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Missed Nursing Care and Related Factors in Iranian Hospitals: A Cross

Sectional Survey

Article in Journal of Nursing Management · May 2020

DOI: 10.1111/jonm.13055

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Qazvin University of Medical Sciences Tabriz University of Medical Sciences
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Received: 25 November 2019 | Revised: 2 May 2020 | Accepted: 19 May 2020

DOI: 10.1111/jonm.13055

SPECIAL ISSUE PAPER

Missed nursing care and related factors in Iranian hospitals: A

cross-sectional survey

Zahra Chegini PhD1,2 | Tohid Jafari-Koshki PhD3 | Marzieh Kheiri MSc4 |

5 2 6
Ali Behforoz BSc | Saeedeh Aliyari MSc | Udita Mitra MSc | Sheikh Mohammed
Shariful Islam PhD7

1
Social Determinants of Health Research
Center, Qazvin University of Medical Abstract
Sciences, Qazvin, Iran Aim: To determine the prevalence of, and reasons for, missed care by nurses and the
2
National Institute for Health Research,
factors associated with it in Iranian hospitals.
Tehran University of Medical Sciences,
Tehran, Iran Background: Despite providing high-quality patient care in hospitals, nurses often
3
Molecular Medicine Research Center, fail to deliver optimum care, which jeopardizes the safety of patients and increases
Department of Statistics and Epidemiology,
Faculty of Health, Tabriz University of
health care costs. Therefore, identifying missed nursing care is essential if the quality
Medical Science, Tabriz, Iran of health services is to be improved.
4
Department of Health Education and Methods: A cross-sectional study was conducted among 215 nurses working in
Promotion, Faculty of Health, Iran University
of Medical Science, Tehran, Iran the medical–surgical wards of eight public and private hospitals in Tabriz, Iran. The
5
Iranian Center of Excellence in Health ‘MISSCARE’ survey tool was used to collect data in relation to the extent of missed
Management , School of Management and
care and the related reasons. Logistic regression models were used to assess the as-
Medical Informatics, Tabriz University of
Medical Sciences, Tabriz, Iran sociation between factors and missed nursing care.
6
The School of Health in Social Science, Results: Results showed that the mean score of overall missed nursing care was 2.57
University of Edinburgh, Edinburgh, UK
7 and 72.1% of the nurses reported that they missed at least one nursing care item
Institute for Physical Activity and Nutrition,
Deakin University, Geelong, Australia on their last shift. ‘Patient discharge planning and teaching’, ‘emotional support to
patient and/or family’ and ‘attend interdisciplinary care conferences whenever held’
Correspondence
Zahra Chegini, Social Determinants of were the most common missed items by nurses in Iran. In a 5-point Likert scale, the
Health Research Center, Qazvin University
most important reasons identified by nurses for missed care were ‘human resources’,
of Medical Sciences, Shahid Bahonar Blvd,
Qazvin, Iran. 3.11 (95% CI: 3.03–3.19); ‘material resources’, 2.7 (95% CI: 2.6–2.8); and ‘communica-
Email: [email protected]
tion’, 2.4 (95% CI: 2.3–2.5), respectively. Missed nursing care was associated with sex
(OR for males = 2.83, 95% CI: 1.01–7.89), age (OR = 1.16, 95% CI: 1.01–1.33) and the
number of patients under care (OR = 1.11, 95% CI 1.01–1.22). A reverse association
was found with the number of patients discharged (OR = 0.89, 95% CI: 0.82–0.96) and
satisfaction with teamwork (OR = 0.60, 95% CI: 0.41–0.89).
Conclusions: There is a need to identify the factors contributing to the incidence of
missed nursing care in hospitals and to develop strategies to address these.
Implications for Nursing Management: The results of this study highlighted the im-
portance of addressing missed nursing care in Iranian public and private hospitals.
Nursing management should consider improving communication between team
members and units. Changes are required regarding task division and payments to

J Nurs Manag. 2020;00:1–11. wileyonlinelibrary.com/journal/jonm© 2020 John Wiley & Sons Ltd | 1
2 | CHEGINI et al.

the nursing staff. Further research is required to understand the reasons behind
missed nursing care, and the development of appropriate policies to address better
nursing care in hospitals is recommended.

KEYWORDS

care left undone, health services misuses, medical errors of omission, missed nursing care

1 | I NTRO D U C TI O N Nurses in Iran face several challenges at work including staff short-
ages, high workloads, high occupational stress, having multiple jobs,
Nurses are the first line of contact in health care settings, and low wages, shortages and defective equipment, absence of nursing
they work as planners, coordinators, providers and evaluators of care at the community level and limitations in the academic curricu-
care. Amidst these multifunctional demands and the shortage of lum of nursing education (Chegini, 2019; Dehghan-Nayeri, Ghaffari,
resources, nurses have to make choices about the delivery of ac- & Shali, 2015; Kakemam et al., 2019). All factors may impact on
ceptable quality care. At times, adverse situations lead to nurses, the quality of services delivered by nurses (Farsi, Dehghan-nayeri,
for a variety of reasons, failing to satisfy standards of care. In these Negarandeh, & Broomand, 2010).
critical situations, nurses might shorten the usual length of care and In recent years, the high prevalence of comorbidity in patients
delay or exclude care. admitted to medical–surgical wards may explain the complexity
‘Missed nursing care’ has recently been identified as any ele- of delivered care and the high rate of medical errors (Boostani
ment of necessary patient care that has been excluded, either partly et al., 2019). Supporting patients with multiple comorbidities re-
or wholly, by a nurse. Missed nursing care is described as an error quires sufficient resources (staff and equipment) (Goodwin, Curry,
of care or exclusion, which can be life-threatening, in line with in- Naylor, Ross, & Duldig, 2010). Previous studies have identified
ternational standards of patient safety and quality of care (Cho several factors can contribute to missed nursing care, including
et al., 2016; Jones, Hamilton, & Murry, 2015). Missed care by nurses limited human resources, communication and financial resources
is a concern in all countries and has been described variously as ‘un- (Kalisch et al., 2015). Increases in unexpected volume of admis-
finished care’, ‘care left undone’, ‘tasks undone’, ‘task incompletion’, sions and discharges, the inadequacy of staff, unavailability of
‘unmet nursing care needs’ and ‘implicit rationing of nursing care’ medicines and emergency situations have been reported to re-
(Jones et al., 2015). sult in missed care (Winsett, Rottet, Schmitt, Wathen, & Wilson,
Previous studies have revealed that 14%–69% of all medication 2016). Previous research has also reported that the complexity
errors were attributable to omissions by nurses (Kalisch, Tschannen, of workloads and disruption adversely impact on job satisfaction
& Lee, 2011). In a study conducted by Hessels, Flynn, Cimiotti, and lead to the missed care (Winsett et al., 2016). A safe health
Cadmus, and Gershon (2015) in the United States, the prevalence care system cannot be developed if nurses are unable to perform
of missed nursing care was shown to be 10%–27%. Another study, their duties related to patient care (Gaffney, Hatcher, Milligan, &
in 12 European countries, reported that an average of 3.6 out of 13 Trickey, 2016).
nursing care activities were left undone (Ausserhofer et al., 2014). The incidences and components of missed nursing care vary
A hospital study in the UK showed that 86% of at least one of the significantly from one country to another (Jones et al., 2015;
13 nursing care activities were left undone due to time constraints Vryonides et al., 2016). The majority of earlier studies examin-
imposed upon nurses during their shift (Ball, Murrells, Rafferty, ing missed nursing care and its related factors were conducted in
Morrow, & Griffiths, 2014). European countries and in the United States (Griffiths et al., 2018)
Findings from a comparative study found that nurses in Cyprus where the working environment is different from developing coun-
were more likely to miss handwashing and the recording of vital tries such as Iran, and there is little literature discussing the omis-
signs, failures that, potentially, have an immediate impact on pa- sion of nursing care in developing countries (Haftu et al., 2019).
tient outcomes, whilst nurses in Italy and Australia were more likely In Iranian hospitals, it has not been broadly assessed with pre-
to miss longer-term treatment-based care in hospitals, which may vious studies adopting a qualitative approach (Dehghan-Nayeri
add to increased hospitalization days or earlier readmission rates et al., 2015) or conducted only in government hospitals in one city
(Blackman et al., 2018). (Khajooee, Bagherian, Dehghan, & Azizzadeh Forouzi, 2019) mak-
Whilst there are reports of missed nursing care in different ing it difficult to generalize the results.
regions (Griffiths et al., 2018), the causes of missed care can vary Consequently, there is a need to investigate the prevalence and
depending on the environment and on the financial and personal factors associated with missed nursing care using a larger sample
resources of a country's health systems. In resource-constrained de- size and standardized tools across multiple hospitals in order to ex-
veloping countries, the question has been raised of what care is spe- plore, in Iranian hospitals, the prevalence of, and reasons for, missed
cifically forgotten and what causes it to be unfinished or left undone. care by nurses and factors associated with it.
CHEGINI et al. | 3

2 | M E TH O DS offered to patients (ranging from ≤ 25%= not appropriate to

100%=fully appropriate).
2.1 | Sampling and data collection Before conducting the study, permission to use the ‘MISSCARE’
tool was obtained and the questionnaire was translated from English
This cross-sectional study was conducted in eight similar-size (at least to Persian and back-translated from Persian to English by two bi-
200 beds) public and private hospitals in Tabriz, northwest Iran, be- lingual language experts in accordance with the WHO guidelines
tween July and August 2019. Study participants were selected, using (WHO, 2009). Researchers then compared the initial English tool
census sampling, from nurses working in medical–surgical wards, these with the Persian tool, which had been back-translated. After minor
being seen as representative of general inpatient wards in Iran. adjustments, a final Persian version of the tool was ready for use.
Having obtained approval from the hospital administration, coor-
dination with the nurse managers began. Nurses working the morning
and evening shifts on the selected wards and who met the inclusion 2.3 | Pilot study
criteria (i.e. having at least 1 year of work experience in medical–surgi-
cal wards, working full-time and willing to participate) were identified A pilot study was conducted to evaluate the readability/understand-
by the nurse managers who distributed the survey questionnaire and ability of the tool and its reliability and validity. First, experts with a
information about the study. In total, 300 questionnaires were circu- nursing background assessed the validity of the questionnaire con-
lated by the nurse managers. Participants were asked to complete and tent. Then, the questionnaire was distributed among 46 nurses in a
return the questionnaire within 4 working days. Those on leave during general hospital. These questionnaires were excluded from the final
the study period and nurse managers not directly involved in patient analysis. After the pilot test, some modifications were performed
care were excluded from the study (Figure 1). to ensure clarity and the questionnaire was re-assessed within the
same cohort after four weeks. The test–retest stability for the two
subscales ranged from 0.71 to 0.79 (p < .001). Cronbach's alpha reli-
2.2 | The survey tool ability coefficients for the questionnaire's part 1 (missed care) and
part 2 (reasons for missed care) were 0.81 and 0.86, respectively.
Data were gathered using the ‘MISSCARE’ survey tool developed
by Kalisch and Williams (2009). This tool evaluates the miss-
ing elements of nursing care and the reasons for the omission of 2.4 | Data analysis
nursing care. The tool consists of two parts: Part 1 includes 24
items in which the respondents were required to indicate how Descriptive statistics were reported as n (%) for categorical variables
frequently they missed providing care during the last working and the mean (95% CI) for continuous variables. Logistic regression
shift using a 5-point Likert scale with scores ranging from 1 to 5 was used to assess the association of variables with the occurrence
(where 1 = never, 2 = rarely, 3 = occasionally, 4 = frequently and of missed care. Due to the large number of included variables in the
5 = always); and Part 2 addressed the reasons why nursing care analysis, backward variable selection method was utilized in the re-
was omitted. It includes 17 items in three subdivisions: human re- gression analysis. The following variables were included in the regres-
sources (9 items), material resources (3 items) and communications sion analysis: sex, age, marital status (single, married), working hours
(5 items). In this section, the nurses were asked to rate each item per week (≤44, >44), working shift, length of shift, taking extra shifts,
with a 4-point Likert scale (1 = not a reason, 2 = minor reason, hours (none, 1–12, >12), professional experience (yr), % of perception
3 = moderate reason and 4 = significant reason). on the adequacy of unit staffing (0, 25, 50, 75 and 100), number of
Nurses were also asked about their intention to leave their pro- admissions, number of patients under care, number of discharged pa-
fession in the next 6 to 12 months with a single question assessed tients, education (associate degree, bachelor's degree and postgradu-
by 2-point scale (1 = yes, 2 = no). Their satisfaction with their cur- ate), employment status (contract, permanent) and satisfaction with
rent role, the nursing profession and the nursing team were assessed the current role, with the profession and with the team on the ward
with three questions using a 5-point Likert scale (1 = very unsatisfied (using a 5-point Likert scale from ‘very dissatisfied’ to ‘very satisfied’).
to 5 = very satisfied). To conduct a logistic regression, the occurrence/non-occur-
A cover page comprising open-ended questions gathering the rence of missed care was summarized for each individual as follows.
respondents' demographic details, such as age, sex, education, pro- The non-missed care group was defined as ‘never missed’ or ‘rarely
fessional role, and the length of their working experience in medi- missed’, and the missed care group was defined as ‘occasionally
cal–surgical wards, full- or part-time work, working hours per week missed’, ‘frequently missed’ and ‘always missed’ (Palese et al., 2015).
(≤ or >44 hr/week), additional working hours and any lost shifts Therefore, for each single question, missed care was defined as
during the last 3 months. ‘not occurred’ (event = 0) if the response was 1–2, and as ‘occurred’
Additionally, nurses were asked about the total number of (event = 1) if the response was 3–5.
patients cared for during the last working shift, total number of In terms of the whole questionnaire, if the average of events
admitted and discharged patients and the relevance of the care for an individual was < 2 (i.e. all answered with never and rarely
4 | CHEGINI et al.

FIGURE 1 Flow diagram showing the study design, sampling and response rate

missed), the occurrence of missed care was considered as ‘No’, 2.5 | Ethical considerations
and if the average was > 2 (i.e. all answered with occasionally, fre-
quently and always missed), the occurrence of missed care was Ethical clearance was obtained from the Ethics Committee of Tabriz
considered as ‘Yes’. Data were analysed using IBM SPSS Statistics University of Medical Science (IR.TBZMED.REC.1397.272). Written
for Windows, version 24 (IBM Corp). Significance level was set at informed consent was obtained from all participants through the
0.05. use of a form signed by them and which advised them that they
CHEGINI et al. | 5

could withdraw from the study at any stage. Confidentiality and

TA B L E 1 Characteristics of participants (n = 215)
anonymity was maintained for all information collected during the
study. The data were exported into SPSS for analysis. Variables n (%) Variables n (%)

Gender Work in the current role

(years)
3 | R E S U LT S Male 88 (40.9) <2 42 (19.5)
Female 127 (59.1) 2–5 52 (24.2)
3.1 | Participants Age (years) >5 121 (56.3)
<25 34 (15.8) Work in the current ward
Two hundred and fifteen nursing staff participated in this study (re- (years)
sponse rate = 85%), 59.1% of which were female and 51.2% were 25–34 110 (51.2) <2 116 (54)
aged 25–34 years. Descriptive statistics on participants and work- 35–44 57 (26.5) 2–5 52 (24.2)
load are summarized in Table 1. The average number of admissions, >45 14 (6.5) >5 47 (21.8)
discharges and patients cared for as perceived by participants in the
Nurse education Extra hours in the last three
shifts prior to the study was 5.35, 4.58 and 14.47, respectively. months
Associate degree 17 (7.9) None 51 (23.7)
Bachelor's 177 (82.3) 1–12 hr 60 (27.9)
3.2 | Work satisfaction and intention to leave degree
Postgraduate 21 (9.8) More than 104 (48.4)
As shown in Table 2, 59.5%, 61.9% and 56.7% of the respondents 12 hr
were satisfied or very satisfied with the current role, profession and Employment status Shifts lost in the last three
working team, respectively. In total, 18.1% (n = 39) of respondents re- months
ported they intended to leave their profession within 6 to 12 months. Contract 146 (67.9) 0 167 (77.7)
Permanent 69 (32.1) 1 20 (9.3)
Working hr/week 2–3 16 (7.4)
3.3 | Missed nursing care and related reasons ≤44 86 (40) >4 12 (5.6)
>44 129 (60) Perception of adequate unit
As shown in Table 3, participants reported missing 2.57 of 24 nursing staffing
care items per shift. The distribution of responses in relation to how fre- Work shift Never 29 (13.5)
quently each element of care was commonly missed showed that 155 Days 28 (13) 25% 12 (5.6)
(72.1%) reported that they had commonly missed at least one nursing
Evenings 5 (2.3) 50% 59 (27.4)
care item on their last shift. Several nursing care activities were reported
Nights 7 (3.3) 75% 68 (31.6)
as frequently or often missed; among these, ‘patient discharge planning
Rotates 175 (81.4) 100% 47 (21.9)
and teaching’ (83.3%, M = 3.3, 95% CI 3.1–3.5) was the most frequently
Length of shift
missed element reported by 156 (83.3%) of the participants, followed
8-hr shift 34 (15.8)
by ‘emotional support to patient and/or family’ (68.4%, M = 3.2, 95%
CI 3.0–3.3), ‘attend interdisciplinary care conferences whenever held’ 12-hr shift 31 (14.4)

(64.2%, M = 3.1, 95% CI 3.0–3.3) and ‘patient teaching about illness, 8-hr and 12-hr 150 (69.8)
rotating shift
tests and diagnostic studies’ (62.8%, M = 3, 95% CI 2.8–3.2).

TA B L E 2 Work satisfaction and

n (%)
intention to leave among participants
(n = 215) Neither
Satisfied/very satisfied nor Unsatisfied/
satisfied unsatisfied very unsatisfied

Satisfaction with the current role 128 (59.5) 29 (13.5) 58 (27)

Satisfaction with the profession 133 (61.9) 28 (13) 54 (25.1)
Satisfaction with the teamwork at 122 (56.7) 20 (9.3) 73 (34)
the current ward
The number of nurses who intended 39 (18.1%)
to leave within 6–12 months
6 | CHEGINI et al.

TA B L E 3 Missed nursing care (1–5 score) and related reasons (1–4 score) reported by participants

Mean
Care provided in the ward n (%)a (95% CI)

Ambulation three times per day or as ordered 123 (57.2) 2.8 (2.6, 3)
Patient discharge planning and teaching 156 (83.3) 3.3 (3.1, 3.5)
Turning patient every 2 hr 133 (61.9) 2.9 (2.8, 3.1)
Mouth care 126 (58.6) 2.9 (2.7, 3)
Patient teaching about illness, tests and diagnostic studies 135 (62.8) 3 (2.8, 3.2)
PRN medication requests acted on within 15 min 120 (55.8) 2.8 (2.6, 3)
Full documentation of all necessary data 112 (52.1) 2.8 (2.6, 3)
Feeding patient when the food is still warm 62 (28.8) 1.9 (1.7, 2.1)
Medications administered within 30 min before or after scheduled time 119 (55.3) 2.9 (2.7, 3.1)
Assist with toileting needs within 5 min of request 126 (58.6) 2.9 (2.7, 3.1)
Response to call light is initiated within 5 min 126 (58.6) 3 (2.8, 3.2)
Emotional support to patient and/or family 147 (68.4) 3.2 (3, 3.3)
Patient bathing/skin care 72 (33.5) 2.1 (1.9, 2.2)
IV/central line site care and assessments according to hospital policy 119 (55.3) 2.9 (2.7, 3.1)
Assess effectiveness of medications 56 (26.0) 1.8 (1.7, 2)
Monitoring intake/output 69 (32.1) 2.1 (1.9, 2.3)
Setting up meals for patient who feeds themselves 45 (20.9) 1.7 (1.5, 1.8)
Vital signs assessed as ordered 48 (22.3) 1.7 (1.6, 1.9)
Focused reassessments according to patient condition 120 (55.8) 2.9 (2.7, 3.1)
Hand washing 75 (34.9) 2.2 (2, 2.4)
Bedside glucose monitoring as ordered 52 (24.2) 1.8 (1.6, 1.9)
Patient assessments performed each shift 127 (59.1) 3 (2.8, 3.2)
Skin/Wound care 61 (28.4) 1.9 (1.7, 2.1)
Attend interdisciplinary care conferences whenever held 138 (64.2) 3.1 (3, 3.3)
Total 155 (72.1) b 2.57 (2.46, 2.68)
Perceived importance in missed care occurrence
Human resources 3.11 (3.03, 3.19)
Material resources 2.7 (2.6, 2.8)
Communication 2.4 (2.3, 2.5)
a
% of participants with answers ‘occasionally’, ‘frequently’ or ‘always’.
b
Participants indicating that the nursing care has been lost (>2) in the last shift.

In contrast, missed care interventions least observed by partic- in male participants (OR = 2.83, 95% CI: 1.01–7.89). Age (OR = 1.16,
ipants included ‘setting up meals for patients who feed themselves’ 95% CI: 1.01–1.33) and the number of patients under care (OR = 1.11,
(20.9%, M = 1.7, 95% CI 1.5–1.8) and ‘vital signs assessed as ordered’ 95% CI 1.01–1.22) were the other factors associated with the occur-
(22.3%, M = 1.7, 95% CI 1.6–1.9). Among the reasons for missed nurs- rence of missed care. On the other hand, the number of patients
ing care, the most important observed reasons were ‘human resources’ discharged (OR = 0.89, 95% CI: 0.82–0.96) and satisfaction with the
(M = 3.11, 95% CI 3.03–3.19) and ‘material resources’ (M = 2.7, 95% CI teamwork (OR = 0.60, 95% CI: 0.41–0.89) were protective factors of
2.6–2.8), followed by ‘communication’ (M = 2.4, 95% CI 2.3–2.5). missed nursing care.

3.4 | Factors associated with the occurrence of 4 | D I S CU S S I O N

missed nursing care
In this study, 72.1% of the nurses commonly miss at least one
Table 4 shows the results from the final step of the backward essential element of nursing care in the medical–surgical ward
method of variable selection in logistic regression with R 2 = 0.20. per shift. These findings are comparable to studies conducted in
Specifically, the prevalence of missed care was significantly higher Ethiopia (Haftu et al., 2019) and in Sweden (Ball et al., 2014) in
CHEGINI et al. | 7

which the results were 74.6% and 74%, respectively. A study con- preparations had a negative impact on patient outcomes leading to
ducted by Ball et al. also reported 74% of nursing care omission in health-related complications and hospital readmissions.
the general medical and surgical wards of Swedish hospitals (Ball Nurses often struggle to perform the highest-priority tasks on
et al., 2016). However, the level of nursing care left undone was the wards and are compelled to limit their care and are more prone
higher in a New Jersey US study (10%–27%) (Hessels et al., 2015). to miss vital work (Ausserhofer et al., 2014). Therefore, it can be
This difference might be due to the study setting and sample size assumed that activities that are time-consuming or require addi-
difference. tional time effort are challenging to estimate; for example, talking
The results of the current study suggest that ‘patient discharge to patients, patient education and management performances (e.g.
planning and teaching’, ‘emotional support to patient and/or family’ patient management and planning) are commonly neglected and re-
and ‘attend interdisciplinary care conferences whenever held’ were ceive the least priority (Ausserhofer et al., 2014). Previous studies
the most missed items by nurses. These results are in line with an conducted in Iranian hospitals have shown that patient education is
earlier study (Moreno-Monsiváis, Moreno-Rodríguez, & Interial- ineffective (Chegini, Janati, Babaie, & Pouraghaei, 2020) due to high
Guzmán, 2015). An earlier study in Pennsylvania reported that about workloads and time constraints. Having to care for a disproportion-
12% of nurses across 168 hospitals missed discharge preparation for ate number of patients has also been found to inhibit such patient
patients and their families (Lucero, Lake, & Aiken, 2010). Another education (Adib Hajbagari & Zare, 2017). Using technology-based
study showed that 35% of nurses lacked confidence in patients learning tools might be helpful in enhancing patient education and
being able to manage their own care after being discharged from reminders for follow-up and improving communication with clini-
hospital (Aiken et al., 2012). In a cross-European study conducted cians and hospital discharge planning. Appropriate individual- and
in 12 countries, professional nurses commonly did not ‘comfort/talk the hospital-level factors, especially the experience of nurses in
with patients’, had tremendous workloads, and lacked autonomy, preparing patients for hospital discharge, need to be reflected in
and their relationships with other health care professionals, the sup- decisions about human resources (Mabire, Bachnick, Ausserhofer, &
port from managers, resources and incorporation in decision-mak- Simon, 2019).
ing processes were the main factors leading to interruptions in the Our findings suggest that attending interdisciplinary care con-
preparation for patient discharge. ferences was the third important element, which may be missed by
Chalco et al. (2006) suggested that emotional support compris- nurses. In a similar Iranian study, this was the most often missed
ing interventions such as information and education can help a pa- nursing care, and high workload and inappropriate time were the
tient to handle their situation and treatments effectively. Lindström probable reasons (Khajooee et al., 2019). In order to improve current
and Eriksson (2006) showed that professionals played an important health care systems, nurses need to increase the effectiveness of
part in helping patients to share their emotions and in situations their communication and their teamwork to deliver optimum patient
where they need to make decisions about their health promotion. care (Weller, Boyd, & Cumin, 2014). A collaborative and excellent
A previous study conducted in five countries reported that a large team performance may lead to value and process improvement, in-
number of patients felt that they received insufficient emotional novation in care and new initiatives and may improve performance
support whilst at the hospitals and experienced difficulties in dis- and work commitment and reduce nurse absenteeism (Jones &
cussing their anxieties and concerns with health care professionals Jones, 2011; Robbins, Garman, Song, & McAlearney, 2012).
(Adamson et al., 2012). Kalisch and Williams (2009) identified that Physicians and nurses working together in a team towards a
the lack of sufficient patient education and the absence of discharge common goal are essential for better patient care, but interdis-
ciplinary collaboration is often poor (Fewster-Thuente, 2015).
TA B L E 4 Factors affecting the occurrence of missed nursing Teamwork and collaboration among health care professionals
care
may support better patient education and self-engagement in-
p cluding involvement in decision-making and self-care (Morley &
Variables OR (95% CI) value Cashell, 2017). There is evidence to suggest that patient partic-
Sex (male) 2.83 (1.01, 7.89) .047 ipation in decision-making and care is vital if safer care is to be
Age (year) 1.16 (1.01, 1.33) .032 achieved (Chegini, Janati, Babaie, & Pouraghaei, 2019). It is neces-
Number of patients 1.11 (1.01, 1.22) .018 sary therefore to improve the quality and effectiveness of clinical
under care collaboration taking into account social, cultural and organisa-
Number of patients 0.89 (0.82, 0.96) .004 tional factors (Mahdizadeh, Heydari, & Moonaghi, 2015). Health
discharged care professionals including nurses should be encouraged and
Satisfaction with the 0.60 (0.41, 0.89) .012 enabled to collaborate through education and communication-re-
teamwork lated capacity building (Morley & Cashell, 2017).
R2 = 0.20 One-third of the participants reported inadequate nursing
Hosmer–Lemeshow χ2 = 7.85, p = .44 staff. Studies have shown multidimensional reasons for inadequate
Note: Occurrence defined as 1= ‘occasionally’, ‘frequently’ or ‘always’; nursing staff including increased workloads due to an increasingly
and 0= ‘others’. elderly population, demographic changes in the workforce, high
8 | CHEGINI et al.

professional experience and required clinical expertise, and the Ageing may decrease professional caution and precision in
high demand for nurses in other sectors (Khademi, Mohammadi, & nurses, which ultimately decreases the capacity to recognize omis-
Vanaki, 2015). Our findings were consistent with studies by Kalisch, sion in care (Palese et al., 2015). In contrast, participants have re-
Tschannen, Lee, and Friese (2011), which examined the relationship ported that the number of discharged patients and satisfaction with
between levels and the reasons for missed care, Cho, Kim, Yeon, teamwork had a reverse association with the occurrence of missed
You, and Lee (2015), which compared missed care in hospitals nursing care. These findings were similar to results from previ-
in Korea with high and low staff; and Min, Yoon, Hong, and Kim ous studies in the US and in Swiss hospitals, which reported that
(2019), which investigated the association between nurses’ breaks, teamwork was a significant factor in missed nursing care (Kalisch,
missed care and patient safety in Korean hospitals. All these stud- Lee, & Salas, 2010; Papastavrou, Andreou, Tsangari, Schubert, &
ies reported inadequate human resource as the most important De Geest, 2014). Other studies in Germany (Cramer, Pohlabeln,
reason for the missed nursing care. & Habermann, 2013), Iran (Ebrahimipour et al., 2016) and Taiwan
In recent years, the shortage of nursing staff due to increased (Tang, Sheu, Yu, Wei, & Chen, 2007) have suggested that a tiring
turnover has been recognized as a significant challenge for health care workload is a chief reason for medical errors.
systems (Chegini, Asghari Jafarabadi, & Kakemam, 2019). However, In a study by Blackman et al. (2015), predictors of missed nursing
in the current study, only 18% of the nurses expressed an inten- care included shift type, nursing resource allocation, health profes-
tion to leave their profession within the next 6–12 months. In this sional communication, workload intensity, workload predictability,
regard, there is a need to consider a mechanism to promote better the nurses’ satisfaction with their current job and their intention
organisational settings and improve in-service training of nurses to to remain in their jobs. The differences in results between studies
increase their professional competency and improve professional may be rationalized by the differences between workplace, available
skills (Chaghari, Saffari, Ebadi, & Ameryoun, 2017). This training may human resources, interactions with the nursing team, workload and
also increase nurses’ knowledge about how to deal effectively with the total number of cared for patients.
patients and caregivers and support them emotionally. A recent sys-
tematic review suggested effective policies to reduce the shortage of
nurses include new payment arrangements, emergency recruitment 4.1 | Limitations
and nurses` residency programmes (Park & Yu, 2019).
Nurses in Iran often perform inappropriate activities such as This study had some limitations. The cross-sectional design hinders
answering phone calls and coordinating patients’ appointments causal interpretations. The study participants were recruited from
with specialists (Adib Hajbagari & Zare, 2017). The distribution and only medical–surgical units, meaning the results cannot be general-
adequacy of medical professionals has been shown to be problem- ized to other specialized disciplines. The analysis did not take into
atic in Iran (Nobakht, Shirdel, Molavi-Taleghani, Doustmohammadi, account the clustering of nurses in units, which is a potential limita-
& Sheikhbardsiri, 2018). The Ministry of Health can prioritize the tion. Furthermore, a self-administered questionnaire was utilized to
design and embedding of a nursing staff estimation model to sup- collect data, which might be prone to bias. Thus, the results need to
port the proper distribution of nurses (Tabatabaee, Vafaee-Najar, be interpreted with caution. Further research is essential to deter-
Amiresmaili, & Nekoie-Moghadam, 2017). mine the effects of care, which was excluded, and the respective
Shortage of facilities can result in the missed care. Whilst the negative outcome on patients, especially the satisfaction levels and
impact of seasonal variation on patient load is recognized in the shift the readmissions.
planning, it is the unplanned and unpredictable circumstances that
need attention (Blackman et al., 2015). Managers in the educational
and clinical sectors must consider staffing resources and how initia- 5 | I M PLI C ATI O N S FO R N U R S I N G
tives might be developed to support educating qualified candidates. M A N AG E M E NT
Job descriptions for nurses should be clearly defined. A proper esti-
mation model for staffing in hospitals can support the proper distri- Nursing managers should develop an adequate discharge planning
bution of nursing professionals according to need. system. Such a system will address the adequacy of resources, and
The current study also found that the likelihood of missed nurs- take into account the readiness of patients for discharge, proper
ing care is higher in male nurses and was positively associated with discharge planning, adequate communication between hospitals
the age and number of patients a nurse is caring for. Another study and nurses, post-discharge and follow-up, all of which are central
also found that being male is a main predictor in medication errors to effective nursing service delivery (Gholizadeh, Janati, Delgoshaei,
(Fathi et al., 2017). The higher frequency of omission error among Gorji, & Tourani, 2018). Involving patients in decision-making puts
male nurses in the current study may be due to the low income in the patient at the heart of patient safety and may support a reduc-
Iran. Because many male nurses have a second job in other sec- tion in forgotten care.
tors to supplement their income, this can cause excess fatigue and Health care systems need to recognize that nurses must balance
exhaustion leading to higher rates of missed nursing care (Russo, the services they provide with their values. Having a trusting rela-
Fronteira, Jesus, & Buchan, 2018). tionship with the patient is an important factor helping nurses to
CHEGINI et al. | 9

determine a patient's needs and to provide adequate care and emo- Healthcare Quarterly, 15(4), 63–69. https://doi.org/10.12927​/
hcq.2012.23193
tional support (Cecil & Glass, 2015). The importance of providing
Adib Hajbagari, M., & Zare, M. (2017). The barriers to patient education
training to nurses based on patients’ needs has also been highlighted from the viewpoint of nurses in Iran: A systematic review. Journal of
(Molazem & Ghadakpour, 2013). Urmia Nursing And Midwifery Faculty, 15(7), 544–558.
Solutions such as optimizing the work environment, increased Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R.,
McKee, M., … Kutney-Lee, A. (2012). Patient safety, satisfaction,
recruitment opportunities for nurses, and maximizing their rights
and quality of hospital care: Cross sectional surveys of nurses and
and benefit package have been suggested as ways to overcome the patients in 12 countries in Europe and the United States. BMJ, 344,
shortage of nursing staff. Furthermore, there is a need for the gov- e1717. https://doi.org/10.1136/bmj.e1717
ernment and hospitals to advance the working environment by si- Ausserhofer, D., Zander, B., Busse, R., Schubert, M., De Geest, S.,
multaneously increasing financial investment and the availability of Rafferty, A. M., … Schwendimann, R. (2014). Prevalence, patterns
and predictors of nursing care left undone in European hospitals:
support programmes for nurses. Managers should also have a vision
Results from the multicountry cross-sectional RN4CAST study. BMJ
to improve the work environment so as to minimize nurses’ non-rel- Quality & Safety, 23(2), 126–135. https://doi.org/10.1136/bmjqs​
evant responsibilities, and support a reduction in the incidence of -2013-002318
missed nursing care. Ball, J. E., Griffiths, P., Rafferty, A. M., Lindqvist, R., Murrells, T., &
Tishelman, C. (2016). A cross-sectional study of ‘care left undone’ on
nursing shifts in hospitals. Journal of Advanced Nursing, 72(9), 2086–
2097. https://doi.org/10.1111/jan.12976
6 | CO N C LU S I O N Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2014).
‘Care left undone’ during nursing shifts: Associations with workload
and perceived quality of care. BMJ Quality & Safety, 23(2), 116–125.
The findings of our study show that missed care is common among
https://doi.org/10.1136/bmjqs​-2012-001767
nurses. The most frequently missed activities reported by Iranian Blackman, I., Henderson, J., Willis, E., Hamilton, P., Toffoli, L., Verrall, C.,
nurses were ‘patient discharge planning and teaching’, ‘emotional … Harvey, C. (2015). Factors influencing why nursing care is missed.
support to patient and/or family’ and ‘attend interdisciplinary care Journal of Clinical Nursing, 24(1–2), 47–56. https://doi.org/10.1111/
jocn.12688
conferences whenever held’. Additionally, limitations associated
Blackman, I., Papastavrou, E., Palese, A., Vryonides, S., Henderson, J.,
with ‘human resources’ were seen as the most important reason for & Willis, E. (2018). Predicting variations to missed nursing care: a
missing care. three-nation comparison. Journal of Nursing Management, 26(1), 33–
Demographic and organisational factors such as age, gender, the 41. https://doi.org/10.1111/jonm.12514
Boostani, K., Noshad, H., Farnood, F., Rezaee, H., Teimouri, S., Entezari-
number of patients under a nurse's care, the number of patients dis-
Maleki, T., … Gharekhani, A. (2019). Detection and management of
charged and job satisfaction were identified as significant factors in common medication errors in internal medicine wards: Impact on
the occurrences of missed nursing care. Given these findings, hos- medication costs and patient care. Advanced Pharmaceutical Bulletin,
pital managers should pay particular attention to the omission of 9(1), 174–179. https://doi.org/10.15171​/apb.2019.020
care and factors associated with missed care. Further studies on the Cecil, P., & Glass, N. (2015). An exploration of emotional protection and
regulation in nurse–patient interactions: The role of the professional
effects of missing nursing care and of strategies to address this are
face and the emotional mirror. Collegian, 22(4), 377–385. https://doi.
needed. org/10.1016/j.colegn.2014.06.002
Chaghari, M., Saffari, M., Ebadi, A., & Ameryoun, A. (2017). Empowering
AC K N OW L E D G E M E N T S education: A new model for in-service training of nursing staff.
Journal of Advances in Medical Education & Professionalism, 5(1), 26.
The authors would like to thank Dr. Lizzie Abderrahim of the
Chalco, K., Wu, D. Y., Mestanza, L., Muñoz, M., Llaro, K., Guerra, D., …
Universitat Rovira i Virgili, Tarragona, Spain, for her assistance Sapag, R. (2006). Nurses as providers of emotional support to pa-
in editing this manuscript. Special thanks are extended to all the tients with MDR-TB. International Nursing Review, 53(4), 253–260.
nurse participants and to Dr. Edris Kakemam for his insightful sug- https://doi.org/10.1111/j.1466-7657.2006.00490.x
Chegini, Z. (2019). Occupational stress among critical care nurses: A
gestions and a careful reading of the manuscript to improve its
comparative study of public and private sector. Iranian Journal of
quality. Nursing and Midwifery Research, 24(4), 306. https://doi.org/10.4103/
ijnmr.IJNMR_218_18
ORCID Chegini, Z., Asghari Jafarabadi, M., & Kakemam, E. (2019). Occupational
stress, quality of working life and turnover intention amongst nurses.
Zahra Chegini https://orcid.org/0000-0001-9125-9453
Nursing in Critical Care, 24(5), 283–289. https://doi.org/10.1111/
Tohid Jafari-Koshki https://orcid.org/0000-0002-6928-1387 nicc.12419
Marzieh Kheiri https://orcid.org/0000-0001-7032-4666 Chegini, Z., Janati, A., Babaie, J., & Pouraghaei, M. (2019). The role of pa-
Sheikh Mohammed Shariful Islam https://orcid. tients in the delivery of safe care in hospital: Study protocol. Journal
of Advanced Nursing, 75(9), 1–9. https://doi.org/10.1111/jan.14045
org/0000-0001-7926-9368
Chegini, Z., Janati, A., Babaie, J., & Pouraghaei, M. (2020). Exploring the
barriers to patient engagement in the delivery of safe care in Iranian
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