The relationship between organizational communication and missed nursing care in oncology wards in Taiwan

Unfavourable communication increases missed nursing care. Oncology wards have more communication complexity than general wards; therefore, creating a positive communication environment is important for ensuring quality care. This study aimed to understand the relationship between organizational communication satisfaction and missed nursing care in Taiwan.

tions, and the staff must maintain patient safety by using effective communication (Vermeir et al., 2017). In 2006, the Joint Commission of Taiwan started promoting team resource management to a improve communication to reduce missed nursing care (Ministry of Health & Welfare, 2018), but the number of patient safety events reported persistently increased (Ministry of Health & Welfare, 2018).
Studies on how communication affects missed nursing care are still missing. Therefore, based on the missed nursing care model that was developed by Kalisch, Landstrom, and Hinshaw (2009), the research questions that we aimed to answer were as follows: 1. What were the oncology nurses' characteristics distributions? 2. What were the items of nursing care and the reasons for missed nursing care in oncology words? How were the items related with the reasons? What type of differences in characteristics could affect the items and the reasons?
3. How did the oncology nurses describe the organizational communication satisfaction? What type of differences in characteristics could affect their descriptions? 4. Did the organizational communication satisfaction relate to missed nursing care?

| Design
This study used a cross-sectional study design. The research setting included all 6 oncology and haematology wards in a 200-bed private specialty cancer hospital in Taipei, Taiwan. The study included nurses who were >20 years old and had worked in the oncology wards for >3 months. Nurses were excluded if they were on holiday, on probation or from other wards. All Registered nurses at the cancer hospital provided all types of care to people with cancer, and the average ratio of beds to nurses in the oncology wards ranged from 6-7 beds to one nurse. Of the nurses who participated in the study, 42 were aged ≤25 years, 49 were 26-34 years, 14 were 35-44 years and 1 was >45 years.

| Methods
This study used a structured questionnaire. To determine the appropriate sample size for this study, a power analysis was performed using G*Power 3.1. The number of samples calculated by G*Power was 76. As all 120 nurses were present in these wards, this study distributed 120 questionnaires. The study's sample size was considered sufficient. The questionnaires were distributed to the participants in sealed envelopes during their ward meeting after explaining the nature and the scope of the study, together with an empty envelope to place their completed questionnaire, before placing it in the box that was left at the staff office for 2 weeks.
The questionnaire for this study included three major sections and the measurement, bias controls and quantitative variables were as follows: 2. Reliability and validity analysis results for reasons for missed nursing care by nurses: The scoring system for this part was based on a four-point Likert scale ranging from 1 (significant related) -4 (not related). The KMO was 0.865, the Chi-square value for Bartlett's test of sphericity was 1027.002, and the significance level was <.001, which means significant. Therefore, this section was suitable for factor analysis. Next, principal component analysis was conducted, and the fixed factor value used for varimax rotation was 1. Finally, one factor was extracted, with an eigenvalue of 6.630. The cumulative explained variation was 39.001%; therefore, extracting one factor was reasonable. The factor load for questions 2 and 6 in this section was <0.400. However, these two questions are extremely important factors in other studies; therefore, they were not removed.
3. Furthermore, the total reliability Cronbach's α was .900. Therefore, all questions were retained. 1. Validity analysis of the organizational communication satisfaction: The KMO value was 0.909, the chi-square value for Bartlett's test of sphericity was 2615.069, and the significance level was <.001, which means significant. Therefore, this section was suitable for factor analysis. Further, principal component analysis was conducted, and the fixed factor value used for varimax rotation was 1. Finally, three factors were extracted, with eigenvalues of 3.841, 4.956 and 3.841. The cumulative explained variation was 82.974%. Therefore, extracting three factors is reasonable. The factor load of all questions in this scale was >0.400; therefore, all questions were retained.
2. Reliability analysis of the organizational communication satisfaction: The total reliability score of the scale was 0.970. Given that the total reliability of the questionnaire was >0.900, the questionnaire has extremely good consistency. Therefore, all questions were retained.

Ethics
The participants were informed about the purpose of the research, the anticipated duration of the study and the procedures that would be used. They also were informed about any potential consequences of participating in the study, including potential risks, adverse effects or discomfort that may occur. After obtaining an Institutional

Review Board approval from The Institutional Review Board /Ethics
Committee of Koo Foundation Sun Yat-Sen Cancer Center (Ethical approval number: 20180605A), the questionnaires were distributed to the participants. This study had an anonymous questionnaire, and the participants were allowed to withdraw at any time point. and had a total work experience of <2 years. Table 1 lists the full details of the participants' demographic information.

| RE SULTS
The top three items influencing high organizational communication satisfaction were the degree of work coordination between self and colleagues from one's assigned department or unit (mean ± SD, 5.52 ± 0.89), degree of communication for goal completion between self and colleagues from one's assigned department or unit (5.50 ± 0.92) and degree of streamlined commu ication between self and colleagues from one's assigned department or unit (5.42 ± 0.90) ( p <.001) and degree of role satisfaction (F = 11.70; p < .001) and teamwork satisfaction (F = 9.0; p < .001) ( Table 5). The analysis of correlation between the items of missed nursing care and the organizational communication satisfaction (Table 9) revealed that basic nursing-related care procedures, and the items of nursing care overall were significantly correlated to the Nurse's characteristics, such as job level, job title, unit manpower, current job satisfaction status, role satisfaction and teamwork satisfaction were associated with organizational communication satisfaction, consistent with the results from previous studies (Kalisch & Lee., 2012;Prip et al., 2017;Vermeir et al., 2017;Villamin et al., 2019;Zeleníková et al., 2020). Most nurses in this study were from Generation Y and had a job rank of N2 (who has comparatively less knowledge and skills). The communication-related characteristics of this generation of nurses are as follows: dislike hierarchy and authority figure, enjoy reform and teamwork, are immensely confident of their capabilities, can multitask and require task directions to be specific (Norouzinia et al., 2016;Sherman, 2015). In this study, Generation Y nurses with a lower job rank had higher organizational communication satisfaction and were more flexible in response to diverse work. Conversely, nursing team leaders were more  (Prip et al., 2017;Vermeir et al., 2017). The team leaders in the present study were responsible for manpower allocation, and their communication satisfaction might be affected by the difficulties in responding to manpower requirements. The intention to resign is high in units with frequent occurrence of missed nursing care (Kalisch et al., ,,,2011, consistent with the present study. Our nurses believed that insufficient manpower affected their intention to resign.

| LI M ITATI O N S
This study had two major limitations that could be addressed in the future research. First, the selection of nurses from a single region in a cancer centre in Taiwan did not allow the extrapolation of the results to the entire country or other types of care units. Second, cross-sectional design and self-reported data may be sources of potential biases.

| CON CLUS ION
This study showed that the nurses tended to miss a part of nursing care when the communication status reason exists. When the nurses were performing basic nursing-related care procedures, these procedures could be missed whether they were not satisfied with the unit manpower status and the organizational communication climate, horizontal and diagonal communication and informal communication. The results can be used to supplement future studies for missed nursing care in clinical practice.
This study recommends using a scenario simulation training to enhance the nurses' communication skills and creating an on-the-job education module according to the needs of different levels and ages.
Moreover, the missing nursing conceptual framework points out that the internal processes of the nurses will affect the implementation of the final nursing priorities and there would be omissions; therefore, this study suggests that managers should pay attention to the impact of organizational ethics on missed nursing care and communication problems. The MISSCARE Survey Chinese version is valid and reliable. Hence, this version was used to preliminarily examine the relationship between missed nursing care and organizational communication satisfaction in a cancer centre in Taiwan.

ACK N OWLED G EM ENTS
The authors would like to acknowledge the Department of Nursing, Koo Foundation Sun Yat-Sen Cancer Centre Hospital.

CO N FLI C T O F I NTE R E S T
There is no author has any conflict of interest to disclose.

E TH I C A L A PPROVA L
The study is approved by The Institutional Review Board /Ethics Committee of Koo Foundation Sun Yat-Sen Cancer Center (Ethical approval number: 20180605A). All procedures in this study are carried out in accordance with the principles of Declaration of Helsinki.
Informed consent for participation was not required. Since this study has an anonymous questionnaire, and the participants can withdraw at any time.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.