Cultural adaptation and internal consistency analysis of the MISSCARE Survey for use in Brazil 1

ion or knowledge and supervision control. The situations involved included lack of care with drains and infusions during patient transportation, non-observation of patients’ clinical conditions, lack of knowledge of resuscitation procedures in case of cardiorespiratory arrest, lack of a laryngoscope at the surgery room where the patient suffered a glottal edema(2). Another study undertaken in three Brazilian hospitals investigated error events in intravenous medication preparation and administration. Based on direct observation of nursing assistants and nursing technicians, findings revealed that, in the preparation phase, missed doses was the most frequent error in two of the hospitals, while wrong doses ocurred in all three hospitals. In the medication administration phase, the highest error rate in the three hospitals referred to wrong doses. Error rates ranged between 2.9 and 11%(3). The authors discussed the influence of work conditions at those hospitals on the occurrence of these errors. They emphasized that an insufficient number of nursing personnel in Brazilian hospitals frequently entails the extension of work hours and, consequently, a higher workload and staff dissatisfaction. Assuring patient safety and quality nursing outcomes represents a significant challenge for nurses and is considered as an individual and institutional issue(4). In 1863, Florence Nightingale already emphasized the importance of patient safety in nursing care delivery. Nevertheless, professional failure and errors are inevitable in organizations. Therefore, learning from errors is essential and is one of the goals of patient safety programs(5). Internationally, a consensus exists that several error-related elements affect nursing practice in hospitals, including the severity and complexity of patients’ diseases, the short length of stay, the number of activities nurses delegate to nurse assistants and technicians, reduction of nursing staff, work overload, high turnover rate and long work hours. In addition, there has been an increase in technology and new knowledge. As nurses need to cope with all of these factors within this context and to make appropriate decisions to guarantee better patient care and surveillance, they also need to prevent errors and assure care quality. If staffing levels are inappropriate, these responsibilities may be compromised(6-7). A study performed at 168 hospitals in the USA analyzed the net effect of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education. The authors found that higher percentages of nurses in hospitals with poor care environments reported high burnout levels and dissatisfaction with their jobs. The care environment had a significant effect on the intention to leave the job. The authors also reported that, even after controlling for the effects of the care environment, the odds of nurses reporting high burnout and dissatisfaction increased with each additional patient per nurse in the mean workload at their hospitals. The odds of patients dying in hospitals with an average workload of eight patients per nurse is 1.26 times greater than in hospitals with a mean workloads of four patients per nurse. Finally, the authors reported that each 10% increase in the proportion of nurses with a bachelor of science degree in nursing was associated with a 4% decrease in the risk of death(8). Nursing care demands a complex thinking process, which includes making inferences and synthesizing information. Nurses’ surroundings have been described as fast and unpredictable, promoting interruptions and errors in nursing care. During their work shifts, nurses constantly shift from one activity to another and manage information from many different sources, often working with two or more tasks at the same time and showing high rates of interruptions in their activities(9). In view of the multiple demands and insufficient resources, these professionals feel unable to meet all nursing care actions required and may often choose not to complete them. In those circumstances, nurses may abbreviate, delay or simply omit care(7). The omission of nursing care (missed nursing care) phenomenon is defined as any aspect of care that is required by the patient and that is missed (partially or as a whole) or delayed(7). It was first identified in a qualitative study in the United States, involving 25 focus groups with


Introduction
Unsafe healthcare is a major cause of morbidity and mortality across the globe. Estimates from developed nations suggest that adverse drug events may contribute to 140,000 deaths annually, and about 5% to 10% patients admitted to hospitals acquire an infection. In the United States, researchers reported a 10% prevalence of pressure ulcers in acute-care hospitals, accounting for the death of over 100,000 persons between 1990 and 2001 (1) .
In Brazil, in a recent study, the errors committed during immediate postoperative nursing care delivery to surgical patients were analyzed at ten hospitals. Errors the patient suffered a glottal edema (2) .
Another study undertaken in three Brazilian hospitals investigated error events in intravenous medication preparation and administration. Based on direct observation of nursing assistants and nursing technicians, findings revealed that, in the preparation phase, missed doses was the most frequent error in two of the hospitals, while wrong doses ocurred in all three hospitals. In the medication administration phase, the highest error rate in the three hospitals referred to wrong doses. Error rates ranged between 2.9 and 11% (3) . The authors discussed the influence of work conditions at those hospitals on the occurrence of these errors. They emphasized that an insufficient number of nursing personnel in Brazilian hospitals frequently entails the extension of work hours and, consequently, a higher workload and staff dissatisfaction.
Assuring patient safety and quality nursing outcomes represents a significant challenge for nurses and is considered as an individual and institutional issue (4) .
In 1863, Florence Nightingale already emphasized the importance of patient safety in nursing care delivery.
Nevertheless, professional failure and errors are inevitable in organizations. Therefore, learning from errors is essential and is one of the goals of patient safety programs (5) .
Internationally, a consensus exists that several error-related elements affect nursing practice in hospitals, including the severity and complexity of patients' diseases, the short length of stay, the number of activities nurses delegate to nurse assistants and technicians, reduction of nursing staff, work overload, high turnover rate and long work hours. In addition, there has been an increase in technology and new knowledge.
As nurses need to cope with all of these factors within this context and to make appropriate decisions to guarantee better patient care and surveillance, they also need to prevent errors and assure care quality. If staffing levels are inappropriate, these responsibilities may be compromised (6)(7) .
A study performed at 168 hospitals in the USA analyzed the net effect of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education. The authors found that higher percentages of nurses in hospitals with poor care environments reported high burnout levels and dissatisfaction with their jobs. The care environment had a significant effect on the intention to leave the job.
The authors also reported that, even after controlling for the effects of the care environment, the odds of nurses reporting high burnout and dissatisfaction increased with each additional patient per nurse in the mean workload at their hospitals. The odds of patients dying in hospitals with an average workload of eight patients per nurse is 1.26 times greater than in hospitals with a mean workloads of four patients per nurse. Finally, the authors reported that each 10% increase in the proportion of nurses with a bachelor of science degree in nursing was associated with a 4% decrease in the risk of death (8) .
Nursing care demands a complex thinking process, which includes making inferences and synthesizing information. Nurses' surroundings have been described as fast and unpredictable, promoting interruptions and errors in nursing care. During their work shifts, nurses constantly shift from one activity to another and manage information from many different sources, often working with two or more tasks at the same time and showing high rates of interruptions in their activities (9) .
In view of the multiple demands and insufficient resources, these professionals feel unable to meet all nursing care actions required and may often choose not to complete them. In those circumstances, nurses may abbreviate, delay or simply omit care (7) .
The omission of nursing care (missed nursing care) phenomenon is defined as any aspect of care that is required by the patient and that is missed (partially or as a whole) or delayed (7) . It was first identified in a qualitative study in the United States, involving 25 focus groups with . Based on those studies, the authors developed and tested the MISSCARE Survey.
The importance of having a specific instrument to assess the phenomenon of missed nursing care relates to the fact that this type of instrument identifies the acts of omission that may result in negative patient care outcomes. Furthermore, the conditions are revealed in which care is not being provided (10) .
We did not find any Brazilian studies on this theme and that adopted the same focus as the authors of the MISSCARE Survey. Some elements of nursing care these researchers presented were also identified in Brazilian studies on quality indicators such as infection rates during hospitalization, readmissions, drug administration errors, occurrence of pressure ulcers and non-use of preventive measures (11)(12) .
Considering that missed care is a universal phenomenon that can be generalized to multiple clinical situations and is likely to cause threats to patient safety, systematic study in various cultural contexts is needed (7) , as well as open recognition, aiming to cope with the problem within a non-punishment culture.  (10) .

Procedures for cultural adaptation
The cultural adaptation process of the MISSCARE Survey was done according to standard procedures for translation of research instruments (13)(14)(15) . To obtain the first are considered acceptable reliability levels (16)(17) .

Results
The Expert Committee's analysis of the conceptual, semantic, idiomatic, experiential and operational equivalence was aimed at the practical applicability of the  (10) and instructions by the primary author.     (18) .
In comparison with the results obtained in the United States (10) , the authors of the original instrument found that most participants were also female (92.16%), worked full-time, possessed ten years of professional experience in nursing on average and the predominant education level was a Bachelor's degree.
Regarding the predominance of 12-hour shifts, this system is generally associated to the worker's need to hold two jobs, which is an important aspect of nursing work in the situation studied.
Studies suggest that the probability of making errors is three times greater when nurses work in shifts of 12 hours or more. A trend towards increased risks exists when nurses work long shifts and working over 40 hours per week significantly increases the chance of errors (19) .

Considering workers' satisfaction, most participants
were satisfied with the position and the profession, but this was not observed for teamwork performance. These outcomes are noteworthy, considering that, according to literature, higher levels of teamwork and perceptions of team adequacy lead to greater satisfaction with the current position and also with the profession (20) .
In another study, in which the relations between missed nursing care and satisfaction were verified, higher perceived levels of missed care corresponded to higher levels of work dissatisfaction. Nursing staff members who reported lower levels of missed care showed greater satisfaction with their work and profession. In the study, it was emphasized that nurses are fully aware of the missed care and that, when there are negative effects, their satisfaction is reduced (21) .

Conclusion
In this paper, the cultural adaptation process Using the instrument in hospitals could provide critical information about what is (or is not) occurring in nursing care delivery and provide a means to improve care, using information to guide any changes necessary.
The instrument has the power to identify barriers or problematic areas that need to be corrected.
The availability of this tool will enable researchers to study the impact of missed nursing care on