Differences between Registered Nurses and nurse assistants around missed nursing care— An observational, comparative study

Background: From a nursing perspective, tasks that are not carried out, and the consequences of this, have been studied for over a decade. The difference between Registered Nurses (RNs) and nurse assistants (NAs) regarding qualifications and work tasks, and the profound knowledge around RN- to-patient ratios, warrants investigating missed nursing care (MNC) for each group rather than as one (nursing staff). Aim: To describe and compare RNs and NAs ratings of and reasons for MNC at in-hospital


INTRODUCTION
Missed nursing care (MNC), which is also known as 'care left undone' or 'unfinished care', may be defined as any aspect of required patient care that, in part or whole, is performed, omitted or delayed [1].Acts of omission are supposed to occur to a greater extent than acts of commission [2].The consequences of acts of omission have been studied for over a decade [1,3,4].The impact of MNC has been studied by many others and one of the most commonly used instruments, the U.S.-developed MISSCARE Survey [5] has been translated into Icelandic [5] Portuguese [6], Turkish [7], Italian [8] and Swedish [9].In a review by Barrientos-Sigo et al., the MISSCARE Survey was ranked as one of the instruments with the highest methodological quality when evaluating the psychometric properties of instruments measuring nursing-sensitive outcomes [10].
Studies have shown that the prevalence of one or more activities of MNCs during the last shift has been reported to vary between 55% and 98% [11].Also, when reporting associations between the frequency of MNC and outcomes, a study from Switzerland has reported an association between a higher frequency of MNC and pressure ulcers, critical incidents and falls [12].Later on, an association with mortality was reported, that is, 30-day mortality [4] and in-hospital mortality [3].
In many countries, the nursing staff comprises different groups of nurses such as Registered Nurses (RNs), nurse assistants (NA) and/or practical nurses with differences in educational levels and work tasks [13][14][15].Since there is no universal definition for nurses working as an assistant/ under the supervision of RNs (in this study referred to as NAs), many of the studies around nurses' impact on patient safety are unclear regarding the term nurse, making comparison difficult.From a Nordic perspective, there are differences across the countries.In Iceland, RNs have a 4year baccalaureate degree [13], in Denmark and Finland three and a half year Bachelor's degree and in Norway and Sweden a 3-year Bachelor's degree [16].In Sweden, nursing staff include RNs and NA.RNs are registered health care professionals while the work and competence needed for NAs are not regulated.The education for NAs varies substantially and in Sweden, the education includes a 3-year high school diploma.In addition, RNs are able to continue with a 1-or 2-year master's programme and/ or PhD studies.At the in-hospital setting, the RNs are responsible for the overall nursing care to the patients and the NAs work as assistants to the RNs, delivering basic care to the patients, that is, the everyday care such as feeding, bathing, dressing, skin care, shifting positions/get the patients started, taking blood samples, transportation, etc.The NAs carry out their tasks independently but report to the RNs the patient status and actions taken.
Patient safety is a crucial component of health care quality [17] and nurses' impact on patient safety has been studied extensively for many years from the perspectives of RNs' level of competence, staff mix, nurses-to-patient ratios and in relation to patient mortality [14,[18][19][20][21][22].Changing the staff mix, that is, increasing the number of NAs, does not affect or reduce mortality as this seems to be associated with the number of patients per RN [4,22].Furthermore, hospitals with an average of approximately 4.5 patients per nurse compared to hospitals with approximately six patients per nurse, have better patient outcomes, such as improvement in mortality, length of stay and readmissions [14].
In 2018 Ball et al. raised the hypothesis that MNC mediates the relationship between RN/patient ratios and in-hospital mortality, and their results showed that more patients died when RNs reported MNC [4].In most of the previously published studies on MNC, data is reported for one nursing staff group [3,11,12,18].A limited number of studies have investigated RNs and NAs as separate groups in which RNs reported higher rating of MNC than NAs [1,13].But considering that specifically, MNC reported by RNs seem to be associated with in-hospital mortality [4], new studies presenting separated MNC data for different nursing staff groups are warranted.Moreover, in 2018 the International Council for Nurses issued a position statement on evidence-based safe nurse staffing, including emphasising the RNs' role in the nursing team [23].Therefore, the differences between RNs and NAs regarding education, qualifications and work tasks, and the profound knowledge around nurse-to-patient ratios, demand investigation in regard to MNC for each competence group.

AIM
The aim was to describe and compare RNs and NAs' ratings of and reasons for MNC at in-hospital wards.

DESIGN
A cross-sectional study with a comparative approach.

Setting and sample
The study was carried out at the Karolinska University Hospital, Sweden.Karolinska University Hospital is a tertiary referral hospital providing acute and highly specialised care for severe injuries, urgent medical conditions and care in connection with surgical procedures.The nursing staff at all medical and surgical wards including mixed, short-stay and high-dependency units were included.The intensive care units and the wards, departments and units within the children's division were excluded.At the time of the data collection, the number of in-hospital beds varied between 700 and 800.

Instrument
The MISSCARE Survey-Swedish version was used for collecting data.The instrument was recently translated and psychometric evaluated in the Swedish context with good results, where test-retest reliability for section A was 0.907 and for section B 0.514.Internal consistency for section B was calculated with Cronbach's alpha and was 0.769 [9].
The survey comprises three sections.The first section contains items on the background information of the participants, such as age and gender, and data on their present workplace, educational level and working role, etc.Also, satisfaction with the level of teamwork, satisfaction with the current work position and intention to leave are included in this section of the instrument.
The second section (section A) comprises 24 items on elements of MNC where the participants are asked about if and to which frequency, nursing care was missed by themselves or colleagues at their unit in the last month.The third section (section B) consists of 17 items on reasons for MNC where the participants are asked to include all nursing staff.Section A in the survey is answered using a five-point Likert scale; 'always missed', 'frequently missed', 'occasionally missed', 'rarely missed' and 'never missed'.Section B is answered with a four-point Likert scale: 'significant reason', 'moderate reason', 'minor reason' and 'not a reason for missed care'.In addition, we included two study-specific questions: 'How do you perceive the quality of care on the ward?' and 'How do you perceive patient safety on the ward?'The answers were given using a five-point Likert scale, with the answering options 'very good', 'good', 'neutral', 'poor' and 'very poor'.

Data collection
Data were collected from November to December 2020.The inclusion criteria were all eligible nursing staff (RNs and NAs) at the in-hospital wards.All eligible nursing staff received an email at their work email address in which they were asked to take part in the study.The email contained an individual link to the MISSCARE Survey-Swedish version.A reminder email was sent to non-responders about 1 week after the first email, and then another after 2 weeks.

Data analysis
Categorical variables are presented as frequencies and percentages.The continuous variable age is presented in median and range.An independent median test was used to compare the ages of the groups.Pearson's chi-square analysis was used to compare background characteristics between RNs and NAs.Satisfaction with the current work position and satisfaction with the level of teamwork were categorised into three categories: satisfied (including answering options 'very satisfied' and 'satisfied'), neutral and dissatisfied (including 'dissatisfied' and 'very dissatisfied').
All variables in sections A and B were treated dichotomously (MNC/not MNC respectively reason for MNC/no reason for MNC) as in line with the instrument originator [24].The answering options in section A 'occasionally', 'frequently' or 'always' missed, were classified as MNC.In section B, 'significant' or 'moderate' reasons were classified as reasons for MNC.Fisher's exact test was used to examine differences between samples concerning MNC in section A and reasons for MNC in section B. The answers about perceived patient safety and quality of care were categorised into three categories: good (including 'very good' and 'good'), neutral and poor ('poor' and 'very poor').Pearson Chi-square tests were used to explore differences in the perception of patient safety and quality of care.
The internal consistency for section B was calculated with Cronbach's alpha.A two-tailed statistical significance level was set at 0.05.No imputation of missing data was conducted.The statistical software used was IBM SPSS Statistics version 25 (IBM, 2017).

RESULTS
A total of 2996 nursing staff were invited.Of these, 424 answered the questionnaire, 205 (48.3%)RNs and 219 (51.7%)NAs, yielding a response rate of 14.2%.Participants' characteristics are shown in Table 1.
Quality of care and patient safety was rated as good by both RNs and NAs with no significant statistical difference between the groups.The level of teamwork was rated as good by both groups of nursing staff (RNs n = 135, 65.9% vs. NAs n = 131, 60.1%, p = 0.469).Both RNs and NAs were satisfied with their current position (n = 142, 69.3% vs. n = 155, 70.8% respectively, p = 0.495).However, more RNs reported they had an intention to leave their current  1).The items on MNC were ranked by the most frequently reported element of MNC in the total sample as well as by RNs and NAs (Table 2).One quarter (n = 6, 25%) of the items were ranked in the same order by both RNs and NAs.Of the top five ranked MNC items, one item ('Ambulation three times per day or as ordered') was at the same rank (rank three) in both nursing staff groups while the other four differed between the groups.The item 'Mouth care', ranked fourth by RNs, was ranked 11th by NAs.The mostrated MNC in the total group was 'Attending interdisciplinary care conferences whenever held' (54.4%).However, in this item, there was a discrepancy between RNs' and NAs' ratings (p = 0.015), where RNs reported more MNC compared to NAs (60.2% vs. 47.2%).NAs reported significantly more MNC in the item 'Medications administered within 30 min before or after scheduled time' (33.1% vs. 19.3%,p = 0.005), 'Patient medication requests acted on within 15 min' (30.6% vs. 10.9%,p < 0.001).In contrast, RNs reported significantly more MNC in the items 'Turning patient every 2 h', 'Ambulation three times per day or as ordered', 'Mouth care', 'Emotional support to patient and/ or family', 'Patient bathing/skin care', 'Wound care' and 'Focused reassessments according to patient condition'.
Reasons for MNC were ranked from the most frequently reported reason to the least frequently reported, and are presented in Table 3.Four (25%) of the 17 items were ranked in the same order by both RNs and NAs.No significant differences were found between the samples concerning reasons for MNC.The most reported reason was 'Unexpected rise in patient volume and/or acuity on the unit' (79.3%), followed by 'Urgent patient situations' (e.g. a patient's condition worsening) (75.2%).
The internal consistency for section B was good in both samples, with a Cronbach's alpha of 0.881 in the RN sample and 0.920 in the NA sample.

DISCUSSION
The study aimed to compare RNs and NAs ratings of and reasons for MNC at in-hospital wards.The main result of this study highlights statistically significant differences between how RNs and NAs rate MNC.This result indicates that RNs and NAs perceive and report MNC differently in little less than half (n = 10) of the 24 items in the MISSCARE Survey-Swedish version.It was more common that RNs reported significantly more MNC compared to NAs, and significant differences between the groups were found in 42% of the items.These items are related to basic care, mainly performed by NAs.The items that were rated in the opposite direction, that is, higher by NAs than RNs, are items that often are restricted to RNs, such as the administration of medicines.
The findings in our study concur with previous studies in which the nursing staff groups have been reported per group.For example, in a study using the Icelandic version of the MISSCARE Survey, 79% of the items were rated higher by the RNs compared to NAs [13].Also, in the USA a similar result to the Icelandic study has been reported [25].Of interest is that in our study the difference across the nursing staff groups occurred in less items than in the previous studies.Since there are limited numbers of studies to compare our results with,   and no other from the Nordic context with similar educational levels, the reasons for the differences found in our study are not known.Additional studies where each nursing staff group is reported groupwise is warranted in order to understand the difference between the groups better.
There is another perspective around MNC as in Sweden, the RNs lead the nursing teams and have a responsibility to provide safe care in a complex environment which requires teamwork and communication.In Swedish health care settings, the NAs are viewed as members of the patient care team and play a critical role in the team, working as assistants to the RNs, and delivering basic care to the patients.A study by Danielsson et al. reported that responsibility was shown as equally important for both NAs and RNs but viewed differently where RNs expressed an individual responsibility and difficulties in setting their limits [26].The NAs viewed their responsibility as vague and sometimes they were not given sufficient responsibility for important tasks.In an American context, in a study by Bellury et al., NAs perceived other NAs as the team who aided them in the achievement of their assigned tasks rather than RNs, and RNs described teamwork as reminding NAs of necessary tasks to be completed [27].Therefore, that RNs reporting MNC to a higher extent than NAs could be explained by the fact that RNs have overall responsibility for patient care and consequently report MNC when there is a lack of teamwork and a different view of responsibilities between NAs and RNs.Bragadóttir et al. argue that the differences in the level of education and training between RNs and NAs, as well as the difference with regard to their roles and responsibilities, could be an explanation for why RNs report higher MNC than NAs [13].This could influence which aspects of care they omit if they need to prioritise some actions.The terms 'nurse' and 'nursing staff' are, according to us, unfortunate and we suggest that future studies clearly define what types of nurses, for example, RNs, NAs or both, the studies are based on.We argue that the findings in our and other studies support our suggestion not to view RNs and NAs as a homogenous group, which is implied by terms such as 'nurses' and 'nursing staff', but as separate groups based on their different knowledge levels and roles when caring for patients.To treat two types of nurses (RNs and NAs) as one complicates comparisons between the groups and may result in important differences between the groups not being identified.Even though differentiation between nursing staff groups such as NAs and RNs often occurs [4], the recently published Australian study [14] around nurse-topatient ratios included different groups of nurses in the term 'nurses'.
Moreover, RNs need to know that their closest coworkers in the nursing team, the NAs, may not experience MNC in the same way as the RNs do.For example, in addition to competence and responsibilities, earlier research has shown that RNs' and NAs' perspectives such as values and norms regarding responsibility are viewed differently [26].We suggest that RN students should be learned about MNCs during their education in order to raise their awareness and able them to take action to mitigate the potential effects when MNCs occur.

LIMITATIONS
The low response rate is the major limitation of the study and is a threat to external validity.However, the lists of nurses who should be included in the study were not collected from the nurse manager; instead, the lists were collected from the human resources department with the goal of including nurses from in-hospital wards for adults as well as emergency departments.Therefore, there might be nurses that received the questionnaires but were not working at the wards, for example, nurses that had recently left their employment, had just gone on maternity leave or who were not working for other reasons.
Our findings show significant differences between RNs' and NAs' MNC reporting in section A, where there were significantly more missing data in some items among NAs.However, the high numbers of missing data in these items mirror which group in the nursing staff has the competence and responsibility to perform those tasks.The Swedish version of the MISSCARE Survey does not include the answering option 'not relevant' [9], which is a limitation we believe contributed to the number of missing data.
Moreover, answering a questionnaire retrospectively may influence the answers.Also, NAs answering for tasks only performed by RNs may be a limitation since there might be difficult for the NAs to be aware of all the tasks performed or not performed by the RNs.

CONCLUSION
This study demonstrated that RNs' and NAs' ratings of MNC to a large extent differed between the groups.RNs and NAs should be viewed as separate groups based on their different knowledge levels and roles when caring for patients.Thus, viewing all nursing staff as a homogenous group in MNC research may mask important differences between the groups.These differences are important to address when taking actions to reduce MNC in the clinical setting.

T A B L E 3
Significant and moderate reasons for missed nursing care by rank, numbers and valid percentages in the total group, and by NAs and RNs.

in section A Rank a Total sample n = 424 Rank a NA sample n = 219 Rank a RN sample n = 205 p b n (%)
, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13175by Dalarna University, Wiley Online Library on [02/05/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Abbreviations: IQR, interquartile range; NA, nurse assistant; RN, Registered Nurse.T A B L E 1 (Continued)14716712, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13175by Dalarna University, Wiley Online Library on [02/05/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License T A B L E 2 Missed nursing care by rank, numbers and valid percentages in the total group, and by NAs and RNs.Items Abbreviations: NA, nurse assistant; RN, Registered Nurse.a Rank: The ranking of reported most missed (1) to least missed nursing care elements in the total sample, the NA sample and the RN sample.b The significance level was set to p ≤ 0.05.14716712 The ranking most frequently reported reason (1) to less frequently reported reason for missed care.Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13175by Dalarna University, Wiley Online Library on [02/05/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License a Rank: