Factors influencing the missed nursing care in patients from a private hospital

ABSTRACT Objective: to determine the factors that influence the missed nursing care in hospitalized patients. Methods: descriptive correlational study developed at a private hospital in Mexico. To identify the missed nursing care and related factors, the MISSCARE survey was used, which measures the care missed and associated factors. The care missed and the factors were grouped in global and dimension rates. For the analysis, descriptive statistics, Spearman’s correlation and simple linear regression were used. Approval for the study was obtained from the ethics committee. Results: the participants were 71 nurses from emergency, intensive care and inpatient services. The global missed care index corresponded to M=7.45 (SD=10.74); the highest missed care index was found in the dimension basic care interventions (M=13.02, SD=17.60). The main factor contributing to the care missed was human resources (M=56.13, SD=21.38). The factors related to the care missed were human resources (rs=0.408, p<0.001) and communication (rs=0.418, p<0.001). Conclusions: the nursing care missed is mainly due to the human resource factor; these study findings will permit the strengthening of nursing care continuity.

the health problems and uses the person's willingness to promote self-care and offer emotional support (6)(7) .
The discharge planning and education help the patient and family to improve their participation and to make informed decisions about the care; the education includes both the knowledge needed during the care process and when the patient is discharged (5) . The basic care interventions are actions to satisfy the patients' basic needs and lack of autonomy, as the user cannot do so by himself; this is considered routine nursing care at most hospitals (8) . The care interventions with continuing assessments are involved in the continuous surveillance process and the continuing assessment of the care provided, aiming to identify any change in the patient's health status and to make decisions on the care process (9-10) .
The nursing staff is responsible for the care quality provided. Therefore, identifying care omissions and factors related to these omissions permits taking the relevant measures involved in the restructuring of nursing services, in order to contribute to the solution of the missed nursing care problem (5) , which enhances the quality and safety of patient care. Therefore, the objective was to determine the factors influencing the nursing care missed in hospitalized patients. To collect the information, the MISSCARE (11) survey was used, an instrument that measures the care missed and associated factors. It consists of 41 assertions, divided in three parts. The first part contains information on the sociodemographic data, providing information on the participants' professional data. The   (11) . The original version of the instrument is in English. Therefore, the survey had to be translated from English to Spanish by two certified agencies for its semantic validation and the achievement of a consensus version in Spanish, with the support of qualified translators. Next, a pilot test was undertaken to verify the semantic clarity of the assertions (12) .

Method
To collect the data, the services were visited during each of the different shifts and the nurses were invited to participate in the study; therefore, they received explanations about the objective and those who accepted to participate received a yellow envelope with the MISSCARE survey. It was verified that this would not interfere in their work activities and, finally, they received instructions for completion.
It should be highlighted that the study complied with the determinations of the Norma Oficial Mexicana en materia de Investigación (13) . Approval for the study was obtained from the Research Ethics Committee at the Faculty of Nursing of Universidad Autónoma de San Luis Potosí, Mexico under registration CEIFE-2014-101.
All participants were asked to sign the Informed Consent Form and the respect for their dignity, privacy, wellbeing and rights was guaranteed throughout the data collection.
To process the data, the statistical software SPSS (Statistical Package for the Social Sciences, version 20) was used to design a global index of care missed, as well as for each of the dimensions, ranging from 0 to 100, in which a higher index corresponds to a higher level of care missed. In addition, indices were designed for the factors related to the care lost, in which higher scores corresponded to higher degrees of importance for the nurses.
The Kolmogorov-Smirnov test was used to determine the normality of the data. The continuous variables did not show normal distribution, so that non-parametric tests were used, such as Kruskal-Wallis and Mann-Whitney's U-test to identify differences in the care lost according to the assigned service, the nurses' category, level of education, experience at the service, professional experience and shift.
To determine the influence of the human resources, communication and material resources on the nursing care missed, first, Spearman's correlation analysis was applied among the coefficients of each factor, the intervention dimension coefficients and the global coefficient. Then, simple linear regression was applied to determine the effect of the factors on the care lost.

Results
Female nurses were predominant in the study with 77.5%, with a mean age of 28.4 years (SD=5.61). The

Elements of the missed nursing care
In Table 1 Concerning the interventions for basic care, the most missed or omitted care element is mouth care (28.2%), followed by help with walking three times per day or as indicated and patient feeding when the food is still warm (both 19.7%); the least omitted care was foot and wound care (1.4%).
In the discharge planning and patient education dimension, the most missed care was patient teaching while in hospital (7%) and the least omitted care the planning of patient discharge and teaching (4.2%).
In the individual needs dimension, the most missed care element is the emotional support to the patient and/or family (14.1%), followed by help with www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2017;25:e2877. Regarding the differences in care missed according to the nurses' labor characteristics, the only difference was found in the assigned service (X2 = 5.82, p = 0.05).
The care missed was more predominant at the inpatient service when compared to the emergency department (U = 166.5, p = 0.045).

Factors influencing the missed care
In Table 2 As for the elements that correspond to the material resource factor, the nurses signaled the unavailability of the drugs when necessary (21.1%) as a significant reason, followed by the supplies and equipment (16.9%).   (Table 3).
After determining the relation between the variables, simple linear regression analysis was applied to determine the influence of human and communication factors in care missed. The human resources explain 13% of the global care lost and communication 14% (Table 4).

Discussion
Based on the study results, it could be identified that there are elements of nursing care that are missed or omitted during the patients' hospital stay, as little more than half of the nurses indicated that at least one care is lost during the patient's hospital stay.
The care dimension where nurses perceive the greatest omission is that of basic care interventions, followed by discharge planning and patient education interventions. As for the dimension of basic care interventions, it is similar to a study from 2009 (5) , but it differs in its proportion, which was lower in the present study, whereas the previously reported study found a much higher proportion (73%). The execution of basic nursing interventions is essential during the patients' hospital stay, especially in patients who lack autonomy due to their health condition (14) . The omission in this type of interventions can be attributed to the fact that nurses do not prioritize them, either because of the low complexity of their condition or because they consider that the patient can perform these care actions by himself or with the support of a relative (15) .
Regarding the elements in the dimension of basic care interventions, the nurses reported greater omission in mouth care and help with walking three times a day or as indicated; these results are similar in proportion to a study carried out in 2011 (4) and another in 2006 (15) , but they differ from other studies (5,16) , where the proportion was much higher. The importance of knowing these omissions is that a significant association exists between missed care and adverse events. Care omissions while walking have been associated with falls in hospitalized patients (17) .
In the planning dimension of patient discharge and education, nurses pointed to a lack of patient education about the disease, tests and diagnostic studies. This result is similar to the findings in some studies (5,15,18) , but differs in proportion, as those studies have reported greater omission. This can be attributed to the characteristics of the institutions where the studies were carried out. According to the literature (3,15) , these aspects are important, as the lack of education prior to hospital discharge has a negative impact on hospital outcomes, such as complications and hospital readmissions.
As for the interventions in individual needs, the nurses perceived fewer omissions. The reported omission is relevant to consider though, especially since care actions are intended to respond to human needs rather than to health problems (6)(7) . The most missed care element according to the nurses was emotional support to the patient, with similar results, but to a lesser extent than in some previous studies (17)(18) . Some authors (4,15,19) point out that the omission can be attributed to the time required for their execution, which nursing often allocates to other care that they consider a priority, such as physician-delegated interventions.
Another element of this dimension the staff perceived with greater omission was help with the interdisciplinary assessment visits. The omission in this intervention is similar, although to a lesser extent than  in a study from 2011 (4) . This could be due to the high work demands as well as to the work system, where interdisciplinary teamwork often is not designed (15) .
Finally, in the dimension of care interventions with continuing evaluations, although the staff perceived little care missed, there are elements that are omitted, such as the complete patient documentation with the necessary data and patient evaluations per shift. These results are similar to some studies (5,15,17) , but to a lesser extent than reported in those studies.
Some authors (4)(5)18) (4)(5)20) , although they report a greater proportion. For the present study, we also looked for an association between missed care and these factors, finding no association between missed care and its dimensions for the material resources. This finding could be attributed to the fact that the present study was carried out at a private institution, where material resources are generally available to cover the care demands.
Nurses consider human resources as the main factor for missed care, where they mentioned that the insufficient number of staff and the unexpected increase in the volume of patients and / or service workload are the most significant elements, which is similar, but to a lesser extent than the findings in 2011 (4) and 2009 (5) .