Missed Nursing Care in Hospitalized Patients in Two Health Institutions

Saturday, 7 November 2015

Maria Guadalupe Moreno Monsivais, DR, MSN, BN, RN1
Ma. Guadalupe Interial Guzmán, MCE1
Sofía Cheverría Rivera, MAAE2
Leticia Vázquez Arreola, n/a1
(1)Facultad de Enfermería, Universidad Autónoma de Nuevo León, Monterrey, N.L., Mexico
(2)Facultad de Enfermería, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico


Patient safety is a priority worldwide and the effectiveness of health systems in different countries is being reconsidered (WHO, 2010). The aim is to prevent patient injury as a result of the care provided or omitted by health personnel. In this care process all health professionals are involved; however, nursing stands out because of its close and continuous contact with patients (Kalisch, Landstrom & Hinshaw, 2009). Therefore, nursing administrators face the challenge of ensuring that their staff, in the different health institutions, both public and private, provides quality care and safety.

It is essential that nursing staff perform all care activities that their assigned patients need to achieve quality and safety; when activities are not performed this is called missed nursing care or errors of omission (Kalisch, 2006; Kalish, Tschannen & Lee, 2012), which favors the presence of harm to the patient, and increases costs and hospital stay (Ausserhofer, Zander, Busse, Schubert, De Geest, Rafferty et al. 2014).

The theoretical basis of this study is the missed nursing care model (Kalisch, 2006), where the different types of nursing that are missed or omitted during care are identified; likewise, organizational factors that contribute to missed care are presented. The most common are attributed to human resources, material resources, and communication (Ball, Murrells, Rafferty, Morrow & Griffiths, 2014). Therefore, this study aims to determine missed nursing care and their contributing factors from the perception of nurses and patient in two health institutions: one public and one private. This study contributes to nursing knowledge, mainly because it includes the perception of the patient and the nursing staff, who are the main individuals involved in care. These results will provide a basis for nursing administrators to design and implement effective strategies that improve the quality and safety of care.



The study design was descriptive (Grove, Burns & Gray, 2013). The population corresponded to nurses and patients hospitalized in two health institutions, one from the public sector and another from the private sector in Monterey, Nuevo León and San Luis Potosi, San Luis Potosi, Mexico, respectively. Thirty-two nurses from the public hospital and 160 from the private hospital participated. Patients were randomly selected, 180 from the public hospital and 160 from the private hospital. A patient assigned to each of the participant nurses was considered. Data collection was done by applying the MISSCARE Nursing Survey (Kalisch & Williams, 2009) to nurses and patients. This survey consists of 64 items in three sections: demographic and labor data of nurses, missed nursing care, and reasons for missed nursing care. This study complies with the ethical guidelines set forth in the Regulations of the General Law on Health in Matters of Health Research (Secretaría de Salubridad y Asistencia, 1987). For data analysis, descriptive statistics were used. Characteristics of the participants were profiled, indices were designed with values from 0 to 100 for each of the dimensions of care as well as factors contributing to missed care; a higher score meant greater care (the difference between the score obtained and the maximum, which equals 100, corresponding to missed nursing care) and greater significance for the reason for missed care.



Regarding the characteristics of nurses in the two institutions, women predominated in the private hospital 86.3%, and 81.3% in the public hospital; regarding age range, in the private hospital a range of 18-25 years predominated, while in the public hospital range of 31-35 years was reported. With regard to the level of education, in the private hospital 53% reported being a general nurse; in the public just over half had bachelor´s degree training.

In relation to patient characteristics, in the two institutions, similar results in gender were found: in the private institution women predominated with 55% and in the public institution it was 47.8%. Regarding level of education, there was a higher percentage of university education in the private institution (50% in the private vs. 18.7% in the public institution).  In terms of age, in the private institution more than half of the participants reported an age over 51 years; in the public institution and age range of 47-56 years predominated.

In both institutions, the patient perceived greater omission in relation to nursing care. The greatest omission from the patient's perspective corresponded to discharge planning and patient education (mean = 44.00, SD = 25.86 public institution; mean 55.00, SD = 28.38, private institution) and the lowest omission in ongoing care evaluations (mean = 20.74, SD = 3.68 public institution; mean = 11.07, SD = 0.30 private institution).

The nurses perceived greater omission of basic care interventions (mean = 41.52, SD = 17.03, public institution; mean = 19.18, SD = 4.60, private institution) and less omissions in ongoing care evaluations (mean = 17.78, SD = 13.73, public institution; mean 5.44, SD = 0.64, private institution). The nursing staff of the public institution perceived greater omission in care.

Regarding the factors that contribute to missed nursing care according to the perception of nurses in both the private and the public institution, those related to human resources predominated (mean = 80.67, SD = 17.06, private institution; mean = 82.46 SD = 12.94, public institution), followed by material resources (mean = 69.72, SD = 23.45, private institution; mean = 73.17, SD = 17.92, public institution) and communication factors (mean = 65.16, SD = 21.55, private institution; mean = 65.62, SD = 19.45, public institution).

Regarding the perception of the patient, while in the private institution missed care was attributed only to aspects of human resources, in the public institution they perceived human resources as the first problem, followed by material resources and communication.



The study results helped identify the care that is missed or omitted during hospitalization as well as factors related to its omission. It is noteworthy that greatest omission of care is perceived by patients in both institutions and by the nurses in the private institution. The findings of the study helped identify errors of omission in a complementary way between the parties involved in the care process. This knowledge allows the nursing administrator, first, to propose action strategies aimed at reducing these areas of opportunity and promote continuity of care with a positive impact on the quality and safety of care; moreover, it strengthens aspects related to human resources, a key factor that contributes to missed care.


Ausserhofer D, Zander B, Busse R, Schubert M, De Geest S, Rafferty AM, et ál. (2014). Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multycountry cross-sectionalRN4CAST study. BMJ Qual Saf; 23:126–135. doi:10.1136/bmjqs-2013-002318

Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P. (2014). “Care left undone” during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf; 23: 116-125.

Grove SK, Burns N, Gray JR. (2013). Practice of Nursing Research. Appraisal, Synthesis, and Generation of Evidence. Elsevier St. Louis Missouri.

Kalisch BJ. (2006). Missed nursing care: a qualitative study. J Nurs Care Qual. Oct-Dec; 21(4):306– 313.

Kalisch BJ, Landstrom G, Hinshaw AS. (2009). Missed nursing care: A concept analysis. J AdvNurs; 65(7):1509–1517.

Kalisch B, Williams R. (2009). The development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm; 39 (5): 211-219.

Kalish, B., Tschannen, D. & Lee, K. H. (2012). Missed nursing care, staffing and patient falls. Journal of Nursing Care Quality, 26(4), 291-299.

Organización Mundial de la Salud. (2010). Seguridad paciente, research. IBEAS: red pionera en la seguridad del paciente en Latinoamérica. Hacia una atención hospitalaria más segura. Disponible en: http://www.who.int/patientsafety/research/ibeas_report_es.pdf

Secretaría de Salubridad y Asistencia. (1987). Reglamento de la Ley General de Salud en Materia de Investigación para la Salud. México: Porrúa.