Omission of nursing care in hospitalization units*

Objective: to describe the prevalence and reasons for omission of nursing care, according to the perception of nursing professionals working in a teaching hospital. Method: a cross-sectional study was carried out with 267 professionals from ten hospitalization units. Data were collected by the MISSCARE-Brasil instrument. Descriptive statistics and Pearson’s Chi-square or Fisher’s exact tests were used to compare differences in the prevalence of omission among professional categories. Results: among the elements of nursing care, the highest prevalence of omission consisted in: to sit up the patient out of bed (70.3%), ambulation three times a day (69.1%), and participation in the discussion of the interdisciplinary team on patient’s health care (67.2%). The most frequent reasons were: inadequate number of staff (85.4%), inadequate number of staff for providing care or in administrative tasks (81.6%), and unexpected increase in the number and/or greater severity of patients (79.8%). Nurses reported major omission than nursing technicians/auxiliaries in four elements of care (p<0.05). Conclusion: according to our study, there is high prevalence of omission of nursing care elements from the professionals’ perspective. Factors related to human and material resources were more reported as causes for such omission.

Regarding nursing professionals, the awareness of not having managed to provide their patients with all the necessary care may generate dissatisfaction, increased intention to quit the job, and the Burnout Syndrome (5) . In their turn, healthcare institutions have their cost increased due to the increase in the length of stay of patients, readmissions, and the need for repair/ treatment of damages caused to the patients (5) .
Evidence of nursing care omission justify the need to understand its reasons. Aspects related to human resources, material resources, and communication have been the most prevalent factors that make professionals unable to perform all the care required by the patients (15) .
It is believed that the identification, mitigation, and transparent discussion on omissions of nursing care can assist in the management of institutional risk and in the creation of a safety culture, consisting in an "early warning" of greater risk to negative results of patients (14) . The study population consisted of all nurses, nursing technicians and auxiliaries who have been working for over one month in the investigated units during the data collection period. Professionals in management positions responsible for more than one unit were excluded, in addition to those who were on leave during the data collection period and those who did not perform nursing actions.  (19) , which regulates research involving human beings. All professionals who agreed to participate in the study received the Informed Consent Form and were asked to read and sign it.

Results
A total of 267 nursing professionals participated in the study, corresponding to a response rate of 71.0% of the population, and 87.6% were women, with a median  considering that four of them were the most mentioned on the part of nurses, and care provided to skin injuries/ wounds was the most mentioned on the part of nursing technicians and auxiliaries (Table 2). Orientations to patients and relatives regarding routines, procedures, and provided care 69 ( The inadequacy of human resources and the unexpected increase in the number and/or greater severity of patients were the most prevalent reasons for omission (Table 3).

Discussion
Our results evidenced a high prevalence of omission of one or more nursing care practices. Such omission is an important variable to reflect on the need to revise the structure and work processes under development, which may be resulting in care-related outcomes lacking quality due to the non-provision of adequate treatment, in addition to causing damages to patients.
The internal consistency of the used instrument, the MISSCARE-Brasil, was considered acceptable, with results similar to other national (16) and international (10, 13,17) studies, proving that it has a high reliability to measure the omission of nursing care.
We identified that sitting up the patient out of bed featured the highest prevalence (70.3%) of omission of care, followed by ambulation of patients three times a day (69.1%). The non-ambulation of the patients was also identified as the care with the highest prevalence of omission in studies conducted on nursing staff professionals in several countries (6,16,20) , and also by patients themselves (41.3%) (21) . In addition to social welfare, it improves quality of life, independence, it decreases anxiety, depressive mood, anguish, and increases patient comfort and satisfaction (22) . Organizational results can also be identified, such as the decrease in the length of stay, mortality of patients, and institutional costs (22) .

Evidences reflect the importance of mobilization
for positive results in the reestablishment of patients and highlight the need for planning and developing methods and routines to ensure that this nursing action is systematically performed (22) .
Another care featuring high prevalence of omission resistance of a technical-scientific rationality prevail, as well as inequalities between specialties and the social valorization attributed to them (23) .
Nursing professionals, for not participating in discussions with professionals from other teams, miss opportunities to share the knowledge of those who The professional responsible for providing the care was outside the unit/sector or was unavailable 114 (42.7) The professional who did not provided the care is not afraid of punishment/dismissal due to the stability in employment 108 (40.4) The professional has no ethical posture and has no commitment and involvement with the work and/or with the institution 101 (37.8) Lack of preparation on the part of nurses to lead, supervise, and conduct teamwork 100 (37.5) The nursing professional is negligent (lazy, lacking attention or insensitivity) 98 (36.7) Lack of motivation for work (due to low salary and/or lack of appreciation of the professional) 88 (33.0) Lima JC, Silva AEBC, Caliri MHL.
accompany the patient 24 hours a day, and to highlight its importance for the patient's recovery and provision of a quality care.
Moreover, we evidenced that another omitted care, with a prevalence of 51.1%, was the planning and teaching of the patient and/or family for hospital discharge. The failure in the education of patients and relatives is not only a Brazilian issue, since it was also evidenced in studies conducted in the USA (9) and in Mexico (10) .
At a time when the active participation of patients and their relatives in their own care, to guarantee the patient's safety (24) , is increasingly sought, patients' lack of guidance and education in health is worrisome, and it may lead to complications in their health conditions and to readmission (4) . Teaching patients and relatives about their health condition and care to be provided after hospital discharge make patients to have greater adherence to treatment and feel engaged in their own care, preventing adverse events and avoiding unnecessary complications and readmissions (24)(25) .
The seek to understand lack of quality, adverse events, and professional dissatisfaction (7,10,26) . The insufficient number of staff reflects in a greater number of patients per nursing professional and may impose burden to workers and generate higher rates of omitted care (27) .
Authors of a study in England identified that the number of patients per nurse was significantly associated with the omission of nursing care, and pointed out that when nurses provided care for a smaller number of patients, less care practices were omitted and the chance to omit some care practice also diminished (7) .
The National Institute for Clinical Excellence (NICE) proposed that the omission of care could be used as a "warning flag" at inadequate levels of staff and as an indicator of the quality of nursing services. It also reinforces the need for more evidence and indicators to determine safe levels of the nursing staff, in addition to studies in order to understand the extent to which they are actually achieved (28) .
Nursing professionals also perceived the lack discuss it, in order to understand its proportion. There must be leadership involvement along with the frontline professionals for planning improvement actions.
The main limitations of our study concern data collection performed in a single institution and the seasonal variation of the data collection period, which took place in eight months. However, it is worth noting that this is one of the first studies to perform a situational diagnosis of the omission of nursing care within the Brazilian context. It is noteworthy that this diagnosis is essential to awaken a differentiated and critical look at this frequent problem, but about which little or nothing was discussed until now. We suggest to carry out studies whose authors seek to analyze and compare the omission of care in other institutions and investigate factors that may influence in the nonperformance of nursing care.
The relevance to professional practice in identifying and understanding reasons that lead to the occurrence of nursing care omission is in recognizing aspects of the nursing work process that require attention and decisionmaking on the part of the management of institutions, in such a way the continuity of care is ensured and adverse events due to lack of care are reduced.

Conclusion
With this study we evidenced that the omission of Authors of studies, such as ours, evidence that nursing has been operating in situations unfavorable to the integral performance of the care process, demanding efforts to plan and adopt strategies to prevent the omission of care and improve care-related practices.