The Effect of Nurses’ Job Characteristics on Missed Nursing Care in Medical and Surgical Departments in Selected Slovenian Hospitals—A Cross-Sectional Study

Missed nursing care (MNC) has been researched in many countries around the world. It is a phenomenon present in nursing care worldwide and was first described in a qualitative study by Kalisch (1). MNC refers to the withdrawal or non-performance of certain nursing care activities due to limited resources such as time, staff or knowledge (2). When nurses are faced with multiple demands and insufficient resources, they tend to prioritise, so they choose to leave some parts of nursing care delayed, only partially done or even undone (3). Since nursing care plays an important role in promoting the health and wellbeing of individuals, families and communities, MNC can lead to various negative public health consequences. Failure to provide nursing care in healthcare facilities decreases the quality of nursing care, causes dangerous events and complications, and ultimately leads to negative patient outcomes, such as patient dissatisfaction and readmissions, affecting patients’ health or even lives (2, 4–12). The antecedents of MNC such as staffing, patient-to-nurse ratios, workload, non-nursing tasks, work environment, nurse characteristics, their experience and education levels, and satisfaction as well as the impact of these antecedents in terms of reducing or increasing MNC are well documented and have been researched over the last fifteen years (13, 14). Different aspects of work environment influenced the extent of MNC (15, 16), so paying attention to variables in the work environment and organisational characteristics is important for decreasing MNC. An unfavourable work environment is an important reason for an increased intent to leave nursing, and the decrease in the nursing care workforce is a predominant reason for the increase in MNC (17).

A representative survey on MNC in medical and surgical departments in Slovenian hospitals has not yet been conducted. Country-specific research is required to identify peculiarities related to the organisation of nursing care and the reasons given by nurses in order to convince policy makers to implement changes in decision-making and resource allocation.

The aim of this study was to investigate and describe the extent of MNC in Slovenian hospitals, the reasons for MNC as identified by nurses and the contribution of nurses’ job characteristics to MNC in medical and surgical departments in selected Slovenian hospitals.

Cross-sectional explorative research was conducted. The study design was modelled after research on this topic conducted worldwide, with the capacity to compare results from other European countries.

Understanding the most frequently missed activities and the underlying reasons for that provides an opportunity to plan changes in the organisation of nursing care in Slovenia by providing decision makers with concrete and valid data on the current situation in hospitals. We found that nursing activities related to the basic life needs and safety of patients are the least frequently missed. For these activities, not implementing them would have the most visible results. The most frequently missed activities are those of talking to patients and their families. A study conducted in 12 European countries (33,659 nurses in 488 hospitals) (21) has also shown that the most frequently missed nursing activity was comforting/talking to patients. Those activities are extremely important for the quality of patient care, but are sidelined due to the priority that medical/technical procedures and nursing interventions take in practice. The absence of these activities is not visible (unlike missed skin care or oral hygiene) and they do not affect immediate patient safety (such as, for example, missed administration of a prescribed medication). As noted by Kirwan & Matthews (22), nurses are more likely to provide care that achieves immediate or short-term outcomes. However, missed psychological care (the dimension ‘Caring, support, activation, education’ falls into that category) which may not have immediate negative effects, often goes unaddressed. The unpredictability of the time required for psychological care, as opposed to physical care, may contribute to a tendency to ration these activities. Other authors (23) also noted that patient education is a frequently cited omission in nursing care. In their qualitative study, the theme of ‘Not priority nursing care due to competing work demands and the missing workplace culture’ emerged, and they emphasised the need for developing strategies for increasing patient education to prevent MNC and to recognise patient education as the next care-related indicator of quality of care. The next frequently missed activity is monitoring confused patients, which led to more frequent physical and drug immobilisation of patients due to a lack of monitoring. Monitoring confused patients is a challenge because it requires constant to very frequent presence of a nurse in the patient’s room. In a Polish study (24), the authors came to somewhat different conclusions. The most frequently missed nursing activities were reviewing nursing care plans to familiarise themselves with the patient’s condition, talking to the patient and/or their family and identifying the needs of newly admitted patients. The average rating of the individual components in our survey shows that ‘Monitoring’ is the most frequently missed nursing activity in Slovenia, closely followed by ‘Care, support, activation, education’. Monitoring of hospital patients is a critical aspect of healthcare and can pose a high safety risk if missed. Interventions that are part of the dimension ‘Care’ have a major impact on the quality of life of patients and their relatives, especially post discharge. As authors (25) state in their comprehensive scoping review, regardless of the concept analysed—missed, rationed or unfinished nursing care—all have a negative impact on patient outcomes related to patient safety and quality of care.

Missed nursing care can be linked to its underlying reasons, the topmost being the insufficient number of staff, which in Slovenia is related to the long-standing and worsening shortage of nurses. We found that the highest mean value in the significance of reasons for MNC is related to ‘Labour resources’ and is confirmed as the most important reason. A shortage of nurses has been recorded since 2007 and varies between 20% and 30% (26). In addition, the number of patients per registered nurse in Slovenia is currently the highest in Europe and higher than in some non-European countries, which poses a high risk to the quality of nursing and healthcare overall (27). The regression model results did not confirm our expectations—that a higher number of patients cared for by the respondents in their last shift would increase MNC—as this was only shown this for the dimension ‘Documentation’. The International Council of Nurses, representing nurses around the world (28), developed guidelines for the retention and continued employment of nurses, but unless policy makers make changes, labour resources will remain high on the list of reasons for MNC. Other authors have come to similar conclusions (22, 29–32), as labour resources were also cited as the most prevalent reason for MNC.

The association between nurse-related organisational factors and missed nursing care shows that, in addition to staffing, the working environment of nursing staff is also a significant reason for MNC. Hospitals with a more favourable working environment, lower patient-to-nurse ratios and fewer professional nurses reporting often carrying out non-nursing tasks had a lower prevalence of nurse-reported MNC (21). In relation to the nurses’ work environment, previous findings (33) have already stated that the working environment in Slovenia needs to be changed and that nurses lack opportunities for professional development; therefore, self-assessment of various aspects of work (e.g. wages, opportunities for advancement and professional development) is low. The results (34) indicate that nursing care is missed due to staff shortages, organisational problems and the working climate. A good working environment reduces MNC, less MNC is present when nurses have no intention of leaving the hospital, when they perceive adequate staffing in the unit, when they are satisfied with their current position, and with being a nurse, and when they are satisfied with the level of teamwork (35, 36). Organisational characteristics, nursing unit features and the degree of teamwork among nursing staff have an impact on MNC. Among other characteristics, professional roles, working hours, and adequate staffing can also potentially contribute to the occurrence of MNC. Our results showed which characteristics of the work environment and job satisfaction have an impact on whether or not nursing care is provided. We found that less nursing care was missed when satisfaction with wages, annual leave, study leave, professional status and work flexibility increased. The same applies to the number of years employed in nursing, the evaluation of nursing care quality, satisfaction with the career and the evaluation of the working environment. Nurses’ work environment has a strong influence on levels of missed care (4, 37), and nurses’ leadership is a very important element of the work environment. As the authors (38) state, the role of management and leadership of the healthcare service is central to mitigating the factors that contribute to the emergence of MNCs, especially labour resources. The main effects of lack of nursing care in the adult setting were an increase in mortality, adverse events and failure of care. A number of causative factors have been identified relating to ward environments, inadequate staffing and skill mix, although the findings are inconclusive. Solutions include continuing education, reorganisation of wards and work, and appropriate skill levels (39).

The differences in the functioning and management of different national healthcare systems are the reason why it is of utmost importance to have national data based on which national solutions can be implemented. Identifying and addressing missed nursing care is crucial for the nursing profession and healthcare organisations so that optimal outcomes for patients and the well-being of nurses can be achieved (22, 34).

Missed nursing care needs to be addressed by healthcare management and policy, especially given the severe shortage of nurses in Slovenia and Europe and the potentially harmful consequences this can have for patients. If we look at the problem from a public health perspective, several consequences are possible: increased morbidity and mortality, delayed or inappropriate treatment, reduced patient safety, increased healthcare costs, poor management of chronic conditions and reduced effectiveness of healthcare interventions and prevention strategies. Nurse leaders can help address missed nursing care by having the opportunity to openly acknowledge and discuss missed nursing care. It is important to recognise this as a possible consequence of staff shortages. However, its effectiveness depends on support from the organisation (22). This study contributes to the understanding of nursing care practices in Slovenia and is internationally comparable, as MNC is an existing problem and the reasons for it need to be known in order for healthcare management to be able to plan and implement change.