Rivera, Sofía; Landeros López, Martha; Interial Guzmán, Ma. Guadalupe. Missed nursing care in patient in public and private institution. Index de Enfermería [Index Enferm] (digital edition) 2017; 26(3). Disponible en <http://www.index-f.com/index-enfermeria/v26n3/2631e.php> Consulted by





Objective: To compare nursing care in patients missed in a public and private hospital, as well as related factors. Methods: descriptive, cross-sectional and comparative study in 2 hospitals (public and private) in San Luis Potosi, Mexico, during 2013-2014. The MISSCARE Survey was administered. The content validity by Cronbach´s alpha 0.91. Results: Missed nursing care was higher in the public institution (Public M=29.89, SD=5.72; private M=9.80, SD=12.10). The biggest omission in care in both hospitals corresponds to basic care interventions (Public M=41.52, SD=12.09; private M=16.66, SD=18.83); the main factor that nurses reported was human resources (public M=82.46, SD=12.94; private M=61.21, SD=21.31). Conclusions: The missed nursing care dominated public institution, in both institutions it is mainly attributed to human resources.
Key-words: Nursing Care/ Patient Atention/ Human Resources/ Communication/ Material Resources.









    The 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 for profit.2 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
    Adverse 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
    Missed 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
    For 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.
    Kalisch mentions that nursing care is an action that involves four dimensions (individual needs, discharge planning and education, basic care, and continuous evaluation care).
10 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 hospitals.13 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 changes.14
    In 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 team.16,18 Finally, the material resource includes the inputs needed to provide care, such as drugs, supplies and medical equipment.13
    In 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.


    The 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.
    The MISSCARE Instrument designed by Kalisch and Williams was used to collect information.
19 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
    For 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.
    The data 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.
    The 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.


    In 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 night shift.
    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).

Elements 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).

    As 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, 2.1% private).
    In relation 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 stay (9.3%).
    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 effectiveness (0%).

Table 1. Global and dimension indices of missed nursing care according to hospital type. San Luis Potosi, Mexico.
2013-2014 (n=80)
Table 1

Table 2. Indices of factors influencing missed nursing care according to hospital type. San Luis Potosi, Mexico.
2013-2014 (n=80)
Table 2

    In 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).

Determining factors 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).
    Regarding 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 missed care.
    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%).
    As 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%).

Determinants of 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).


    There 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
    With 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 and Kalisch;18 however, both to a lesser extent.
    The 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 and Kalisch,18 these aspects are important. Failure to provide education prior to hospital discharge negatively affects hospital outcomes, such as hospital complications and readmissions.
    Nurses 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
    The 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 comprehensive care.24 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 of work.26,29
    Finally, 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
    Some 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.
    Another 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 reported.
30,31 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
    Nursing 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 patient.32,33
    In 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.
    In 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
    Finally, 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.


    Missed 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.
    Nursing managers 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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