Missed nursing care and its influencing factors among neonatal intensive care unit nurses in South Korea: a descriptive study

Article information

Child Health Nurs Res. 2022;28(2):142-153

Publication date (electronic) : 2022 April 30

doi : https://doi.org/10.4094/chnr.2022.28.2.142

Soohyun Kim¹, Sun-Mi Chae^,2

¹Registered Nurse, Seoul National University Hospital, Seoul, Korea

²Professor, College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Korea

Corresponding author Sun-Mi Chae College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea TEL: +82-2-740-8816 FAX: +82-2-766-1852 E-MAIL: schae@snu.ac.kr

This article was adapted from a thesis by Soohyun Kim in partial fulfillment of the requirements for the master's degree at Seoul National University.

Received 2022 March 8; Revised 2022 March 27; Accepted 2022 April 4.

Abstract

INTRODUCTION

Patient safety is an issue of the utmost importance for nurses. To ensure patient safety, nursing care quality, which is positively correlated with patient safety, must constantly be improved. Nursing care quality may in part be measured through missed nursing care [1], which refers to the commonly encountered phenomenon of nurses omitting or delaying a necessary part of their work [2].

Missed care may ultimately lead to decreased patient satisfaction, increased medication errors, and patient readmission [3]. Prevention of missed care is especially important in the neonatal intensive care unit (NICU) since neonates are extremely vulnerable to lapses in safety. They cannot verbally express their symptoms, and their condition can deteriorate rapidly under insufficient surveillance [4]. Therefore, accumulated incidents of missed care can have a detrimental impact on an infant’s growth and development in the long term [4]. For example, delayed oral feedings have been linked to longer hospital stays [5]. Even missed comfort activities may undermine the social-emotional development of extremely preterm infants [6]. Thus, to ensure a high degree of nursing quality for infants, missed care must not be tolerated in the NICU.

Research on missed care inside the NICU is needed since it is the first step required to strengthen safety within the NICU. Research on missed care in the NICU may function as a probing mechanism and as a summary report of which NICU practices most require intervention [7]. For example, if oral feedings are missed more often compared to other activities inside the NICU, a follow-up study could be conducted to confirm the mechanisms and solutions related to delayed oral feedings.

Multiple international studies have examined missed nursing care in the NICU. Studies measuring the overall prevalence of missed care found that 36% to 52% of pediatric and neonatal nurses missed at least one nursing task during their most recent shift [8-10]. Studies on the frequency of missing individual items have shown that infant comfort care was among the most commonly missed types of care compared to other nursing tasks [11]. In the existing body of literature in Korea, studies on missed care have been conducted mostly in adult settings [12,13]. Studies conducted in the NICU have focused on individual activities, such as developmental care, outside the comprehensive context of other NICU activities [14,15].

Existing studies have demonstrated that the types of missed tasks and their frequency can vary across countries according to differences in organizational factors, nursing education programs, and nurses’ average length of clinical experience [16]. This implies that the results of an analysis of missed care can be contingent on the specific traits of Korean nurses, such as having less break time and a higher nurse-to-patient ratio [17-19], both of which are significant antecedents to missed nursing care [13,20]. Therefore, this study aimed to investigate missed care in Korean NICUs.

The purpose of this study was to conduct a cross-sectional analysis of the current state of missed nursing care and its influencing factors among Korean NICU nurses. The specific aims of this study were to examine the following among Korean NICU nurses: 1) the frequency of missed nursing care for 32 individual nursing activities, 2) the significance of 23 reasons for missed nursing care, 3) the overall frequency of missed nursing care, and 4) the factors that influenced the overall frequency of missed nursing care.

METHODS

RESULTS

1. Characteristics of the Participants

The participants’ characteristics are shown in Table 1. The average age of the sample was 28.5 years (standard deviation [SD]=4.7 years). The average length of clinical experience in the NICU was 57.8 months (4.8 years), with a wide range (SD=42.9 months) from a minimum of 12 months (1 year) to a maximum of 261 months (21.8 years). A total of 92.6% of participants had been assigned an average of three or more patients in a single shift during the last month (mean=3.38, SD=.80). They also looked after an average of 1.51 ventilated patients (SD=.78) and 1.2 patients receiving inotropes or sedation (SD=.79) per shift during the past month.

Table 1.

Demographic Characteristics of the Participants (N=118)

2. Individual Frequencies of Missed Nursing Care

Table 2 shows the frequency of missed individual care items in order of missed frequency (the total rate of responses ranging from rarely missed to frequently missed). The most frequently missed care item was “provide developmental care for the baby”, which was missed by 93.2% of nurses. This was followed by “provide emotional support for guardians or family members”(88.1%), “relay all important information about the baby during handover”(86.4%), “have parents participate in the baby’s care”(83.1%), and “perform hand hygiene during the 5 moments of hand hygiene”(82.2%).

Table 2.

Frequencies of Missed Individual Nursing Care Items (N=118)

The least frequently missed care items were “routinely monitor input/output as prescribed”(23.7%), “assess vital signs every 4 hours or as prescribed”(27.1%), “carry out prescribed tests/gather necessary samples”(29.6%), “apply oxygen or adjust oxygen concentration as prescribed”(33.1%), “bathe the baby”(33.9%), and “provide feedings at prescribed intervals”(33.9%).

3. Significance of Reasons for Missed Nursing Care

Table 3 shows the reasons for missed nursing care in order of their impact (the total rate of responses ranging from small to very large impact). All participants (100.0%) replied that “emergency within the unit or deterioration of one of the assigned patients” and “various interruptions during work” were small, considerable, or very large reasons for missed nursing care. The next most-cited items were “shortage of nurses” (99.1%), “too many admissions or discharges” (99.1%), and “increase in the number of patients” (98.3%).

Table 3.

Impact of Reasons for Missed Nursing Care (N=118)

4. Overall Frequency of Missed Nursing Care According to Demographic Characteristics

All participants missed at least one nursing activity during work. The average total number of missed care items was 19.35 items out of 32, with a range of 1 to 32 items. Table 4 shows the results of the t-test and one-way ANOVA, which were conducted to determine whether the total number of missed care items differed according to any of the 12 demographic characteristics collected in this study (gender was excluded from the analysis due to the extreme distribution of participants between subgroups). Only two variables were related to the total number of missed care items: the number of hospital beds (t=2.03, p=.045) and the average daily number of assigned patients receiving inotropes or sedation over the last month (t=2.07, p=.040). Meanwhile, the average daily number of assigned patients on ventilator care over the last month (t=0.39, p=.695) did not have a significant influence on missed nursing care.

Table 4.

Difference in the Total Number of Missed Care Items by Demographic Characteristics (N=118)

5. Influencing Factors Related to the Overall Frequency of Missed Nursing Care

Multiple regression analysis (using the enter method) was conducted to determine which of the significant variables from the t-test and ANOVA influenced the total number of missed care items. Table 5 shows the parameters of the resulting regression model. This model explained 9.6% of variance in missed nursing care (the total number of missed care items)(R²=.096, F=5.66, p=.005). The average daily number of assigned patients receiving inotropes or sedation over the last month (β=.26, p=.006) was the only significant influencing factor related to the total number of missed care items. The number of hospital beds (β=.12, p=.195) was not a significant influencing factor.

Table 5.

Factors Influencing the Total Number of Missed Care Items

Multicollinearity was excluded by confirming the model’s tolerance (.96), variance inflation factor (1.04), and condition index (1.00-8.42). In addition, the Durbin-Watson statistic (2.22) showed that there was no autocorrelation within the model. As another method for assessing the fit of the regression model, the assumptions of multiple regression (normality and homoscedasticity of residuals) were tested. The normality of the residuals was contradicted by the Shapiro-Wilk test (z=.97, p=.012), while the homoscedasticity of the residuals was confirmed by the Breusch-Pagan test (F=0.28, p=.756).

DISCUSSION

In nursing, because the total work time is fixed, more time spent on a single activity means there is less time for other activities. Thus, nurses prioritize direct care and safety-related care over less urgent care-related tasks [16,25]. Accordingly, in this study, as well as in existing studies [8,12,20], the least frequent missed care items were related to patient safety (“routinely monitor input/output as prescribed”, “assess vital signs every 4 hours or as prescribed”, and “carry out prescribed tests/gather necessary samples”). In other words, the frequently missed items in this study (“provide developmental care for the baby”, “provide emotional support for guardians or family members”, and “relay all important information about the baby during handover”) may have been items that were viewed by nurses as time-consuming and less urgent in terms of patient safety, for which reason they were considered to be low-priority [16,25].

In this study, “provide developmental care for the baby” was missed more frequently than any other NICU activity. Developmentally supportive care is central to neonatal nursing, embodying the ideals of caregiving such as enhancing infant comfort, reducing care-related trauma, and providing care that is contingent on the infant’s sleep-wake state [7]. These infant-centered strategies require patience and time. Thus, in the fast-paced reality of the clinical nursing field characterized by the prioritization of safety, a lack of time, and inadequate working conditions [14,15], NICU nurses may feel developmental care to be laborious [26].

Most investigations on developmental care suggest education targeting nurses’ knowledge, attitudes, and perceptions about developmental care as a solution [14,15]. However, education is necessary when nurses’ levels of knowledge and perception are low. The fact that developmental care was the most frequently missed item in this study, even though Korean NICU nurses perceived developmental care to be important [15], suggests that interventions to enhance developmental care should adopt a new approach. Interventions focusing on work system-related factors rather than education may be more effective at enabling nurses to carry out the necessary developmental care. Such interventions may include efforts to improve nurse staffing and infant-to-nurse ratios in the NICU and to develop strategies for unit managers to effectively plan patient assignments [14].

“Shortage of nurses”, “too many admissions or discharges”, and “increase in the number of patients” were all included as major reasons for missed care in this study. This further supports the proposal that the performance of developmental care may benefit from systematic changes. In addition, all study participants agreed that the reasons for missed care with the largest impact were “emergency within the unit or deterioration of one of the assigned patients” and “various interruptions during work”, both of which reflect workflow disruptions. When emergencies or interruptions occur, the time it takes for a nurse to successfully prepare medications, administer medications, and complete documentation increases significantly. This leads to increased medication errors and takes time away from other nursing activities, resulting in missed care [27].

Interruptions may also explain why the number of patients on inotropes or undergoing sedation therapy was associated with an increased overall frequency of missed nursing care. In the NICU, inotropes or sedatives are usually administered via continuous infusion using pumps. Pumps are major sources of alarms in the NICU. An increase in non-urgent or unidentifiable alarms can interrupt nurses’ workflow, increasing the risk of missed care [28].

Moreover, in the NICU, inotropic or sedative therapies are often applied simultaneously with mechanical ventilation because ventilation causes stress and pain for neonates. In these cases, the level of sedation varies for each neonate [29]. Compared to heavily sedated patients, slightly sedated patients on ventilator care are more difficult to look after, possibly due to ventilator fighting, variable conditions, and more alarms [30]. This can be especially true in the NICU, where infants are more prone to inconsolable crying and lack self-control abilities. Such an increase in caregiver workload can negatively affect missed care. Notably in this study, the average daily number of assigned patients on ventilator care was not a significant influencing factor related to overall missed nursing care. This may be due to a lack of distinction between different levels of sedation for patients on ventilator care. Future studies should investigate the influence of ventilator care moderated by sedation levels on missed nursing care.

This study has several limitations. First, the meaning of developmental care in this study should be interpreted with caution. Unlike other studies [14], this study did not use an instrument designed specifically to measure developmental care. Thus, developmental care as conceptualized in this study may differ from developmental care in other studies. Second, the participants in this study may not have reflected the real-life composition of Korean NICU nurses since the participants most likely shared the survey link with nurses working in the same hospital. This is an innate limitation of the snowballing method. Third, the final regression model explained only 9.6% of the variance in missed care, which implies that many other antecedents must also be taken into consideration in future studies. Lastly, there may have been limitations for participants in responding to several items, such as those related to parents and guardians, due to the current coronavirus disease 2019 outbreak and visitation restrictions.

CONCLUSION

This study is significant because it addressed the lack of studies on missed care in Korean NICUs by generating data to fill this gap in the nursing literature. Through this study, missed care was found to be prevalent among Korean NICU nurses. Patients on specific types of medications may be a source of more intensive workload for NICU nurses, thus resulting in more missed care. Furthermore, this study also raised questions on how well certain types of nursing care, especially developmental care, are carried out in the NICU. Since safety is a top priority for nurses in managing their work, less urgent and time-consuming tasks are the most likely to be omitted. This suggests that NICU nurses’ working conditions need to be improved so that they have adequate time to carry out overlooked nursing activities. Ultimately, this study can serve as a foundation for the development of interventions tailored to the specific characteristics of Korean NICUs, contributing to neonatal patient safety.

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