A cross‐sectional observational study of missed nursing care in hospitals in China

Abstract Aim To identify the risk of missed nursing care (MNC), and contributing factors, in Chinese hospitals. Background National reporting of adverse incidents diminishes errors of commission. To further improve service quality and patient safety, MNC should be reduced. Methods An online survey comprising the MISSCARE Survey and the McCloskey/Mueller Satisfaction Scale was conducted with a convenience sample of nurses (n = 6,158) in 34 Chinese hospitals. Results Participants’ mean age was 30.6 (SD = 7.014), and 2.5% were male. The most frequently missed nursing care items were basic care (12.7%–51.8%). The most frequently reported reasons were human resource issues (63.1%–88.2%). Being female, no child, better educated, a manager, permanently employed, no night shift, inadequate friend support and job dissatisfaction influenced the perception of MNC (odds ratio 1.00–4.848). Conclusions MNC often occurred in basic care involving informal caregivers or in surge status due to a sudden increase in workload. Implications for Nursing Management Nurse managers should prioritize effective measures that target delegation competency and mobilization of nurses for flexible repositioning during need.


| Conceptualization of MNC
pioneered the investigation of MNC in a qualitative inquiry about regularly missed medical-surgical care and associated reasons. MNC (Figure 1) has been validated regarding its antecedents (e.g. care demand, labour or material allocation, and communication), attributes (e.g. omission of required care because of individual nurse's internal working mechanism: underpinned by values and beliefs, team norms, priority decisions and habits), and consequences or patient outcomes (Kalisch, Landstrom, & Hinshaw, 2009).
According to Donabedian's theory, organisational and human characteristics are interwoven with the structure (hospital and unit level), process (nursing and interprofessional) and outcome components (patients, nurses and systems) of quality health care (Ayanian & Markel, 2016;Kalisch & Xie, 2014). Both patients and nurses benefit from positive processes in the service delivery system.
Conversely, negative processes can jeopardize health care systems, threaten individual health and create other detrimental outcomes (e.g. patient falls, health complications, mortality and psychological distress, or nurses' dissatisfaction) (Ball et al., 2018;Kalisch & Xie, 2014). The nurses integrate structural, process and outcome components of health services for optimal patient outcomes. They are also expected to maximize patient benefit and prevent harm through assessment, care planning, monitoring and surveilling, double-checking, assistance and interprofessional collaboration (Blackman et al., 2018;Vaismoradi, Tella, Logan, Khakurel, & Vizcaya-Moreno, 2020).
The initial study on MNC engaged RNs and nursing assistants (Kalisch, 2006), so the influence of the scope of practice and job responsibilities warrants more investigation. Saqer, Rub, and R. F.  (Hui, Wenqin, & Yan, 2013;Liang et al., 2018).
Generally, nurses reminded family/paid caregivers to execute basic care, which was often associated with genuine and committed family support. Paid caregivers affiliated with companies that had contractual agreements with the hospitals without explicating that nurses took full responsibility for paid caregivers' performance. It was patients or families who decided whom to be employed (Liang et al., 2018). Many family/paid caregivers cannot follow nurses' guidance, yet nurses rarely intervened in such cases, and this ultimately led to MNC.

| Knowledge gap
Despite the increased attention to MNC, little knowledge was gleaned from interventional studies (Fitzpatrick, 2018). The exceptions to this statement were a train-the-trainer study (Kalisch, Xie, & Ronis, 2013) and a study about the effect of a primary nursing model (Moura et al., 2019). The quasi-experimental study revealed the causal relationship between improved teamwork and reduced MNC among 238 medical-surgical nurses (RNs, licensed practical nurses and nursing assistants) (Kalisch, Xie, et al., 2013). The predictive correlational study detected positive effects of the primary nursing model on MNC, demonstrating that MNC was a good indicator of changes to nursing process, organisation model and accountability (Moura et al., 2019).
The growth of MNC research worldwide did not yield much concerning MNC in China, as existing studies were limited to 500-740 nurses from between two and four tertiary hospitals (Chen et al., 2011;Chen, Liu, & Li, 2015;Si & Qian, 2017

| Aims
This study aimed to investigate the perceived occurrence of, and rea-

| ME THODS
A cross-sectional observational design was employed in the online survey of RNs at hospitals in a coastal province's capital city (approximate population: 8.7 million; area: 10, 244 km 2 ).

| Sampling and participants
Using convenience sampling (participant details in

| Instrument
The primary outcome was MNC, defined as the failure to accomplish required care, as anticipated (Kalisch & Xie, 2014 (Mueller & McCloskey, 1990) were used to measure the aforementioned outcome variables.

| Background information sheet
In addition to sociodemographic data (e.g. age, ethnicity, sex, years of work, marriage, education and position), clinical job features (e.g. preceptorship, night shifts and overtime) and subjective perceptions (i.e. intention to resign, support from family/friends and stressful events such as bereavement) deemed relevant to MNC were also inquired about.

| MISSCARE Survey
The MISSCARE Survey is comprised of Part A (MNC; ranged from 1 (none), 2 (mild), 3 (moderate), to 4 (severe harm). The rating of 1 or 2 was scored as 0 (no/low risk), while that of 3 or 4 was scored as 1 (risky). The kappa of 0.308 suggested a fair inter-rater agreement between experts, according to the criteria of 0.21-0.40 (Landis & Koch, 1977). Items that were disagreed upon (17/29, 58.6%) were discussed to arrive at a solution.

| Data collection
An online survey with a sharable hyperlink was created through the Wenjuanxing Web-based platform (Ranxing, Changsha, China).
The platform integrated the information and consent sheet,

| Data analysis
Descriptive and frequency analyses, and correlation, and reli-

| Participants' characteristics
Participants were 19 to 60 years old (mean 30.56, SD 7.014), and 2.5% were male. The majority were married and had worked as contract-

| Factors influencing MNC
All sociodemographic (e.g. marriage and education) and job-related (e.g. employment, manager position and night shift) factors, as well as some psychological ones (e.g. job satisfaction and family/friend support), significantly affected the reporting of MNC (Table 1). It was more likely (odds ratio [OR]: mean 1.454, SD 1.248) for the following participants to report MNC (β > 0, ps < .05): females, those not working the night shift, those with inadequate friend support and those with low job satisfaction. Participants who reported less (β < 0, ps < .05) had lower education, were staff nurses, were from lower levels of the hospital, were non-parents or were non-permanent employees (Table 4).

| MNC and job satisfaction
Participants were moderately satisfied with their job, as demonstrated by a mean MMSS item score of 3.269 (SD 0.404). MNC was negatively and fairly correlated with MMSS (r s = −.280, p < .001) and professional opportunity dimension (r s = −0.320, p < .001).

| D ISCUSS I ON
This study detected the perceived occurrence of MNC (mean 1.55, SD 0.404) approaching others (mean 1.56, SD 0.4) (Kalisch et al., 2011), suggesting a lower occurrence or reporting of missed care. Although family/paid caregivers were routinely involved in basic and psychosocial care (Hui et al., 2013), these were still the most frequently missed items. The findings of this study are distinct in their revelation of the notable frequency of missed emotional support items and family/paid caregiver refusal. Consequently, nursing managers in Chinese hospitals should review the practice of involving informal caregivers in professional services. Moreover, nurses' accountability (Srulovici & Drach-Zahavy, 2017) and delegation competency (Saqer et al., 2018) should be strengthened to improve collaboration with informal caregivers and colleagues.
Regarding the reasons for MNC, the most commonly reported reasons were directly or indirectly related to human resources, as hypothesized (i.e. shortage of nurses). This may be due to staffing inadequacy or heavy workloads (e.g. sudden rise in cases or in severe cases, discharge/admission and uneven workload). Surprisingly, 81.3% of participants indicated patient/family refusal as a moderate or major reason for MNC. This phenomenon is rarely investigated, particularly in comparison with life-saving treatment refusal (Jin & Zhang, 2020 Like others (Bragadóttir et al., 2017;Kalisch, Doumit, et al., 2013;Kalisch et al., 2011), this study observed the significant impact of many sociodemographic factors such as age, education and shifts.
Participants with certain characteristics were more likely to report or not to report MNC, for example females, those with job dissatisfaction and those echoing the findings of other studies (Duffy, Culp, & Padrutt, 2018;Kalisch et al., 2011). This study was one of very few to reveal the impact of psychosocial factors such as friend support, life events and job satisfaction. Psychosocial wellness greatly facilitates the reduction of MNC, so nursing managers should pay more attention to measures of psychosocial health in nurses.
In summary, hypotheses related to the influence of informal caregivers' engagement, individual and contextual characteristics, human resources and job satisfaction over MNC were supported by the findings from this study. For comprehensive interpretation, however, study limitations must be addressed.

| Limitations
The sample size exceeded estimates, and 84.3% eligible nurses completed the study. Convenience sampling was used instead of random because rosters for participating hospitals were unavailable.
Nonetheless, the use of the former limits study findings' generalizability to the target population.
Also, nursing directors disseminated the survey hyperlink to potential participants, which may have introduced implicit coercion.
It was, however, impossible to successfully recruit nurses to report hospital events while circumventing nursing directors. Since we asked about MNC in participants' units (instead of omissions or delays on the part of the participants themselves), the impact of social desirability should not be so high as to undermine the truthfulness of responses.
To select the most appropriate version of the three Chinese versions of the MISSCARE Survey (Chen et al., 2011;Chen et al., 2015; Si & Qian, 2017), we used subjective judgement instead of an objective approach (e.g. a concurrent test of three versions). This decision may have jeopardized the internal validity of this study. Besides, the use of multiple versions of the MISSCARE Survey makes it difficult to compare the outcomes in the same country.

| Implications for nursing management
Medical error is becoming one of the main causes of death, after cancer and cardiovascular disease. MNC precedes medical errors in nursing, so the effective prevention of the former may contribute significantly to the reduction of the latter.
This study revealed that human resource issues were the most frequently reported reason for MNC, which were associated with sudden increases in workload and/or critical cases. Beyond planning for more nurses, it is more practical to mobilize existing workforces, for the immediate solution for challenging situations (e.g. surges).
Flexible scheduling or repositioning of nurses and on-call staffing may release the reservoir of nurses to support places with urgent or suddenly increased needs, for example during a pandemic, emergency or disaster. This requires specific training and assessment to bank nurses-especially the young, motivated and willing.
Qualified trainees could be deployed immediately for urgent or critical care. The identification and regular training of deployable nurses could be integrated with other nursing development efforts, to reduce conflicts of interest or competition for resources.
This study also revealed gaps in basic care where family/paid caregivers are involved. Nurses' responsibility and competency in delegating, monitoring and supervising family/paid caregivers shall be strengthened. More specific training (e.g. delegation competency) and professional responsibilities should be emphasized. This way, attending nurses can improve their communication with, and supervision and assistance of direct care involving family/paid caregivers to prevent MNC.

ACK N OWLED G EM ENTS
We are very grateful to all nursing directors, head nurses and nursing participants for their contribution to this study. Without their support, this large-scale online survey would never be possible. We are also very thankful to Jinan Municipal Health Commission for financial support (Number: 2018-2-06).

E TH I C A L A PPROVA L
The Hospital Medical Ethics Committee (No. 2018-106-01) approved this study according to the principles of the Declaration of Helsinki. The original developers approved the use of the existing scales. All nursing directors and eligible nurses were informed of the study and the ethical principles that centred human rights protection and the minimization of harm (e.g. benefit vs. harm, voluntary participation, withdrawal, anonymity and confidentiality). Two authors answered enquires when they were made. All data were saved in password-protected computers, to be destroyed five years later. No one but the research team can access these data.