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International Journal of Nursing Studies Advances logoLink to International Journal of Nursing Studies Advances
. 2024 Mar 27;6:100196. doi: 10.1016/j.ijnsa.2024.100196

Prevalence of missed nursing care and its association with work experience: A cross-sectional survey

Hanne Mainz a,b,⁎, Randi Tei c, Karen Vestergaard Andersen a, Marianne Lisby a, Merete Gregersen d
PMCID: PMC11080405  PMID: 38746807

Abstract

Background

Nurses faced with multiple demands in hospitals are often compelled to prioritize nursing care. Knowledge of missed nursing care provides insight into whether necessary nursing care is delivered, what is missed, and the reasons for missed nursing care. This insight is essential to support evidence-based policy and practice to improve patient care, enhance nursing practice, and optimize the work environment. Research on factors influencing missed nursing care is imperative to implement targeted strategies. However, studies investigating work experience as a predictor are inconclusive, and no identified studies have examined how nurses’ work experience is associated with different elements of missed nursing care.

Objectives

To investigate the prevalence and reasons for missed nursing care and whether nurses' work experience was associated with missed nursing care.

Design

The design was cross‐sectional, using the Danish version of the MISSCARE survey.

Setting

The study was conducted at a public Danish university hospital with 1,150 beds and approximately 10,350 employees.

Participants

Across 34 surgical, medical, and mixed bed wards for adults, 1,241 nurses were invited by email to respond anonymously to the Danish MISSCARE survey. Of these nurses, 50.3% responded, and 42.6% fully completed the questionnaire.

Methods

A total score mean and a mean score were calculated and then compared between experience (≤5 years/>5 years) in a linear regression model adjusting for unequally distributed variables.

Results

More than two thirds of the nurses reported that emotional support, patient bathing, ambulation, mouth care, interdisciplinary conferences, documentation, and assessing effectiveness of medication were frequently missed elements of nursing care. The most significant reasons for missed nursing care were an inadequate number of nurses, an unexpected rise in patient volume, urgent patient situations, heavy admission, and discharge activity. Nurses with work experience of less than 5 years reported more missed nursing care, especially within fundamental care.

Conclusions

Nursing elements to avoid potentially critical situations and nursing related to treatment observations were rarely missed, while nursing care elements visible only to the patient and the nurse were most often missed. By increasing transparency and explicitness within nursing care, the results enable critical evaluation of prioritization of nursing care elements. The number of staff not balancing the number and acuity of patients was the main reason for missed nursing care. The perception of missed nursing care was most pronounced in less experienced nurses. The study contributes to the global research community to achieve a broader understanding of missed nursing care.

Tweetable abstract

Nursing to avoid potentially critical situations and treatment observations are prioritized over fundamental care, perceived mainly by less experienced nurses.

Keywords: Nursing Care; Nursing Staff, Hospital; Workload, Job Performance, Workforce, Work Experiences, Nurse Management, Nursing Shortage, Personnel Staffing and Scheduling

What is already known about the topic.

  • •

    The MISSCARE survey is a validated and used questionnaire that examines nurses' perceptions of the prevalence and reasons for missed nursing care.

  • •

    Missed nursing care leads to adverse events such as medication errors, nosocomial pneumonia, and decreased patient satisfaction.

  • •

    Several factors are associated with missed nursing care, such as day shifts, absenteeism, workload, and patient load.

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What this paper adds.

  • •

    When nurses need to prioritize necessary nursing, potentially critical situations and treatment observations are less likely to be missed compared with more invisible fundamental nursing care elements.

  • •

    Staffing levels not balancing the number and acuity of patients was the primary reason for missed nursing care.

  • •

    Nurses with shorter work experience reported a higher frequency of missed nursing care, particularly within the fundamental nursing care elements, compared to their more experienced colleagues.

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1. Background

Nurses faced with multiple demands under time pressure are often compelled to prioritize which nursing elements to provide and which to omit (Hessels et al., 2019; Kalisch et al., 2009). Missed nursing care refers to any necessary aspects of required care that are missed either in part or in whole or delayed (Kalisch et al., 2009). In a review including 42 quantitative studies, nurses in hospitals reported leaving an average of at least one task unfinished per nurse per shift (Jones et al., 2015). Studies on missed nursing care provide critical knowledge about what does and does not occur at the point of delivering nursing care. When required nursing care is missed, care quality and patient safety are compromised (Blegen et al., 2001; Hessels et al., 2019). Missed nursing care is related to adverse events, such as medication errors, nosocomial pneumonia, and decreased patient satisfaction (Ausserhofer et al., 2013; Baker et al., 2019; Chaboyer et al., 2021; Lake et al., 2016; Plevová et al., 2021). In Denmark, healthcare performance data are followed from various registries. However, data on provided nursing care are monitored only to a very limited extent (Mainz et al., 2023). Therefore, insight into missed nursing care is essential for nurses, nurse managers, and healthcare decision-makers to ensure patients receive the necessary nursing care.

Several tools have been developed to measure missed nursing care, mainly in hospitals (Jones et al., 2015). The MISSCARE survey developed by Kalisch and Williams (2009) has been designed to address the prevalence and reasons for missed nursing care. The questionnaire is widely used (Palese et al., 2021). It can provide insights into nursing care in Denmark that will contribute to the global research community to achieve a broader understanding of the phenomenon.

In studies using the MISSCARE survey, nurses generally report that the most frequently missed element is fundamental nursing care (Du et al., 2020; Nahasaram et al., 2021), such as ambulation (Gurková et al., 2021; Hammad et al., 2021; Jarošová et al., 2021; Kalisch et al., 2009; Lee and Kalisch, 2021; Nahasaram et al., 2021; Plevová et al., 2021; von Vogelsang et al., 2021), emotional support to patients and families (Chegini et al., 2020; Gurková et al., 2021; Jarošová et al., 2021; Plevová et al., 2021), turning patients (Kalisch et al., 2009; Lee and Kalisch, 2021; von Vogelsang et al., 2021), mouth care (Hammad et al., 2021; Jarošová et al., 2021; Kalisch et al., 2009; Lee and Kalisch, 2021), assessing the effectiveness of medications (Kalisch et al., 2009; von Vogelsang et al., 2021), and teaching patients (Kalisch et al., 2009; Nahasaram et al., 2021). The reasons for missed nursing care differ between countries; however, the most reported is a nursing shortage (Chiappinotto et al., 2022; Du et al., 2020; Lee and Kalisch, 2021).

Predictors associated with missed nursing care are working day shifts, absenteeism (Kalisch et al., 2011a), workload (Bragadóttir et al., 2020), patient load (Ball et al., 2014), educational level (Kalisch et al., 2011a), practice environment (Chiappinotto et al., 2022), and job satisfaction (Bragadóttir et al., 2017). Age also influences whether nursing care is provided (Bragadóttir et al., 2017; Kalisch et al., 2011a). In Iceland, nurses younger than 35 years reported more missed nursing care than nurses 45 years or older (Bragadóttir et al., 2017). Also, in Italy, younger nurses with a median year of 28 reported missed nursing care most frequently (Campagna et al., 2022). As younger nurses, by default, have shorter work experience in their roles, there may be a relation between shorter work experience in roles and missed nursing care. This could be the explanation for the fact that younger nurses more often consider leaving the profession (Heinen et al., 2013). In a study from the United States (US), 26% of newly graduated registered nurses left their first nursing job, and 2% left the nursing profession within the first 2 years of their career (Kovner and Djukic, 2009). This challenge contributes negatively to the global nursing shortage, which has become a huge problem in recent years (Buchan and Catton, 2023).

Therefore, an in-depth investigation of the association between work experience in role and missed nursing care is needed. Only a few studies have examined this potential association. Some researchers demonstrated that nurses with more work experience reported more missed nursing care (Aydin et al., 2015; Blegen et al., 2001; Castner et al., 2015; Kalisch et al., 2011a; Palese et al., 2015; Phelan et al., 2018), while other researchers did not find any association (Al‐Faouri et al., 2021; Danielis et al., 2021; Kalisch et al., 2011a). In investigating the association between work experience and missed nursing care, Kalisch et al. (2011a) used the median cut-off value of 5 years of experience in role as the division to compare more or less experience in the nurses’ perception of missed nursing care. Phelan et al. (2018) the same 5-year cut-off value in their study of missed nursing care among community nurses.

The researchers mentioned above have examined correlations or associations with the average amount of missed care or the mean score of all 24 nursing care elements in the MISSCARE survey. Until now, no researchers have examined how nurses perceive each of the 24 different nursing care elements in the MISSCARE survey according to nurses’ work experience in their roles. Therefore, in a Danish university hospital, we aimed to investigate the prevalence of missed nursing care, the reasons for missed nursing care and whether work experience of 5 years or less was associated with missed nursing care within the different care elements.

2. Methods

2.1. Design, setting, and respondents

The cross-sectional design used the MISSCARE survey (Kalisch et al., 2009). The study was conducted at a public university hospital in Denmark with 1150 beds and approximately 10,350 employees, whose healthcare system follows the Beveridge model (Wallace, 2013). All educated, authorized nursing staff (referred to as nurses) employed across 34 surgical, medical, and mixed surgical-medical adult bed wards were invited to participate in the survey. Nurse managers, staff on leave, nursing substitutes, students, and nurses without direct patient care were excluded. The nurses received the questionnaire by their working e-mail in November and December 2020.

2.2. MISSCARE survey

The questionnaire MISSCARE survey for hospital nurses was chosen to measure the nurses’ perceptions of missed nursing care (Kalisch, 2006; Kalisch and Williams, 2009). The survey was translated and validated in a Danish context in a previous study, including 11 cognitive interviews and a psychometric test. The questionnaire was useful in a Danish context, showing acceptable psychometric values with an overall Cronbach's alpha of 0.81 (Lisby et al., 2023). The survey included a background section asking for general information about the respondents and their ward, followed by sections A and B. Section A involved 24 nursing care elements, such as ambulation, turning, discharge planning, emotional support, documentation, and surveillance. Nurses were asked to answer how frequently, in general, elements of nursing care were missed. A specific time frame was not used for the questions. A 'not applicable' response option was added to each nursing care element approved by the developer, Beatrice Kalisch (Lisby et al., 2023). The respondents were asked to assess how frequently each element of nursing care was missed on a Likert scale with the scores: 1=never/rarely missed, 2=occasionally missed, 3=frequently missed, and 4=always missed'. The non-applicable option had a score of 1 because it would not be missed if it was not a maintenance nursing task in the ward. Section B investigates 17 reasons for missed nursing care in three dimensions: Communication, Material resources, and Labour resources. The reasons for missed nursing care were assessed on a Likert scale with the scores: 1=not a reason, 2=minor reason, 3=moderate reason, and 4=significant reason. A higher score represents a higher perception of missed nursing care in Section A and a more frequent reason for its occurrence in Section B.

2.3. Data collection

The survey was transformed into an online questionnaire built in REDCap (a web application for creating and managing surveys) (Harris et al., 2009). It was pretested by 12 nurses from the target group resulting in only minor layout changes (Lisby et al., 2023). Next, all eligible nurses were informed of the survey by their nurse managers and invited by their work e-mail to respond anonymously. In the invitation, they received an automatically-created REDCap link to the survey. To prevent multi-participation, the nurses could answer the questionnaire only once. A brief description of the study was posted on the hospital intranet before data collection. The research group visited all wards to deliver postcards about the survey to remind the nurses to respond to the questionnaire and to encourage the nurse managers to remind the nurses to open their work e-mail. Three e-mail reminders were sent to the eligible respondents during the study period.

2.4. Data analysis

Incomplete questionnaires were excluded from our analysis. Therefore, multiple imputations were not performed. We described the prevalence of missed nursing care elements from Section A in two ways. First, we calculated the percentage of each element based on the categories: 'always missed', 'frequently missed', 'occasionally missed', 'never missed', 'rarely missed', and 'not applicable'. Secondly, we dichotomized the answers; missed nursing care was defined as 'always missed', 'frequently missed', or 'occasionally missed'. No missed care was defined as 'rarely missed', 'never missed', or 'not applicable'.

In Section B, the prevalence of reasons for each of the missed nursing care elements was described. Further, we dichotomized the reasons: a reason for missed nursing care was defined as a 'significant or moderate reason', and no reason was defined as a 'minor reason' or 'not a reason'. The five-categoric variable on work experience in the role was dichotomized as shorter experience, including 'up to 6 months', 'greater than 6 months to 2 years' and 'greater than 2 years to 5 years; and longer experience, including 'greater than 5 years to 10 years' and 'greater than 10 years'. The baseline characteristics of the work experience groups were compared by Chi-squared test or Fisher's exact test, as appropriate, according to each of the 24 dichotomized nursing care elements in Section A. In a logistic regression model, we compared the dichotomized answers of each care element in the two groups of work experience and adjusted for unequally distributed variables of the baseline characteristics with a p-value < 0.05. We evaluated the area under the receiver operating characteristic curve to check the model for the current estimation results.

Furthermore, to compare with similar studies, we calculated a total score presented with a Standard Deviation (SD) by adding the mean scores of the 24 nursing care elements measured on a 4-point Likert scale. The total score interval ranged from 24 to 96 points. Also, a mean score of the total score was calculated by dividing the total score by 24, the number of the nursing care elements. The mean score interval ranged from 1 to 4. A higher score indicated a higher level of missed nursing care. A linear regression model compared the total score and the mean scores for each of the two groups of shorter- and longer work experience. The regression model used the robust cluster method to account for clustering responses within the wards. In the model, we adjusted for unequally distributed variables of the baseline characteristics with a p-value < 0.05. The models were checked by normal probability plots of the standardized residuals and scatter plots of the residuals versus predicted values.

A p-value < 0.05 was considered statistically significant. Data analysis was conducted in Stata version 17 (StataCorp LLC, College Station, TX).

2.5. Ethical considerations

The study was approved by the board of directors at the university hospital. According to Danish law on health science questionnaire surveys Law § Section 14, subsection 2 (The Danish National Committee on Health Research Ethics, 2018), approval by the Ethical Committee in Central Denmark Region was not required, as the survey was answered anonymously. The study was performed in line with the principles of the Helsinki Declaration ll (World Medical Association, 2018). The authors obtained written permission from head nurses and nurse managers to forward the questionnaire to nurses at the involved wards. The nurses were informed about the survey and that answering the questionnaire was voluntary. Answering and returning the questionnaire was considered informed consent to participate in this study. The respondents were allowed to answer the questionnaire during working hours.

3. Results

In total, 1241 nurses fulfilled the inclusion criteria and received the questionnaire. The response rate was 50.3%, with 529 respondents (42.6%) completing all sections. (Flow diagram is included in Supplementary Material).

Table 1 shows the characteristics of all nurses and a distribution according to work experience. Most were females, between 25 and 34 years old, and registered nurses. Slightly more than half of all nurses had more than 5 years of work experience. Most respondents had rotating working hours with frequent overtime, a low number of missed days at work, and satisfaction with being a nurse.

Table 1.

Characteristics of the respondents of MISSCARE survey.

Characteristics All respondents N = 529 Experience ≤ 5 years n = 247 Experience > 5 years n = 282 p-value
Gender, n (%)
 Males 14 (3) 6 (2) 8 (3) 0.49
 Females 510 (96) 239 (97) 271 (96)
 No response 5 (1) 2 (1) 3 (1)
Age groups, n (%)
 < 25 years 14 (3) 14 (6) 0 (0) <0.001
 25–34 260 (49) 211 (85) 49 (17)
 35–44 113 (21) 18 (7) 95 (34)
 45–54 78 (15) 3 (1) 75 (27)
 55–64 55 (10) 1 (1) 54 (19)
 65+ 9 (2) 0 (0) 9 (3)
 No response 0 (0) 0 (0) 0 (0)
Wards, n (%)
 Surgical 209 (40) 92 (37) 117 (42) 0.005
 Medical 245 (46) 107 (43) 138 (49)
 Mixed 73 (14) 47 (19) 26 (9)
 No response 2 (0) 1 (1) 1 (0)
Role, n (%)
 Practical nurse 2 (1) 0 (0) 2 (1) <0.001
 Nursing assistant 40 (7) 3 (1) 37 (13)
 Registered nurse 479 (90) 243 (98) 236 (84)
 No response 8 (2) 1 (1) 7 (2)
Highest educational degree, n (%)
 PN diploma 1 (0) 0 (0) 1 (0) <0.001
 NA diploma 39 (8) 3 (1) 36 (13)
 RN diploma 95 (18) 5 (2) 90 (32)
 Bachelor's degree in nursing 357 (68) 233 (94) 124 (44)
 Bachelor's degree outside nursing 12 (2) 3 (1) 9 (3)
 Master's degree or higher in nursing 17 (3) 2 (1) 15 (6)
 Master's degree or higher outside nursing 6 (1) 0 (0) 6 (2)
 No response 2 (0) 1 (1) 1 (0)
Work experience in role, n (%)
 < 6 months 30 (6) 30 (12) 0 (0) <0.001
 6 months to 2 years 97 (18) 97 (39) 0 (0)
 > 2 years to 5 years 120 (23) 120 (49) 0 (0)
 > 5 years to 10 years 72 (13) 0 (0) 72 (26)
 > 10 years 210 (40) 0 (0) 210 (74)
 No response 0 (0) 0 (0) 0 (0)
Work hours, n (%)
 Day 140 (26) 37 (15) 103 (36) <0.001
 Evening 37 (7) 9 (4) 28 (10)
 Night 7 (1) 0 (0) 7 (2)
 Rotating shift 339 (65) 198 (80) 141 (51)
 No response 6 (1) 3 (1) 3 (1)
Hours of overtime within the past 3 months, n (%)
 None 29 (6) 12 (5) 17 (6) 0.52
 1–12 389 (74) 182 (74) 207 (74)
 > 12 96 (18) 50 (20) 46 (16)
 No response 15 (2) 3 (1) 12 (4)
Days of missed work due to illness, injury within the past 3 months, n (%)
 None 227 (43) 100 (40) 127 (45) 0.46
 1 day 92 (17) 42 (17) 50 (18)
 2–3 days 126 (24) 60 (24) 66 (24)
 4–6 days 33 (6) 19 (8) 14 (5)
 > 6 days 47 (9) 26 (11) 21 (7)
 No response 4 (1) 0 (0) 4 (1)
Satisfied being a nurse, n (%)
 Yes 385 (72) 173 (70) 212 (75) 0.32
 Neutral 105 (20) 57 (23) 48 (17)
 No 36 (7) 17 (7) 19 (7)
 No response 3 (1) 0 (0) 3 (1)
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∼p-value: comparison between groups of respondents with experience ≤ 5 years and > 5 years. Bold font refers to statistical significance (p < 0.05).

'A reason' for missed nursing care was defined as a significant or moderate reason. 'Not a reason' was defined as a minor reason or not a reason. Population size (N). Sample size (n).

In Fig. 1, the prevalence of missed nursing care was ranked for each nursing care element, with the most frequently missed nursing care at the top (76%) and the least frequently missed at the bottom (10%). More than two thirds of the nurses reported missed nursing care in the following elements: emotional support, patient bathing, ambulation, attending interdisciplinary care conferences, assessment of medications, documentation, and mouth care. The most performed nursing care reported by two thirds of the nurses were the following patient assessment, hand washing, setting up for meals, reassessments according to patient condition, vital signs assessment, glucose monitoring, and patient discharge planning.

Fig. 1.

Fig. 1

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Ranked percentage of perceived missed nursing care for each element of nursing care showed as percentage for dichotomized answers and the percentage for each answer category.

Missed nursing care was defined as an answer of always, frequently, or occasionally missed (N = 529). *PRN: pro re nata (as needed).

In Fig. 2, the ranking of reasons for missed nursing care is presented, with the most frequent reason for missed nursing care at the top (86%) and the least perceived reason at the bottom (7%). Two thirds of the nurses assessed the inadequate number of staff, unexpected rise in patient volume or acuity, heavy admission and discharge activity, and urgent patient situations as the most frequent reasons for missed nursing care. The less frequent reasons for missed nursing care were communication breakdowns and lack of support within the nursing team, communication breakdowns with support departments, and equipment not functioning correctly.

Fig. 2.

Fig. 2

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Ranked percentage of perceived reasons for missed nursing care showed as the percentage for dichotomized answers and the percentage for each answer category.

The dichotomized answers were defined as 'a reason' (significant or moderate reason) and 'not a reason' (minor or not a reason) (N=529),

In Table 2, the perception of missed elements of nursing care was compared between nurses with shorter experience (47% of all nurses) and nurses with longer experience (53% of all nurses).

Table 2.

Elements of perceived missed nursing care related to work experience in role reported by 529 responders.

Missed nursing care Experience ≤ 5 years n = 247 n (%) Experience > 5 years n = 282 n (%) Odds Ratio∼(95% CI) p-value
Ambulation three times per day or as ordered (n = 528) 187 (76) 194 (62) 1.56 (1.02–2.38) 0.04
Turning patients every 2 h (n = 527) 171 (69) 158 (57) 1.97 (1.33–2.92 0.001
Feeding patient when the food is still warm (n = 525) 126 (52) 120 (43) 1.58 (1.09–2.30) 0.02
Setting up meals for patient who feeds themselves (n = 527) 50 (20) 66 (23) 0.75 (0.48–1.18) 0.21
Medications administered within 60 min before or after scheduled time (n = 526) 113 (46) 114 (41) 1.18 (0.81–1.72) 0.39
Vital signs assessed as ordered (n = 525) 57 (23) 81 (29) 0.73 (0.48–1.12) 0.15
Monitoring intake/output (n = 522) 146 (60) 176 (63) 0.79 (0.54–1.17) 0.25
Full documentation of all necessary data (n = 526) 171 (70) 189 (68) 1.07 (0.71–1.62) 0.75
Patient teaching about illness, tests, and diagnostic studies (n = 523) 167 (68) 181 (66) 0.98 (0.66–1.47) 0.93
Emotional support to patient and/or family (n = 527) 200 (81) 202 (72) 1.53 (0.97–2.41) 0.07
Patient bathing (n = 523) 199 (81) 199 (71) 2.01 (1.28–3.14) 0.002
Mouth care (n = 525) 186 (75) 172 (62) 1.79 (1.19–2.70) 0.005
Hand washing (staff) (n = 527) 34 (14) 34 (12) 1.05 (0.61–1.81) 0.85
Patient discharge planning (n = 522) 101 (42) 120 (43) 0.95 (0.64–1.39) 0.80
Bedside glucose monitoring as ordered (n = 519) 66 (27) 81 (29) 0.81 (0.53–1.23) 0.32
Patient assessments performed each shift (n = 524) 21 (9) 29 (10) 0.89 (0.46–1.70) 0.74
Focused reassessments according to patient condition (n = 523) 54 (22) 70 (25) 0.89 (0.57–1.39) 0.61
Intravenous/central line site care and assessments according to hospital policy (n = 526) 154 (63) 164 (59) 1.06 (0.72–1.56) 0.79
Response to call light is initiated within 5 min (n = 526) 148 (60) 129 (46) 1.86 (1.27–2.74) 0.001
PRN* medication requests acted on within 15 min (n = 525) 107 (43) 105 (38) 1.28 (0.88–1.87) 0.21
Assess effectiveness of medications (n = 524) 185 (75) 174 (63) 1.82 (1.21–2.76) 0.004
Attend interdisciplinary care conferences whenever held (n = 522) 171 (69) 198 (72) 0.97 (0.64–1.46) 0.87
Assist with toileting needs within 5 min of request (n = 527) 159 (64) 141 (50) 1.69 (1.16–2.48) 0.007
Wound care (n = 527) 139 (56) 119 (43) 1.72 (1.18–2.51) 0.005
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∼

Adjustment for type of ward, role and work hours.

⁎

PRN: pro re nata (as needed)

Bold font refers to statistical significance (p < 0.05). Population size (N). Sample size (n).

Comparing the perceived missed nursing care elements between nurses with shorter and longer experience, nurses with 5 years experience or less reported more missed nursing care of the care elements: emotional support, bathing, assessment of medication effect, mouth care, turning patients, assisting toileting, responding to calls, and wound care (Table 2).

The total score of missed nursing care was highest in the nurses with shorter experience (Table 3). When the total score was adjusted for the unequally distributed independent variables, ward, role, and work hours (Table 1), the difference in the total score remained statistically significant between the groups of experience (Table 3).

Table 3.

Total score of the MISSCARE survey and mean score of the total score related to experience in role estimated by the coefficient in a linear regression model.

Missed nursing care All respondents N = 529 Experience ≤ 5 years n = 247 Experience > 5 years n = 282 Unadjusted coefficient (95% CI) Adjusted* coefficient (95% CI)
Total score (SD) 41.1 (9.9) 42.3 (9.7) 39.8 (10.0) 2.65 (0.77–4.53)
p = 0.006		 2.70 (0.63–4.77)
p = 0.011
Mean score (SD) 1.71 (0.41) 1.76 (0.40) 1.66 (0.42) 0.11 (0.03–0.19)
p = 0.006		 0.11 (0.03–0.20)
p = 0.011
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⁎

Adjusted for type of ward, role, and work hours.

Population size (N). Sample size (n). Standard Deviation (SD). Confidence Interval (CI).

4. Discussion

In this present MISSCARE survey, the prevalence of different missed nursing care elements ranged from 10% to 76%. More than two thirds of nurses reported that emotional support, patient bathing, ambulation, mouth care, interdisciplinary conferences, documentation, and assessing the effectiveness of medications were the most frequently missed elements of nursing care. The most significant reasons for missed nursing care were inadequate staffing, unexpected rise in patient volume, heavy admission or discharge activity, and urgent patient situations. Nurses with less work experience reported more missed nursing care compared to the perception of their more experienced colleagues.

4.1. Comparing the missed nursing care score internationally

When comparing the results to other countries, nurses in the US, Australia, and Iceland reported missed nursing care less often, with a total score between 30.4 and 36.6 compared to 41.1 at our hospital (Bragadóttir et al., 2020). On the contrary, nurses in Turkey reported a total score as high as 52.6 (Bragadóttir et al., 2020). Variations in the healthcare systems might explain the differences, and the time of collecting data should also be considered. The increasing global shortage of nurses and the recent difficulties recruiting and retaining nurses, combined with more complex older patients, shorter admissions, and limited economic conditions, (Health Pharma Medtech, 2021) might have influenced the extent of missed nursing care. As no follow-up studies of missed nursing care have been identified, more studies are needed to highlight the changes in missed nursing care over time.

The most frequently reported elements of missed nursing care were emotional support, patient bathing, ambulation, mouth care, attending interdisciplinary conferences, assessing medication effectiveness, and documentation. These results are comparable with the international studies; however, patient bathing was more frequently missed in our study than generally observed in other studies (Gurková et al., 2021; Hammad et al., 2021; Jarošová et al., 2021; Kalisch et al., 2009; Lee and Kalisch, 2021; Nahasaram et al., 2021; Plevová et al., 2021; von Vogelsang et al., 2021). It might be explained by a different understanding of the word 'bathing'. In the Danish language; bathing is generally understood as showering the patient rather than personal hygiene performed in bed. As some patients cannot safely leave their beds to bathe, it may explain why bathing is a highly-reported missed nursing care element in Denmark. Despite a thorough validation and test of the Danish translation, "To assist with personal hygiene” would be a more accurate translation of bathing in a Danish context.

Consistent with other studies, the least missed nursing care elements were generally related to treatment observations like assessments each shift, reassessment, vital signs, and glucose monitoring, which could be critical to patient safety and potentially life-threatening (Gurková et al., 2021; Hammad et al., 2021; Jarošová et al., 2021; Kalisch et al., 2009; Lee and Kalisch, 2021; Nahasaram et al., 2021; Plevová et al., 2021; von Vogelsang et al., 2021). However, the less-prioritized fundamental nursing care elements may have similar consequences for patients and be life-threatening in the long run; e.g., lack of ambulation and assuring the effectiveness of the medicine. Furthermore, the most often missed nursing care elements included nursing care that is usually invisible to anyone other than the patient and the nurse, such as emotional care for the patient and family, hygiene, mouth care, and teaching the patient. These nursing care elements are generally challenging to monitor, but in the MISSCARE survey, it is possible to gain knowledge of these more invisible elements of nursing care. However, qualitative studies are needed to shed light on what underlies the nurses' priorities.

Hand washing was rarely missed in our survey, compared to other studies. Differences in nurses' perception of missed hand washing might be due to different hospital cultures across countries. However, our results based on data collected shortly after the first wave of the COVID-19 pandemic may reflect the impact of careful prevention of the spread of the virus, which was emphasised during this period. Our findings are consistent with those of Falk et al. (2022), who found that nurses' perceptions of hand washing improved during the Covid-19 pandemic.

4.2. Reasons for missed nursing care

The most frequently reported reason for missed nursing care was inadequate staffing, which means a need for balancing the number and acuity of the patients. Unplanned critical situations with demanding nursing interventions and heavy admission and discharge activities were reported as frequent reasons for missed nursing care. This is in line with other researchers who found that inadequate labor resources were the most often reported reason for missed nursing care (Griffiths et al., 2018).

4.3. Work experience and perceived missed nursing care

In our study, 53% of the respondents had more than 5 years of work experience. Compared with other Western countries, the work experience in the role was highest in Iceland, with 72% of the responding nurses having 5 years or more of work experience (Bragadóttir et al., 2017). However, the frequencies in other Western countries are mostly between 40% and 61% (Bragadóttir et al., 2020; Kalisch et al., 2011a; von Vogelsang et al., 2021). Our relatively high proportion of nurses with less than 5 years of work experience can be explained by the fact that, in Denmark, nurses often start their careers in medical /surgical wards at hospitals and primarily in rotating shifts.

Nurses with work experience of less than 5 years reported a higher prevalence of missed nursing care than nurses having more work experience. This result differs from other studies, where no difference has been found between experienced and less experienced nurses reporting missed nursing care (Al‐Faouri et al., 2021; Danielis et al., 2021) or that the most experienced nurses reported a higher prevalence of missed nursing care (Blackman et al., 2018; Castner et al., 2015; Kalisch et al., 2011a; Palese et al., 2015). The less experienced nurses responded more frequently that fundamental nursing care elements were missed than the more experienced nurses. It could be explained by the division of tasks, with the experienced nurse undertaking the most complex tasks and the less experienced assigned to fundamental nursing care tasks.

4.4. Strength and limitations

The strength of this study was the data collection from various departments and specialities across a large university hospital. The response rate of 42.6% corresponded to the proportion of respondents who completed the whole questionnaire for the analyses. Our response rate was considered satisfactory when compared to that reported in similar studies, ranging from 23.5% to 69.3% (Bragadóttir et al., 2017; Hübsch et al., 2020; Kalisch et al., 2009; Kalisch et al., 2011b). Like our study, Swedish researchers also sent their survey to nurses' work e-mails. They described that not all nurses opened their e-mails during the workday (von Vogelsang et al., 2021). This may have been a similar explanation in our study.

Several nurses did not complete the questionnaire to the end, possibly due to interruptions while answering. A potential bias in underestimating missed nursing care may occur if the nurses from the most understaffed wards more frequently were non-responders. As the survey was anonymous, we could not perform a sensitivity analysis of the non-responders. Another cause of non-response could be that nurses often react to missed nursing care with great emotion; e.g., embarrassment, anger, sadness, frustration, powerlessness, and guilt (Kalisch et al., 2009). As the study was conducted shortly after the first wave of the COVID-19 pandemic, it could be that the pandemic influenced the situation. However, only a few COVID-19 patients were hospitalized during the data collection period, and the nursing staff did not appear to be particularly burdened by the pandemic.

Missed nursing care studies using the MISSCARE survey are based on the staff's perceptions, not observations of the actual care provided. Furthermore, the nurses are not specifically asked what each nurse left undone during their shift but whether each of the 24 nursing care elements was missed in general in their ward. Consequently, the responses were influenced by the nurses' knowledge and individual beliefs, as well as norms, habits, and the time frame for their assessment (Kalisch et al., 2009). Nevertheless, reviews of missed nursing care indicate that the associations between missed nursing care and several different patient outcomes (e.g., complications such as pneumonia, pressure injury, urinary tract infection, and delirium) seem consistent across different settings and countries (Chaboyer et al., 2021). These associations support the idea that missed nursing care is a valuable and valid predictor of adverse events.

This initial study on missed nursing care in Denmark was conducted in one hospital. More studies are needed to investigate whether our results represent nurses in all Danish hospital settings and whether differences may occur between specialties and hospitals. However, this single study contributes to a broader understanding of missed nursing care in the global research community. It adds credibility to international findings by confirming similar trends related to missed nursing care.

4.5. Implications for nursing

In this study, we provided insight into how nurses prioritize the nursing care elements, described as a significant hidden problem in the healthcare system (Zeleníková et al., 2019). It allows reflecting on and influencing this prioritization. Recognizing that necessary nursing care is not always possible may be an ethical issue for nurses and managers. This issue must be carefully addressed practically among less experienced nurses to prevent low job satisfaction, burnout, or nurses leaving the profession, which could lead to an even more significant nursing shortage. Knowledge about the nurses' perception of reasons for missed nursing care can further be used to develop targeted interventions and strategies. A periodic assessment of the level of missed nursing care elements could gain knowledge about the effect of different interventions.

5. Conclusion

The study contributes to essential knowledge about missed nursing care in a Danish university hospital, with a prevalence of missed nursing care elements ranging from 10% to 76%. We found that this result demonstrates how nurses frequently need to prioritize among necessary nursing elements. Nursing elements to avoid potentially life-threatening situations and nursing related to treatment and observations are perceived as rarely missed. In contrast, nursing care invisible to other than the nurse and patients, such as emotional care, hygiene, and mouth care, is often missed. Nurses with shorter work experience reported more missed nursing care, especially within the fundamental nursing care elements, compared to their more experienced colleagues. The number of staff not balancing the number and acuity of patients was the main reason for missed nursing care. More studies about missed nursing care in Denmark are needed to investigate the different factors associated with it and to highlight the importance of sufficient nursing care to ensure patient safety. The results contribute to the global research community to achieve a broader understanding of missed nursing care.

CRediT authorship contribution statement

Hanne Mainz: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Randi Tei: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Karen Vestergaard Andersen: Writing – review & editing, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Marianne Lisby: Writing – review & editing, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Merete Gregersen: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The study has no conflicts of interest.

Acknowledgments

Funding sources

The research did not receive specific funding but was performed as part of the authors' employment at Aarhus University Hospital in the Central Denmark Region.

Acknowledgement

We are grateful for the support from the hospital nursing directors Inge Pia Christensen and later Susanne Lauth for the opportunity to carry out the study at Aarhus University Hospital. We also thank the chief nurses and nurse managers for motivating the nurses to answer the questionnaire during a busy working day. Finally, we are grateful that the nurses prioritized contributing their perceptions about missed nursing care.

Footnotes

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijnsa.2024.100196.

Appendix. Supplementary materials

mmc1.docx (96.3KB, docx)

Data availability

  • The data underlying this article can be shared on reasonable request to the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

mmc1.docx (96.3KB, docx)

Data Availability Statement

  • The data underlying this article can be shared on reasonable request to the corresponding author.

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