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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: J Nurs Manag. 2021 Nov 26;30(2):447–454. doi: 10.1111/jonm.13501

Nurse Staffing, Missed care, Quality of Care and Adverse Events: A Cross Sectional Study

Apiradee Nantsupawat 1, Lusine Poghosyan 2, Orn-Anong Wichaikhum 1, Wipada Kunaviktikul 3, Yaxuan Fang 1,6, Supakorn Kueakomoldej 2, Hunsa Thienthong 4, Sue Turale 5
PMCID: PMC9017335  NIHMSID: NIHMS1785995  PMID: 34719833

Abstract

Aim:

To illustrate the relationship between nurse staffing and missed care, and how missed care affects quality of care and adverse events in Thai hospitals.

Background:

Quality and safety are major priorities for health care system. Nurse staffing and missed care are associated with low quality of care and adverse events. However, examination of this relationship is limited in Thailand.

Methods:

This cross-sectional study collected data from 1,188 nurses in 5 university hospitals across Thailand. The participants completed questionnaires that assessed the patient-to-nurse ratio, adequacy of staffing, missed care, quality of care, and adverse events. Logistic regression models were used to estimate associations.

Results:

Higher patient-to-nurse ratio, poor staffing, and lack of resource adequacy were significantly associated with higher odds of reporting missed care. Higher nurse-reported missed care was significantly associated with higher odds of adverse events and poor quality of care.

Conclusions:

Poor nurse staffing was associated with missed care and missed care was associated adverse events and lower quality of care in Thai university hospitals.

Implications for Nursing Management:

Improving nurse staffing and assuring adequate resources are recommended to reduce missed care, adverse events, and increase quality of care.

Keywords: Nurse Staffing, Missed Care, Quality of Nursing, Adverse Events, Thailand

1. Background

Safety and quality are foundational components of health care system, which are also used as indicators to measure the quality of care in hospitals (Lam et al.,2018). However, enhancing safety and quality are challenging since they represent a significant burden in many countries (Ball et al., 2018). Strong evidence reveals that nurses play a critical role in ensuring patient safety while providing direct patient care (Malliaris, Phillips, & Bakerjian, 2021). Nurses are frontline health care professionals who are constantly present at the bedside. They bring clinical expertise to monitor patients for deterioration, detect errors and near misses, design care process that protect patient safety, and accomplish the goals of patient safety management. Nurse managers are tasked with the challenge of helping bedside nurses ensure quality patient care and safety and improve hospital quality and performance.

Systematic reviews have demonstrated the association of missed care and patient safety and quality of care (Recio-Saucedo et al., 2018; Zhao et al., 2019; Kalánková et al., 2020). ‘Missed care’ is termed by Kalisch, Landstrom, and Hinshaw (2009) --also called ‘unfinished care’ (Lucero, Lake, & Aiken, 2009) or ‘rationed care” (Schubert, Glass, Clarke, Schaffert-Witvliet, & DeGeest, 2007)--to describe important patient care tasks that are omitted. Missed care reflects nurses’ decision-making processes and the prioritization of care when resources are not sufficient to provide all the needed care to patients. Missed nursing care is an issue worldwide and previous studies in the United States (Campbell et al., 2020), Europe (Eskin Bacaksiz, Alan, Taskiran Eskici, & Gumus, 2020; Senek et al., 2020), Asia (Labrague et al., 2020), and Australia (Henderson, Willis, Xiao, & Blackman, 2017) have shown that large numbers of nurses leave care undone. Further significant international research studies have demonstrated the impact of missed nursing care on patient outcomes, including poor overall quality of care, increased mortality, decreased patient satisfaction, and increased patient adverse events such as medication errors, falls, pressure ulcers, critical incidents, infections, and readmission (Recio-Saucedo et al., 2018; Aiken et al., 2018; Bail et al., 2020; Chaboyer, Harbeck, Lee, & Grealish, 2021).

Reasons for higher levels of missed care can often be traced to organizational factors, such as inadequate staffing levels, and poor work environment, teamwork, and hospital safety climate. Among those factors, nurse staffing and work environment have been explicitly identified as contributing factors to missed care. Empirical evidence documents that poor nurse staffing, staffing and resource inadequacy (Park, Hanchett, & Ma, 2018; Smith, Morin, Wallace, & Lake, 2018; Lee & Kalisch, 2021) and higher patient-to-nurse ratio (Griffiths et al., 2018; Al-Faouri, Obaidat, & AbuAlRub, 2020; Lee & Kalisch, 2021) are associated with increased missed care. A recent longitudinal study by Lake, Riman, & Sloane (2020) found that, with improved work environments and nurse staffing, the prevalence and frequency of missed care decreased significantly.

The conceptual framework to guide the understanding of how nurse staffing is related to missed care, and how missed care is related quality and safety is the missed nursing care model (Kalisch, Landstrom, & Hinshaw, 2009). This framework is based on Donabedian’s model (Donabedian, 1988) that linear conception of quality that structure affect processes, which in turn affects outcomes. The model proposes a direct relationship between nursing staffing, missed care, and outcomes (Lucero, Lake, & Aiken, 2010). The missed nursing care model describes how the structure (e.g., nurse staffing) may influence nursing care processes (e.g., missed care) which potentially impact patient outcomes (e.g., quality of care, adverse events). It is possible that when the number of nurses is limited, there is a heavy workload burden; nurses may not be able to properly carry out tasks that require professional skills, such as training their patients and their family, and lack the time to provide patients with necessary care. This, in turn, may affect the quality of the healthcare service provided at the hospital as illustrated in Figure 1.

FIGURE 1.

FIGURE 1

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Diagram of hypothesized relationships

The public hospitals under the Ministry of Public Health are the main healthcare service providers in Thailand. These hospitals deliver care services for Thai peoples with accessibility, equality, and service excellence. However, nursing shortage is still an issue and data from healthcare facilities show that in order to effectively meet the demand 122,170 nurses are required and there are currently only 98,070 nurses in the system. The hospitals need to recruit an additional 24,100 nurses but turnover rate is around 4.45% among nurses (Sawangdee, 2017). Moreover, on the supply side, 86 nursing schools can produce around 11,000–12,000 nurses per year which may not be enough to meet the demand. Thus, it is necessary to understand how existing nurse staffing affects healthcare quality in Thai hospitals. Such evidence will help hospitals to administer strategies to retain nursing workforce and maintain the quality of care.

While previous studies provide the empirical knowledge that poor nurse staffing is associated with increased missed care, and increase missed care is associated with increased adverse events, little is known about the relationship between nurse staffing and adverse events via missed care in Thailand.

2. Aim

To illustrate the relationship between nurse staffing and missed care, and how missed care affects quality of care and adverse events in Thai university hospitals.

3. Methods

3.1. Study design, sampling method, and setting

This was a cross-sectional study with data collected by paper questionnaires from 43 units in five university hospitals (Nantsupawat et al., 2015). The sample was selected using multi-stage random sampling. First, five university hospitals were selected from five regions across Thailand using simple random sampling. Then, proportional stratified random sampling was used to select 50 nurses from each in-patient hospital’s unit. Inclusion criteria included nurses who provided direct patient care with at least one year of bedside experience. Exclusion criteria included nurses having a managerial position. The questionnaires were distributed to 1,750 nurses and 1,450 nurses returned the questionnaires (82.86% response rate). Total of 1,188 questionnaires were completed (67.89% usable data) and used in this study. Based on the number of study parameters to analysis, a sample size of 1,188 nurses was verified as acceptable.

3.2. Research instrument

Nurse staffing

Patient to Nurse Ratio

Patient to Nurse Ratio was measured based on a question about the nurse-reported number of patients assigned to each nurse. That is, nurses were asked how many patients were assigned to them on their last shift. This question has been previously used in a study in Thailand (Nantsupawat et al., 2011). Nurse responses were calculated as the mean patient load across all registered nurses who reported having responsibility for at least one patient, but fewer than 30 patients, on the last shift they worked.

Staffing and Resource Adequacy

Staffing and Resource Adequacy was measured with The Practice Environment Scale of the Nursing Work Index (PES-NWI) (Lake, 2002). The PES-NWI is a validated instrument often used in international studies to measure the work environment of nurses (Aiken et al., 2011). The subscale had previously been translated into Thai and has been used in previous research (Nantsupawat et al., 2011). Nurses rate each item on a 4-point Likert scale from strongly disagree to strongly agree. (i.e., 1=strongly disagree, 2= somewhat disagree, 3=somewhat agree and 4=strongly agree). For this study, we used the staffing and resource adequacy subscale of the PES-NWI. This subscale measures the adequacy of unit staffing and consist of items such as “I have enough staff to get the work done”, “Enough opportunity to discuss patient care problems with other nurses”, “Adequate support services allow me to spend time with my patients”, and “Enough registered nurses on staff to provide quality patient care. Cronbach’s alpha was 0.85 for the Thai version of the staffing and resource adequacy. Additionally, in this study the staffing and resource adequacy was significantly correlated with the number of patients assigned to nurse (r= −.38; p<.05).

Missed care

Missed care reflects the process of care and was defined as necessary nursing activities that were missed due to a lack of time. Items for this measure were informed by missed care instruments used in USA and European studies (Ausserhofer et al., 2014; Ball et al., 2018). Nurses were asked whether 7 nursing care activities: adequately document nursing care, comfort /talk to patients, develop or update the nursing care plan, prepare patient and family for discharge, educate patients and family, provide oral hygiene, and provide skin care were necessary but left undone because they lacked the time to complete them. Nurses responded on a 4-point Likert scale, and responses were dichotomized into missed care (occasionally and frequently) or not missed care (never and rarely). Missed care frequency was the number of activities missed, which was summed for each nurse and averaged. The items measuring nursing activities were translated into Thai using a back translation process. The Cronbach alpha on the tool in this study was 0.88. We created a global dichotomous missed care indicator for each patient on each shift if a nurse reported missing any of the 7 items during the shift.

Adverse events

Nurse-reported patient adverse events included medication error, infection, fall, patient complaint, and verbal abuse toward nurses (Lucero, Lake, & Aiken, 2010). The 4-point Likert response options were: never, rarely, sometimes, and often. Nurse-reported patient adverse events were categorized as frequent (sometime, and often) and infrequently (never and rarely) to facilitate the interpretation of the results from the logistic regression models. The adverse events were translated into Thai using a back translation process. We calculated the Cronbach alpha which was 0.84.

Quality of care

Nurses rated the overall quality of care provided on their unit using a 4-point scale (poor to excellent). This questionnaire’s reliability has been confirmed with analysis of administrative patient data, showing correlation between nurse report of quality and hospital quality (McHugh & Stimpfel, 2012). The questionnaire was translated and has been used in Thai context (Nantsupawat et al., 2011). The Cronbach alpha value in this study was 0.81. Reponses of poor or fair were classified as poor quality of care and good or excellent as excellent quality of care.

3.3. Data Collection

Data were collected after ethical committee approval from the Faculty of Nursing, Chiang Mai University, Thailand (EXP:016-2014) and from the hospital and nursing directors of the participating hospitals. Questionnaires and informed consent forms were distributed to hospital coordinators via mail and then they distributed the questionnaires to nurses. Nurses returned the completed questionnaires in a sealed envelope to hospital coordinators and completed questionnaires were sent to researchers by mail. The data were de-identified for analysis.

3.4. Data Analysis

Data were cleaned carefully for missing data and checked for normality. We calculated descriptive statistics. Logistic regression models with and without control variables (adjusted and unadjusted) were used to describe how patient-to-nurse ratio and resource adequacy related to missed care. We also used logistic regression to examine whether, and to what extent missed care affected quality of care and adverse patient events. Control variables included nurses’ age, education, years of experience as RN, and unit type which influence outcomes (Audet, Bourgault, & Rochefort, 2018). Analyses were performed using STATA 14.0 (StataCorpLP, College Station, TX, USA).

4. Results

4.1. Prevalence of nurse staffing missed care, quality of care as poor, and adverse events.

The majority (97.4%) of participants were female, with average age of 34 years (SD=0.27). The majority held a bachelor’s degree (87.7%) and the average years of RN experience was 11 (SD=0.25) and average number of years worked in unit was 9 (SD=0.22). The average number of patients per nurse was 8 (SD=0.17). The staffing and resource adequacy subscale had the mean score of approximately 2.40 (SD=0.15). Only 11% of nurses reported that they “adequately document nursing care” and 14–18% of nurses reported that “comforting/talking with patients”, and “developing or updating nursing care plan” were left undone. Around 21–24% of nurses reported that “preparing patient and family for discharge”, “educating patients and family”, and “oral hygiene” were left undone. Around 50% of nurses reported that “skincare” was left undone. Roughly 10% of nurses perceived that the quality of care in their units had deteriorated in the last shift. Around 4–25.6% of nurses reported that adverse events of medication error, infection, patient fall, patient complaint and verbal abuse occurred occasionally or frequently (see Table 1).

Table 1.

Nurse characteristics and distribution of nurse staffing, missed care, quality of care, and adverse events (n=1,188)

Nurse Characteristics Frequency (%) Mean (SD) Range
Age 34 (0.27) 22–60
Gender
 Male 31 (2.61%)
 Female 1,156 (97.39%)
Education
 Bachelors Nursing Science 1,037 (87.66%)
 Higher Nursing degree 146 (12.34%)
Years of experience as RN 11 (0.25)
Years worked in unit 9 (0.22)
Nurse staffing
Patient to nurse ratio 8 (0.17) 1–30
Staffing and resource adequacy 2.40 (0.15)
Missed care
Adequately document nursing care 133 (11.20%)
Comfort /talk with patients 167 (14.06%)
Develop or update nursing care plan 215 (18.10%)
Preparing patient and family for discharge 250 (21.04%)
Educating patients and family 274 (23.06%)
Oral hygiene 287 (24.16%)
Skin care 594 (50%)
Rating the quality of care as poor 118 (10%)
Adverse Events
 Medication error 87 (7.39%)
 Infection 301 (25.62%)
 Patient fall 55 (4.68%)
 Patient complaint 44 (3.74%)
 Verbal abuse toward nurses 228 (19.39%)
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4.2. Nurse staffing and missed care

The results of the logistic regression analysis are shown in Table 2. Adjusted models revealed that each additional patient per nurse was associated with an increase in the odds of nurses reporting missed care in terms of providing comfort for patients (OR = 1.05, 95% CI 1.02–1.08), documentation of care (OR = 1.04, 95% CI 1.01–1.08), providing skincare (OR = 1.05, 95% CI 1.03–1.08), providing oral care (OR = 1.05, 95% CI 1.03–1.08), updating nursing care plan (OR = 1.03, 95% CI 1.00–1.05), and total missed care (OR = 1.06, 95% CI 1.02–1.08).

Table 2.

Odds ratio estimating the relationship between nurse staffing and missed care (n=1,188)

Missed care Odds Ratio (95% CI)
Patient to nurse ratio Staffing and resource adequacy
Unadjusted Adjusted* Unadjusted Adjusted*
Patient teaching 1.01 (0.99–1.03)
P=0.175		 1.00 (0.98–1.03)
P = 0.479		 1.50 (1.23–1.82)
P=0.001		 1.47 (1.20–1.79)
P=0.001
Discharge 0.97 (0.95–1.00)
P=0.115		 0.97 (0.95–1.00)
P = 0.068		 1.31 (1.07–1.60)
P=0.008		 1.30 (1.06–1.60)
P=0.011
Providing comfort for patient 1.04 (1.02–1.07)
P=0.001		 1.05 (1.02–1.08)
P = 0.001		 2.16 (1.70–2.76)
P=0.001		 2.18 (1.70–2.79)
P=0.001
Documenting care 1.05 (1.02–1.08)
P=0.001		 1.04 (1.01–1.08)
P=0.005		 1.98 (1.53–2.58)
P=0.001		 2.10 (1.60–2.75)
P=0.001
Patient skincare 1.04 (1.02–1.06)
P=0.001		 1.05 (1.03–1.07)
P=0.001		 1.33 (1.12–1.57)
P=0.001		 1.36 (1.15–1.61)
P=0.001
Patient oral care 1.05 (1.03–1.07)
P=0.001		 1.05 (1.03–1.08)
P = 0.001		 1.68 (1.38–2.04)
P=0.001		 1.69 (1.38–2.06)
P=0.001
Nursing care plan 1.04 (1.01–1.06)
P=0.001		 1.03 (1.00–1.05)
P = 0.011		 1.53 (1.24–1.90)
P=0.001		 1.57 (1.26–1.95)
P = 0.001
Overall missed care** 1.05 (1.02–1.08)
P=0.001		 1.06 (1.03–1.08)
P = 0.001		 1.35 (1.12–1.62)
P=0.001		 1.39 (1.15–1.67)
P = 0.001
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CI=confidence interval

*

Adjusted models controlled for nurse age, education, years of experience as RN, and Unit Type.

**

Overall missed care derived from the aggregated average sum of nursing care activities left undone.

Adjusted models revealed that the odds of missed care for patient teaching (OR = 1.47, 95% CI 1.20–1.79), providing patient and family for discharge (OR = 1.30, 95% CI 1.06–1.60), comforting patients (OR = 2.18, 95% CI 1.70–2.79), documenting care (OR = 2.10, 95% CI 1.60–2.75), providing skincare (OR = 1.36, 95% CI 1.15–1.61), providing oral care (OR = 1.69, 95% CI 1.38–2.06), updating nursing care plan (OR = 1.57, 95% CI 1.26–1.95), and total missed care (OR = 1.39, 95% CI 1.15–1.67) were significantly higher for nurses who worked in units with lower staffing and resource adequacy scores than nurses who worked in units with higher staffing and resource adequacy scores.

4.3. Missed care and the relationship with quality of care and adverse events

The results of the logistic regression analysis are shown in Table 3. Adjusted models revealed that the odds of nurses’ reporting quality of care as poor (OR = 1.40, 95% CI 1.25–1.58) were significantly higher for nurses who reported higher missed care scores. Adjusted models revealed that the odds of nurse-reported adverse events including medication error (OR = 2.28, 95% CI 1.25–4.13), infection (OR = 1.66, 95% CI 1.21–2.26), patient complaint (OR = 2.31, 95% CI 1.01–5.25), verbal abuse toward nurses (OR = 1.53, 95% CI 1.01–5.25), and overall adverse events (OR = 1.68, 95% CI 1.29–2.20) were significantly higher for nurses who reported higher missed care scores than for nurses who reported lower missed care scores.

Table 3.

Odds ratio estimating the effect of missed care on quality of care and adverse events (n=1,188)

Patient Outcomes Odds Ratio (95% CI)
Missed Care
Unadjusted Adjusted*
Quality of care as poor 1.36 (1.22–1.53) P = 0.001 1.40 (1.25–1.58) P = 0.001
Medication error 2.00 (1.14–3.49) P = 0.015 2.28 (1.25–4.13) P = 0.006
Infection 1.69 (1.25–2.30) P= 0.001 1.66 (1.21–2.26) P= 0.001
Fall 1.27 (0.68–2.36) P= 0.443 1.41 (0.73–2.75) P= 0.301
Patient complaint 2.33 (1.03–5.29) P = 0.042 2.31 (1.01–5.25) P = 0.045
Verbal abuse 1.53 (1.09–2.15) P = 0.012 1.53 (1.09–2.15) P = 0.012
Adverse events** 1.69 (1.30–2.2) P= 0.001 1.68 (1.29–2.20) P = 0.001
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CI=confidence interval

*

Adjusted models controlled for nurse age, education, years of experience, and unit type.

**

Adverse events are total of medication error, infection, fall, patient complaint, verbal abuse.

5. Discussion

This is the first study in Thailand to explore missed care, the relationship between nurse staffing and missed care, and the relationship between missed care and quality of care and adverse events. Our findings indicate that patient-to-nurse ratio in the university hospitals was 8 to 1 which is less than the patient-to-nurse ratio in general hospitals where each nurse cares for 10 patients (Nantsupawat et al., 2011) and in community hospitals where each nurse cares for 11 patients (Nantsupawat et al., 2015). University hospitals deliver tertiary health care services where nurse care for complex patients and also the hospitals are focused more on research and education, which may explain the lower patient-to-nurse ratio. All university hospitals are accredited by the standards from International Society for Quality in Healthcare. These standards determine the number of patients. When compared with international studies, patient-to-nurse ratio in Thai university hospitals are similar to those in hospitals in nine European countries (Ball et al., 2018), Jordan (Al-Faouri, Obaidat, & AbuAlRub, 2020), but less than those in other settings such as South Korea (Cho et al., 2020).

The staffing and resource adequacy subscale had the mean score of approximately 2.40 which higher than the score in hospitals in South Korea (Kim, Yoo, & Seo, 2018) and less than in settings such as South Western U.S. hospitals (Smith et al., 2018). University hospitals provide health care to complex patients and nurses need to deal with learning new technologies and coordinate with interdisciplinary health care professionals. These challenging environments may make nurses report high workload and lack of enough time or staff to get the work done. In our study, skin care and oral hygiene were the most left undone activities. It is possible that university hospitals have a nursing skill mix. Moreover, the study results show that infection was the highest adverse events happening in university hospitals and these findings are consistent with the findings from another Thai study (Indrawattana & Vanaporn, 2015). It is possible that patients who admitted to university hospitals are those with complicated diseases treated with a variety of antibiotics.

Both patient-to- nurse ratio, staffing and resource adequacy are significantly associated with missed care after controlling for potential confounders. Each increase of one patient per nurse during the shift was associated with a 6% increase in likelihood of missed care. The study’s findings are consistent with previous studies that reported associations between high patient-to-nurse ratio and missed care (Henderson et al., 2017; Griffiths et al., 2018; Aiken et al., 2018; Tubbs-Cooley, Mara, Carle, Mark, & Pickler,2019; Al-Faouri et al., 2020; Lee & Kalisch, 2021). Additionally, one unit increase of poor staffing and resource adequacy score was associated with a 39% increase in likelihood of missed care. These findings are consistent with previous studies (Park et al., 2018; Smith, et al., 2018).

Moreover, this study showed a significant association between missed care and patient adverse events. After controlling for RN age, education, years as RN, and unit type, one unit increase in missed care score increased the relative proportion of nurses reported frequency of quality of care as poor (40%), medication error (128%), infection (66%), complaint (131%), verbal abuse (53%), and adverse event (68%). Similarly, previous studies have found that higher missed care was also associated with patient adverse events such as medication errors, falls, pressure ulcers, critical incidents and nosocomial infections (Simpson & Lyndon, 2017; Aiken et al., 2018; Bail et al., 2020; Cho et al., 2020; Chaboyer et al., 2021), and quality of care as poor and nurses’ lower perception of quality of care (Recio-Saucedo et al., 2018; Smith, Lapkin, Sim, & Halcomb, 2020).

Like prior studies, this study demonstrates evidence of significant associations between nurse staffing and missed care, and between missed care and quality of care and adverse events. The potential explanation for this pattern is reflected in the Missed Nursing Care Model (Kalisch et al., 2009). This model describes that the structure (e.g., nurse staffing) influences nursing care processes (including missed care) which in turn potentially impacts patient outcomes (e.g. quality of care, adverse events). It may possible that nurses in university hospitals function as gatekeepers of patient care through their roles as planners, coordinators, providers, and evaluators of care. Nurses carry out orders prescribed by other providers to treat illness and treatment complications; they provide nursing care which include surveillance and early detection of deterioration in patient status. If the flow of care through nurses to patients is blocked, patients may not receive all services as prescribed by nurses and/or other health care providers, leaving the care processes unfinished. This may result in adverse events and poor care delivery by nurses.

6. Strength and Limitations

This study was the first to examine nurse staffing, missed care, quality of care, and adverse events in university hospitals in Thailand. The findings addressed the relationship between nurse staffing, missed care, quality of care, and patient outcomes which supported the evidence of the missed care model. Limitations of this study include its cross-sectional design which explain the association among variables rather than causation. Thus, it is not possible to establish a causal link between nurse staffing and missed care. In addition, the findings were from self-report instruments which relied on nurses’ responses. Lastly, the study sites are parts of university hospital serving tertiary care with academic medical center therefore may not representatives of other hospitals. We recommend that further research examine a casual model, utilize clinical documentation or other objective data sources, and study larger and more diverse samples of nurses and hospitals.

7. Conclusions

Our study revealed that nurse staffing is associated with missed care, and missed care is associated with lower quality of care and adverse patient outcomes. Decreasing missed care could help decrease patient adverse outcomes and improve the quality of care.

8. Implication for Nursing Management

Nurse managers are challenged with ensuring quality improvement and safety in nursing units. The findings of this study suggest that nurse managers should develop effective strategies to support nurse staffing and design regulations on safe staffing. In addition, considering staffing factors such as skill mix and elimination of non-nursing tasks should be considered. Moreover, in order to improve missed care on the unit, nurse managers should encourage transparency and communication around missed care events. Creating a non-punitive culture of transparency around missed care events may promote missed care reporting and monitoring (McCauley et al., 2020).

Acknowledgement:

This study was supported by the Chiang Mai University Visiting Professor Fellowship Program. SK is supported by NIH-NINR T32NR014205 training grant.

Footnotes

Ethical Approval: Approval to conduct the study was obtained from the Faculty of Nursing, Chiang Mai University, Thailand. (Approval no. EXP:016-2014)

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