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Nursing Work and Life
Effects of increasing nurse staffing on missed nursing care S.-H. Cho1 RN, PhD, Y.-S. Kim2 MSW, PhD, K.N. Yeon3 S.-J. You4 RN, PhD & I.D. Lee5 RN, MSW
RN, MPH,
1 Associate Professor, College of Nursing, Research Institute of Nursing Science, Seoul National University, 2 Chief Researcher, 3 Associate Researcher, Public Health Policy Institute, Seoul Metropolitan Government, 5 Director, Department of Nursing, Seoul Medical Center, Seoul, 4 Assistant Professor, Department of Nursing, Mokpo National University, Mokpo, South Korea
CHO S.-H., KIM Y.-S., YEON K.N., YOU S.-J. & LEE I.D. (2015) Effects of increasing nurse staffing on missed nursing care. International Nursing Review 62, 267–274 Background: Inadequate nurse staffing has been reported to lead nurses to omit required nursing care. In South Korea, to reduce informal caregiving by patient families and sitters and to improve the quality of nursing care, a public hospital operated by the Seoul Metropolitan Government has implemented a policy of increasing nurse staffing from 17 patients per registered nurse to 7 patients per registered nurse in 4 out of 13 general nursing units since January 2013. Aim: The study aims to compare missed nursing care (omission of required care) in high-staffing (7 patients per nurse) units vs. low-staffing (17 patients per nurse) units to examine the effects of nurse staffing on missed care. Methods: A nurse survey conducted in July 2013 targeted all staff nurses in all four high-staffing and all nine low-staffing units; 115 nurses in the high-staffing units (response rate = 94.3%) and 117 nurses in the low-staffing units (response rate = 88.6%) participated. Missed nursing care was measured using the MISSCARE survey that included 24 nursing care elements. Nurses were asked how frequently they had missed each element on a 4-point scale from ‘rarely’ to ‘always’. Results: Overall, nurses working in high-staffing units had a significantly lower mean score of missed care than those in low-staffing units. Seven out of 24 nursing care elements were missed significantly less often in high-staffing (vs. low-staffing) units: turning, mouth care, bathing/skin care, patient assessments in each shift, assistance with toileting, feeding and setting up meals. Conclusion: The findings suggest that increasing nurse staffing is associated with a decrease in missed care. Less omission of required nursing care is expected to improve nursing surveillance and patient outcomes, such as patient falls, pressure ulcers and pneumonia. Implications for nursing and health policy: Adequate nurse staffing should be ensured to reduce unmet nursing needs and improve patient outcomes. Keywords: Hospitals, Korea, Missed Nursing Care, Nurses, Nursing, Quality, Staffing, Quality and Safety
Correspondence address: Yong-Soo Kim, Public Health Policy Institute, Seoul Metropolitan Government, Seoul Medical Center, 156, Sinnae-ro, Jungnang-gu, Seoul 131-130, South Korea; Tel: +82-2-2276-7130; Fax: +82-2-2276-7437; E-mail: [email protected]
Funding: This research was conducted by the Public Health Policy Institute of Seoul Metropolitan Government as a part of the government policy implementation of increasing nurse staffing in a city-government hospital funded by the Seoul Metropolitan Government. Conflict of interest: No conflict of interest has been declared by the authors.
© 2015 International Council of Nurses
267
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S.-H. Cho et al.
Introduction Nurse staffing, missed nursing care and patient outcomes
Nurse staffing has been reported to influence the quality of nursing care and patient outcomes (Cho et al. 2008; International Council of Nurses 2006; Kane et al. 2007; Rafferty et al. 2007). Missed nursing care, which is defined as the omission of any aspect of required nursing care, provides a mechanism for explaining how nurse staffing influences patient outcomes in the Missed Nursing Care Model (Kalisch et al. 2009, 2011a). This Model suggests that inadequate nurse staffing may lead to nurses’ omission of necessary nursing care, and this error of omission ultimately results in poor patient outcomes (Kalisch et al. 2009). Empirical studies have reported that nurse staffing was a significant predictor of missed nursing care and that missed nursing care mediated the relationship between nurse staffing and patient falls (Kalisch et al. 2011b, 2012a). The MISSCARE survey, which had been developed to measure missed nursing care (Kalisch et al. 2011a), has been utilized in not only the USA but also other countries such as Turkey and Lebanon (Kalisch et al. 2012b, 2013). Recent studies of ‘care left undone’ conducted by the international RN4CAST consortium also reported the relationships between nurse staffing, care left undone by nurses, and the quality and safety of care (Ausserhofer et al. 2014; Ball et al. 2014). In a study of nurses working in English hospitals, 86% reported leaving at least one of the 13 nursing care activities undone due to a lack of time on their most recent shift (Ball et al. 2014). Across 12 European countries, an average of 3.6 out of 13 nursing care activities had been left undone (Ausserhofer et al. 2014). These two studies reported that better nurse staffing (i.e. fewer number of patients per nurse) was associated with a smaller number of nursing care activities left undone. A smaller amount of care left undone was also related to the nurses’ better perceptions of the quality and safety of care (Ball et al. 2014). Informal caregiving by inpatient families and its impact on nurse staffing
It has been a social expectation in South Korea that when patients are hospitalized, their family members stay at the patients’ bedside during hospitalization and provide patients with basic care (e.g. feeding and toileting assistance). For example, when older people are hospitalized, their spouse or adult children, particularly female family members (e.g. wife, daughter and daughter-in-law), are expected to stay at the patients’ bedside (Cho & Kim 2006). However, as more women have begun to participate in economic activities, fewer families
© 2015 International Council of Nurses
have been able to stay with patients during hospitalization. When families have no members available at the patients’ bedside, they often hire a patient sitter as their substitute who can look after the patient 24 h and pay the cost of the sitter out of their own pocket. In 2010, 71% of the patients hospitalized in acute care settings had informal caregivers during hospitalization; 95% of the caregivers were patients’ family or relatives and 4% were patient sitters (Jung et al. 2012). On average, approximately USD 800 was paid to a patient sitter per hospitalization (Jung et al. 2010). Although informal caregiving by patient families and sitters would have the advantages of providing patients with personalized care and of strengthening family bonds, it has caused several issues for hospitals, nurses and patients. First of all, hospitals may set up and maintain their nurse staffing level as low as possible by letting the patients’ family and sitter, not nursing staff, provide basic care. Under this approach to nurse staffing, nurses have little time available for providing basic care even if they are still responsible for all patient care. As the omission of care by nurses is repeated for an extended period of time, nurses would conclude that the care provided by the patients’ family and sitter was ‘not my job’ any longer and get used to missing the care (Kalisch 2006). Repeated omission of basic nursing care may also prevent nurses from ‘knowing the patients’, which is essential to sound clinical judgement, safe care and a positive nurse–patient relationship (Zolnierek 2014). Patients’ families also experience social and economic burdens because they have to be absent from school or the workplace and are withdrawn from social interactions to stay at the patients’ bedside. More importantly, caregiving by families and sitters can threaten the quality and safety of nursing care at any time when nursing care is fragmented and omitted (Cho & Kim 2006). Implementing a policy of increasing nurse staffing to reduce informal caregiving and improve the quality of nursing care
To reduce informal caregiving and improve the quality of nursing care, the Metropolitan Government of Seoul, the capital of South Korea, has implemented a new policy of increasing nurse staffing in general medical–surgical units (excluding specialty units such as intensive care units) of a city government hospital since January 2013. Typical staffing in a general unit with 50 beds was 17 patients per registered nurse (RN) by shift and one nursing assistant only on a day shift. The new policy has increased nurse staffing to 7 patients per RN in addition to one nursing assistant on every shift. Under this policy, when patients were admitted to those units with increased nurse staffing, their family members were allowed to stay with patients only under the physician’s permission; as of July 2013 in these units with increased nurse staffing, 6% of patients had their
Nurse staffing and missed nursing care
family members staying with them during hospitalization. Nursing units whose nurse staffing has increased are called ‘Anshim’ units, which means peace of mind or freedom from worries in the Korean language. Therefore, the new policy is aimed at relieving the burdens and worries of patients and their families by having nurses provide patients with the necessary nursing care.
Study aim This policy of increasing nurse staffing was considered a natural experiment that enabled the researchers to examine how nurse staffing could influence missed nursing care as a measure of the quality of nursing care. The purpose of this study was to compare missed nursing care between nursing units with high vs. low nurse staffing to examine the effects of nurse staffing on missed nursing care.
Methods Study design
This study employed a cross-sectional study design that compares missed nursing care in nursing units with high staffing (7 patients per RN) and low staffing (17 patients per RN). As of 1 July 2013, the policy of increasing nurse staffing had been implemented in 4 nursing units out of the 13 general nursing units. A nurse survey was conducted on 10–16 July 2013, targeting all staff nurses working on all the four high-staffing units and the rest of the nursing units (i.e. nine units with low staffing). Participants
Survey questionnaires were distributed to all staff nurses in all high-staffing units (four units) and all low-staffing units (nine units). Because the survey was conducted for the purpose of evaluating the new staffing policy in a public hospital, all staff nurses were encouraged to participate in the survey. In the highstaffing units, 115 nurses participated in the survey (response rate = 94.3%) and 117 nurses in the low-staffing units participated (response rate = 88.6%).
269
on their unit. In this study, however, nurses were asked to answer the care missed by them to focus on the omission by nurses, instead of all the nursing staff. Part B consisted of 17 reasons for missed care, and they were categorized into three subscales: labour resources, material resources and communication (Kalisch & Williams 2009; Kalisch et al. 2011a). The nurses were asked to identify all the reasons because of which the nursing care was missed on a 4-point scale (not a reason, minor reason, moderate reason or significant reason). The permission to use the MISSCARE and its Korean translation (unpublished) were obtained from the developer and a Korean researcher. After making a few revisions in this Korean translation, a panel of nursing researchers finalized the translation of the MISSCARE and verified that the elements of nursing care and the reasons for missed care were applicable to nursing practice in South Korea. Kalisch & Williams (2009) tested the validity and reliability of MISSCARE and reported that the instrument met the requisite psychometric standards. In the present study, Cronbach’s α coefficient for the 24 elements of missed care was 0.89. Cronbach’s α coefficient for the 17 reasons for missed care was 0.90; Cronbach’s α of three subscales of labour resources, material resources and communication were 0.76, 0.80 and 0.88, respectively. Data analysis
The 4-point scales of the extent of missed care and reasons for the missed care were converted into 1–4 points such that a higher score indicates a greater extent of missed care and a stronger reason for the missed care. The extent of missed care for each element and the overall value (i.e. the average of the 24 elements) was compared between high- and low-staffing units by using t-test. Because differences in the nurses’ educational level and work experience were found between the high- and the low-staffing units, a multiple regression analysis with multilevel modelling was conducted to isolate the relationship between nurse staffing and missed nursing care by controlling for the effects of educational level and work experience. The overall value and the values for the 17 reasons for the missed nursing care were also compared between the high- and the low-staffing units using t-test.
Instrument
Missed nursing care was measured using the MISSCARE survey (Kalisch et al. 2011a). The MISSCARE consists of two parts: perceptions of missed care (Part A) and the reasons for missed care (Part B). In Part A, nurses were asked to answer how frequently they had missed each item of the 24 nursing care elements with a 4-point scale (rarely, occasionally, frequently or always). The original MISSCARE survey asks nurses to check the care missed by all of the nursing staff, including themselves,
© 2015 International Council of Nurses
Ethical consideration
This study was approved by the institutional review board of the hospital. A survey packet that included a study introduction letter, a consent form, the questionnaire and a return envelope was distributed to the nursing units. The nurses sealed their questionnaire after completing it and returned it using the return envelope. A dataset was created without any information that could identify the individuals.
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S.-H. Cho et al.
Results The study sample included 115 nurses in the high-staffing units and 117 nurses in the low-staffing units. Female nurses accounted for 100% and 95.7% in the high- and the lowstaffing units, respectively. In the high-staffing units, 38.3% had a baccalaureate or higher degree, whereas 32.8% had such a degree in the low-staffing units. The high-staffing units had a greater proportion (27.8%) of nurses with less than 1 year of RN experience than the low-staffing units (17.1%). Table 1 presents the comparison of the overall value and the values for the 24 elements of the missed nursing care between the high- and the low-staffing units. Nurses working in the high-staffing units had a significantly lower overall score of missed nursing care (M = 1.39) than those in the low-staffing units (M = 1.51). The high-staffing units had significantly lower mean scores of missed nursing care for seven elements: bathing/skin care, mouth care, setting up meals, turning, assis-
tance with toileting, feeding and patient assessments in each shift. Among these seven elements, the greatest differences were found in turning (mean difference = 0.77) followed by mouth care (mean difference = 0.51) and bathing/skin care (mean difference = 0.44). In the high-staffing units, the three most frequently missed elements were ambulation (M = 2.04), bathing/skin care (M = 1.84) and mouth care (M = 1.83); these three elements were also ranked as the fourth (M = 1.94), second (M = 2.28), and first (M = 2.34) most frequently missed care elements in the low-staffing units, respectively. Even though bathing and mouth care were less frequently missed in the high-staffing (vs. lowstaffing) units, they still remained the most frequently missed care elements in the high-staffing units. While patient turning was ranked as the ninth missed care element in the high-staffing units, it was the third most frequently missed care element in the low-staffing units. The six least frequently missed care
Table 1 Comparison of missed nursing care between high vs. low nurse staffing units High staffing (n = 115)
Overall missed nursing care Ambulation three times per day or as ordered Patient bathing/skin care Mouth care Attend interdisciplinary care conference whenever held Emotional support to patient and/or family Full documentation of all necessary data Patient teaching about procedures, tests and other diagnostic studies Setting up meals for patients who feed themselves Turning patient every 2 h Assist with toileting needs within 5 min of request Assess effectiveness of medications Hand washing Skin/wound care PRN medication requests acted on within 15 min Medications administered within 30 min before or after scheduled time IV/central line site care and assessments according to hospital policy Focused reassessments according to patient condition Feeding patient when the food is still warm Patient discharge planning and teaching Response to call light is initiated within 5 min Patient assessments performed each shift Monitoring intake/output Vital signs assessed as ordered Bedside glucose monitoring as ordered IV, intravenous.
© 2015 International Council of Nurses
Low staffing (n = 117)
P-value
M ± SD
Rank
M ± SD
Rank
1.39 ± 0.23 2.04 ± 0.82 1.84 ± 0.69 1.83 ± 0.72 1.75 ± 0.69 1.73 ± 0.63 1.50 ± 0.55 1.48 ± 0.57 1.46 ± 0.63 1.43 ± 0.59 1.40 ± 0.56 1.37 ± 0.54 1.36 ± 0.55 1.35 ± 0.54 1.31 ± 0.47 1.30 ± 0.48 1.26 ± 0.46 1.25 ± 0.46 1.18 ± 0.38 1.12 ± 0.35 1.12 ± 0.35 1.07 ± 0.29 1.06 ± 0.24 1.05 ± 0.22 1.02 ± 0.13
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
1.51 ± 0.39 1.94 ± 0.85 2.28 ± 0.96 2.34 ± 0.96 1.79 ± 0.79 1.75 ± 0.76 1.49 ± 0.57 1.44 ± 0.64 1.79 ± 1.01 2.21 ± 0.82 1.63 ± 0.71 1.43 ± 0.61 1.42 ± 0.67 1.52 ± 0.65 1.27 ± 0.58 1.31 ± 0.61 1.22 ± 0.49 1.31 ± 0.53 1.53 ± 0.82 1.15 ± 0.47 1.09 ± 0.35 1.20 ± 0.55 1.09 ± 0.41 1.10 ± 0.38 1.07 ± 0.37
4 2 1 6 7 11 12 5 3 8 13 14 10 17 16 18 15 9 20 22 19 22 21 24
0.003 0.386
Nursing Work and Life
Effects of increasing nurse staffing on missed nursing care S.-H. Cho1 RN, PhD, Y.-S. Kim2 MSW, PhD, K.N. Yeon3 S.-J. You4 RN, PhD & I.D. Lee5 RN, MSW
RN, MPH,
1 Associate Professor, College of Nursing, Research Institute of Nursing Science, Seoul National University, 2 Chief Researcher, 3 Associate Researcher, Public Health Policy Institute, Seoul Metropolitan Government, 5 Director, Department of Nursing, Seoul Medical Center, Seoul, 4 Assistant Professor, Department of Nursing, Mokpo National University, Mokpo, South Korea
CHO S.-H., KIM Y.-S., YEON K.N., YOU S.-J. & LEE I.D. (2015) Effects of increasing nurse staffing on missed nursing care. International Nursing Review 62, 267–274 Background: Inadequate nurse staffing has been reported to lead nurses to omit required nursing care. In South Korea, to reduce informal caregiving by patient families and sitters and to improve the quality of nursing care, a public hospital operated by the Seoul Metropolitan Government has implemented a policy of increasing nurse staffing from 17 patients per registered nurse to 7 patients per registered nurse in 4 out of 13 general nursing units since January 2013. Aim: The study aims to compare missed nursing care (omission of required care) in high-staffing (7 patients per nurse) units vs. low-staffing (17 patients per nurse) units to examine the effects of nurse staffing on missed care. Methods: A nurse survey conducted in July 2013 targeted all staff nurses in all four high-staffing and all nine low-staffing units; 115 nurses in the high-staffing units (response rate = 94.3%) and 117 nurses in the low-staffing units (response rate = 88.6%) participated. Missed nursing care was measured using the MISSCARE survey that included 24 nursing care elements. Nurses were asked how frequently they had missed each element on a 4-point scale from ‘rarely’ to ‘always’. Results: Overall, nurses working in high-staffing units had a significantly lower mean score of missed care than those in low-staffing units. Seven out of 24 nursing care elements were missed significantly less often in high-staffing (vs. low-staffing) units: turning, mouth care, bathing/skin care, patient assessments in each shift, assistance with toileting, feeding and setting up meals. Conclusion: The findings suggest that increasing nurse staffing is associated with a decrease in missed care. Less omission of required nursing care is expected to improve nursing surveillance and patient outcomes, such as patient falls, pressure ulcers and pneumonia. Implications for nursing and health policy: Adequate nurse staffing should be ensured to reduce unmet nursing needs and improve patient outcomes. Keywords: Hospitals, Korea, Missed Nursing Care, Nurses, Nursing, Quality, Staffing, Quality and Safety
Correspondence address: Yong-Soo Kim, Public Health Policy Institute, Seoul Metropolitan Government, Seoul Medical Center, 156, Sinnae-ro, Jungnang-gu, Seoul 131-130, South Korea; Tel: +82-2-2276-7130; Fax: +82-2-2276-7437; E-mail: [email protected]
Funding: This research was conducted by the Public Health Policy Institute of Seoul Metropolitan Government as a part of the government policy implementation of increasing nurse staffing in a city-government hospital funded by the Seoul Metropolitan Government. Conflict of interest: No conflict of interest has been declared by the authors.
© 2015 International Council of Nurses
267
268
S.-H. Cho et al.
Introduction Nurse staffing, missed nursing care and patient outcomes
Nurse staffing has been reported to influence the quality of nursing care and patient outcomes (Cho et al. 2008; International Council of Nurses 2006; Kane et al. 2007; Rafferty et al. 2007). Missed nursing care, which is defined as the omission of any aspect of required nursing care, provides a mechanism for explaining how nurse staffing influences patient outcomes in the Missed Nursing Care Model (Kalisch et al. 2009, 2011a). This Model suggests that inadequate nurse staffing may lead to nurses’ omission of necessary nursing care, and this error of omission ultimately results in poor patient outcomes (Kalisch et al. 2009). Empirical studies have reported that nurse staffing was a significant predictor of missed nursing care and that missed nursing care mediated the relationship between nurse staffing and patient falls (Kalisch et al. 2011b, 2012a). The MISSCARE survey, which had been developed to measure missed nursing care (Kalisch et al. 2011a), has been utilized in not only the USA but also other countries such as Turkey and Lebanon (Kalisch et al. 2012b, 2013). Recent studies of ‘care left undone’ conducted by the international RN4CAST consortium also reported the relationships between nurse staffing, care left undone by nurses, and the quality and safety of care (Ausserhofer et al. 2014; Ball et al. 2014). In a study of nurses working in English hospitals, 86% reported leaving at least one of the 13 nursing care activities undone due to a lack of time on their most recent shift (Ball et al. 2014). Across 12 European countries, an average of 3.6 out of 13 nursing care activities had been left undone (Ausserhofer et al. 2014). These two studies reported that better nurse staffing (i.e. fewer number of patients per nurse) was associated with a smaller number of nursing care activities left undone. A smaller amount of care left undone was also related to the nurses’ better perceptions of the quality and safety of care (Ball et al. 2014). Informal caregiving by inpatient families and its impact on nurse staffing
It has been a social expectation in South Korea that when patients are hospitalized, their family members stay at the patients’ bedside during hospitalization and provide patients with basic care (e.g. feeding and toileting assistance). For example, when older people are hospitalized, their spouse or adult children, particularly female family members (e.g. wife, daughter and daughter-in-law), are expected to stay at the patients’ bedside (Cho & Kim 2006). However, as more women have begun to participate in economic activities, fewer families
© 2015 International Council of Nurses
have been able to stay with patients during hospitalization. When families have no members available at the patients’ bedside, they often hire a patient sitter as their substitute who can look after the patient 24 h and pay the cost of the sitter out of their own pocket. In 2010, 71% of the patients hospitalized in acute care settings had informal caregivers during hospitalization; 95% of the caregivers were patients’ family or relatives and 4% were patient sitters (Jung et al. 2012). On average, approximately USD 800 was paid to a patient sitter per hospitalization (Jung et al. 2010). Although informal caregiving by patient families and sitters would have the advantages of providing patients with personalized care and of strengthening family bonds, it has caused several issues for hospitals, nurses and patients. First of all, hospitals may set up and maintain their nurse staffing level as low as possible by letting the patients’ family and sitter, not nursing staff, provide basic care. Under this approach to nurse staffing, nurses have little time available for providing basic care even if they are still responsible for all patient care. As the omission of care by nurses is repeated for an extended period of time, nurses would conclude that the care provided by the patients’ family and sitter was ‘not my job’ any longer and get used to missing the care (Kalisch 2006). Repeated omission of basic nursing care may also prevent nurses from ‘knowing the patients’, which is essential to sound clinical judgement, safe care and a positive nurse–patient relationship (Zolnierek 2014). Patients’ families also experience social and economic burdens because they have to be absent from school or the workplace and are withdrawn from social interactions to stay at the patients’ bedside. More importantly, caregiving by families and sitters can threaten the quality and safety of nursing care at any time when nursing care is fragmented and omitted (Cho & Kim 2006). Implementing a policy of increasing nurse staffing to reduce informal caregiving and improve the quality of nursing care
To reduce informal caregiving and improve the quality of nursing care, the Metropolitan Government of Seoul, the capital of South Korea, has implemented a new policy of increasing nurse staffing in general medical–surgical units (excluding specialty units such as intensive care units) of a city government hospital since January 2013. Typical staffing in a general unit with 50 beds was 17 patients per registered nurse (RN) by shift and one nursing assistant only on a day shift. The new policy has increased nurse staffing to 7 patients per RN in addition to one nursing assistant on every shift. Under this policy, when patients were admitted to those units with increased nurse staffing, their family members were allowed to stay with patients only under the physician’s permission; as of July 2013 in these units with increased nurse staffing, 6% of patients had their
Nurse staffing and missed nursing care
family members staying with them during hospitalization. Nursing units whose nurse staffing has increased are called ‘Anshim’ units, which means peace of mind or freedom from worries in the Korean language. Therefore, the new policy is aimed at relieving the burdens and worries of patients and their families by having nurses provide patients with the necessary nursing care.
Study aim This policy of increasing nurse staffing was considered a natural experiment that enabled the researchers to examine how nurse staffing could influence missed nursing care as a measure of the quality of nursing care. The purpose of this study was to compare missed nursing care between nursing units with high vs. low nurse staffing to examine the effects of nurse staffing on missed nursing care.
Methods Study design
This study employed a cross-sectional study design that compares missed nursing care in nursing units with high staffing (7 patients per RN) and low staffing (17 patients per RN). As of 1 July 2013, the policy of increasing nurse staffing had been implemented in 4 nursing units out of the 13 general nursing units. A nurse survey was conducted on 10–16 July 2013, targeting all staff nurses working on all the four high-staffing units and the rest of the nursing units (i.e. nine units with low staffing). Participants
Survey questionnaires were distributed to all staff nurses in all high-staffing units (four units) and all low-staffing units (nine units). Because the survey was conducted for the purpose of evaluating the new staffing policy in a public hospital, all staff nurses were encouraged to participate in the survey. In the highstaffing units, 115 nurses participated in the survey (response rate = 94.3%) and 117 nurses in the low-staffing units participated (response rate = 88.6%).
269
on their unit. In this study, however, nurses were asked to answer the care missed by them to focus on the omission by nurses, instead of all the nursing staff. Part B consisted of 17 reasons for missed care, and they were categorized into three subscales: labour resources, material resources and communication (Kalisch & Williams 2009; Kalisch et al. 2011a). The nurses were asked to identify all the reasons because of which the nursing care was missed on a 4-point scale (not a reason, minor reason, moderate reason or significant reason). The permission to use the MISSCARE and its Korean translation (unpublished) were obtained from the developer and a Korean researcher. After making a few revisions in this Korean translation, a panel of nursing researchers finalized the translation of the MISSCARE and verified that the elements of nursing care and the reasons for missed care were applicable to nursing practice in South Korea. Kalisch & Williams (2009) tested the validity and reliability of MISSCARE and reported that the instrument met the requisite psychometric standards. In the present study, Cronbach’s α coefficient for the 24 elements of missed care was 0.89. Cronbach’s α coefficient for the 17 reasons for missed care was 0.90; Cronbach’s α of three subscales of labour resources, material resources and communication were 0.76, 0.80 and 0.88, respectively. Data analysis
The 4-point scales of the extent of missed care and reasons for the missed care were converted into 1–4 points such that a higher score indicates a greater extent of missed care and a stronger reason for the missed care. The extent of missed care for each element and the overall value (i.e. the average of the 24 elements) was compared between high- and low-staffing units by using t-test. Because differences in the nurses’ educational level and work experience were found between the high- and the low-staffing units, a multiple regression analysis with multilevel modelling was conducted to isolate the relationship between nurse staffing and missed nursing care by controlling for the effects of educational level and work experience. The overall value and the values for the 17 reasons for the missed nursing care were also compared between the high- and the low-staffing units using t-test.
Instrument
Missed nursing care was measured using the MISSCARE survey (Kalisch et al. 2011a). The MISSCARE consists of two parts: perceptions of missed care (Part A) and the reasons for missed care (Part B). In Part A, nurses were asked to answer how frequently they had missed each item of the 24 nursing care elements with a 4-point scale (rarely, occasionally, frequently or always). The original MISSCARE survey asks nurses to check the care missed by all of the nursing staff, including themselves,
© 2015 International Council of Nurses
Ethical consideration
This study was approved by the institutional review board of the hospital. A survey packet that included a study introduction letter, a consent form, the questionnaire and a return envelope was distributed to the nursing units. The nurses sealed their questionnaire after completing it and returned it using the return envelope. A dataset was created without any information that could identify the individuals.
270
S.-H. Cho et al.
Results The study sample included 115 nurses in the high-staffing units and 117 nurses in the low-staffing units. Female nurses accounted for 100% and 95.7% in the high- and the lowstaffing units, respectively. In the high-staffing units, 38.3% had a baccalaureate or higher degree, whereas 32.8% had such a degree in the low-staffing units. The high-staffing units had a greater proportion (27.8%) of nurses with less than 1 year of RN experience than the low-staffing units (17.1%). Table 1 presents the comparison of the overall value and the values for the 24 elements of the missed nursing care between the high- and the low-staffing units. Nurses working in the high-staffing units had a significantly lower overall score of missed nursing care (M = 1.39) than those in the low-staffing units (M = 1.51). The high-staffing units had significantly lower mean scores of missed nursing care for seven elements: bathing/skin care, mouth care, setting up meals, turning, assis-
tance with toileting, feeding and patient assessments in each shift. Among these seven elements, the greatest differences were found in turning (mean difference = 0.77) followed by mouth care (mean difference = 0.51) and bathing/skin care (mean difference = 0.44). In the high-staffing units, the three most frequently missed elements were ambulation (M = 2.04), bathing/skin care (M = 1.84) and mouth care (M = 1.83); these three elements were also ranked as the fourth (M = 1.94), second (M = 2.28), and first (M = 2.34) most frequently missed care elements in the low-staffing units, respectively. Even though bathing and mouth care were less frequently missed in the high-staffing (vs. lowstaffing) units, they still remained the most frequently missed care elements in the high-staffing units. While patient turning was ranked as the ninth missed care element in the high-staffing units, it was the third most frequently missed care element in the low-staffing units. The six least frequently missed care
Table 1 Comparison of missed nursing care between high vs. low nurse staffing units High staffing (n = 115)
Overall missed nursing care Ambulation three times per day or as ordered Patient bathing/skin care Mouth care Attend interdisciplinary care conference whenever held Emotional support to patient and/or family Full documentation of all necessary data Patient teaching about procedures, tests and other diagnostic studies Setting up meals for patients who feed themselves Turning patient every 2 h Assist with toileting needs within 5 min of request Assess effectiveness of medications Hand washing Skin/wound care PRN medication requests acted on within 15 min Medications administered within 30 min before or after scheduled time IV/central line site care and assessments according to hospital policy Focused reassessments according to patient condition Feeding patient when the food is still warm Patient discharge planning and teaching Response to call light is initiated within 5 min Patient assessments performed each shift Monitoring intake/output Vital signs assessed as ordered Bedside glucose monitoring as ordered IV, intravenous.
© 2015 International Council of Nurses
Low staffing (n = 117)
P-value
M ± SD
Rank
M ± SD
Rank
1.39 ± 0.23 2.04 ± 0.82 1.84 ± 0.69 1.83 ± 0.72 1.75 ± 0.69 1.73 ± 0.63 1.50 ± 0.55 1.48 ± 0.57 1.46 ± 0.63 1.43 ± 0.59 1.40 ± 0.56 1.37 ± 0.54 1.36 ± 0.55 1.35 ± 0.54 1.31 ± 0.47 1.30 ± 0.48 1.26 ± 0.46 1.25 ± 0.46 1.18 ± 0.38 1.12 ± 0.35 1.12 ± 0.35 1.07 ± 0.29 1.06 ± 0.24 1.05 ± 0.22 1.02 ± 0.13
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
1.51 ± 0.39 1.94 ± 0.85 2.28 ± 0.96 2.34 ± 0.96 1.79 ± 0.79 1.75 ± 0.76 1.49 ± 0.57 1.44 ± 0.64 1.79 ± 1.01 2.21 ± 0.82 1.63 ± 0.71 1.43 ± 0.61 1.42 ± 0.67 1.52 ± 0.65 1.27 ± 0.58 1.31 ± 0.61 1.22 ± 0.49 1.31 ± 0.53 1.53 ± 0.82 1.15 ± 0.47 1.09 ± 0.35 1.20 ± 0.55 1.09 ± 0.41 1.10 ± 0.38 1.07 ± 0.37
4 2 1 6 7 11 12 5 3 8 13 14 10 17 16 18 15 9 20 22 19 22 21 24
0.003 0.386
