Of the 4,086 respondents, 90% were female, and 51% held a baccalaureate degree or higher. The majority of respondents (77%) were registered nurses, and the remaining 23% were nursing assistants. Day shift was the most frequently reported work schedule (49%), followed by nights (35%), then evenings or rotating shifts (16%); most subjects (76%) worked 12 hour shifts. Work experience was widely distributed, with 32% reporting more than 10 years; 5% reporting fewer than 6 months, with the remainder evenly distributed across 6 months and 10 years of experience. One-third of subjects reported missing one shift in the last 3 months and 24 percent reported 2 or more shifts missed. The majority of subjects worked in medical-surgical units (52%), followed by intensive care (24%), intermediate care (19%), and rehabilitation (4%).
Amount and type of missed care
shows the distribution of responses for how frequently each element of care was reported missed (always missed, frequently missed, occasionally missed, or rarely missed). Ambulation of patients three times per day (or as ordered) was the most frequently-reported element of missed care, with 32.7% of nurses reporting this action being frequently or always missed. Additional elements that were frequently or always missed included attendance at care conferences (31.8%), mouth care (25.5%). Conversely, performance of patient assessments (97.7%), glucose monitoring (97.6%) and vital signs (95.8%) were reported as only rarely or occasionally missed by almost all participants. The overall mean score of missed care was 1.56 (SD = 0.4).
Missed Nursing Care in 10 Hospitals: Frequency (Percent*) (n = 4086)
shows the elements of the least- and most- missed care across the ten hospitals. Although the percentages differed slightly, the least and the most-missed care items were similar across all ten hospitals. Bedside glucose monitoring and patient assessments were the least frequently reported as missed across all ten hospitals. Conversely, ambulation was among the top five elements of missed care reported across all ten hospitals, eight of which reported this as the most frequently missed element of care.
Elements of Care Most- and Least- Frequently Missed
Reasons for missed care
Reasons for missed care were also identified similarly in the ten hospitals (see ). Inadequate labor resources was the most often cited reason for missed care (93.1% across the 10 hospitals), followed by material resources (89.6%) and communication (81.7%). Within the labor resources subscale, unexpected rise in patient volume and/or acuity was consistently identified as the top reason for missed care (94.9% for all respondents), with a range in frequency between 87.4% to 98.3% across hospitals. The most common item reported in the material resources subscale was the lack of availability of medications when needed (94.6% overall, range across hospitals 88.6% to 97.8%). Communication items were less similar across hospitals, however the most frequently reported item in this scale across hospitals was unbalanced patient assignments (91.0% overall, range across hospitals 82.2% to 95.4%).
Reasons for Missed Nursing Care across 10 Hospitals
Missed nursing care by unit and staff characteristics
Using the overall sample (n = 4,086), a series of bivariate regression analyses using robust cluster estimation were conducted to find significant variations reported in missed care by unit staff characteristics, work schedules and perceived staffing adequacy. Eight variables were significantly associated with missed care: gender, age, job title, shift worked, years of experience, absenteeism, perceived adequacy of staffing, and number of patients they cared for. When nursing staff members were female (B = 0.84, robust S.E. = 0.02, p < 0.001), older (B = 0.03, robust S.E. = 0.01, p < 0.001), RNs (versus NAs) (B = 0.19, robust S.E. = 0.03, p < 0.001), working on a day shift (compared to those on night shifts, B = 0.05, robust S.E. = 0.02, p < 0.05), or experienced more (B = 0.04, robust S.E. = 0.01, p < 0.001), they reported more missed care. Nursing staff who missed more shifts in the past 3 months (compared to those who did not miss any shifts, B = 0.08, robust S.E. = 0.02, p < 0.001), perceived their staffing less adequate (B = 0.11, robust S.E. = 0.01, p < 0.001), or cared for more patients in the previous shift (B = 0.01, robust S.E. = 0.00, p < 0.05), reported significantly more missed care. Education level, weekly work hours, and type of unit were not significantly associated with missed care. Significant independent variables were then entered into the following multivariate analysis to determine the significant predictors of missed care.
Predictors of missed nursing care
A multiple regression model that includes variables significant from the bivariate analyses is shown in . The model significantly predicted the missed care score (R2=0.16, F[19, 109] = 28.0, p < 0.001). NAs (versus RNs) and staff with fewer years of experience reported significantly less missed care (p < 0.001). Night shift workers reported less missed care than day shift workers (p < 0.01). Nursing staff who missed 2 or more shifts in the past 3 months reported missed care more than those who did not miss any shifts (p < 0.01). Those who cared for more patients in the previous shift reported more missed care (p <0.001), while nursing staff who perceived their staffing as adequate more often reported less missed care (p < 0.001). Gender and age were not significantly associated with missed care.
Summary of Multiple Regression for Missed Nursing Care (n = 4086)