Missed nursing care in relation to registered nurses' level of education and self-reported evidence-based practice

Background: Patient safety is one of the cornerstones of high-quality healthcare systems. Evidence-based practice is one way to improve patient safety from the nursing perspective. Another aspect of care that directly influences patient safety is missed nursing care. However, research on possible associations between evidence-based practice and missed nursing care is lacking. Aim: The aim of this study was to examine associations between registered nurses' educational level, the capability beliefs and use of evidence-based practice, and missed nursing care. Methods: This study had a cross-sectional design. A total of 228 registered nurses from adult inpatient wards at a university hospital participated. Data were collected with the MISSCARE Survey-Swedish version of Evidence-Based Practice Capabilities Beliefs Scale. Results: Most missed nursing care was reported within the subscales Basic Care and Planning . Nurses holding a higher educational level and being low evidence-based practice users reported significantly more missed nursing care. They also scored significantly higher on the Evidence-based Practice Capabilities Beliefs Scale. The analyses showed a limited explanation of the variance of missed nursing care and revealed that being a high user of evidence-based practice indicated less reported missed nursing care, while a higher educational level meant more reported missed nursing care. Linking evidence to action: Most missed nursing care was reported within the sub-scales Planning and Basic Care . Thus, nursing activities are deprioritized in comparison to medical activities. Nurses holding a higher education reported more missed nursing care, indicating that higher education entails deeper knowledge of the consequences when rationing nursing care. They also reported varied use of evidence-based practice, showing that higher education is not the only factor that matters. To decrease missed nursing care in clinical practice, and thereby increase the quality of care, educational level, use of evidence-based practice, and organizational factors must be considered.

Methods: This study had a cross-sectional design.A total of 228 registered nurses from adult inpatient wards at a university hospital participated.Data were collected with the MISSCARE Survey-Swedish version of Evidence-Based Practice Capabilities Beliefs Scale.
Results: Most missed nursing care was reported within the subscales Basic Care and Planning.Nurses holding a higher educational level and being low evidence-based practice users reported significantly more missed nursing care.They also scored significantly higher on the Evidence-based Practice Capabilities Beliefs Scale.The analyses showed a limited explanation of the variance of missed nursing care and revealed that being a high user of evidence-based practice indicated less reported missed nursing care, while a higher educational level meant more reported missed nursing care.
Linking evidence to action: Most missed nursing care was reported within the subscales Planning and Basic Care.Thus, nursing activities are deprioritized in comparison to medical activities.Nurses holding a higher education reported more missed nursing care, indicating that higher education entails deeper knowledge of the consequences when rationing nursing care.They also reported varied use of evidence-based practice, showing that higher education is not the only factor that matters.To decrease missed nursing care in clinical practice, and thereby increase the quality of care, educational level, use of evidence-based practice, and organizational factors must be considered.

BACKG ROU N D
Research shows that patients trust registered nurses (RNs) to plan and deliver care based on the best available evidence, their clinical expertise, and the patients' own preferences (Cleary-Holdforth, 2019;Mazurek Melnyk & Newhouse, 2014).Considering such close involvement with patients and members of the wider multidisciplinary team, RNs play an integral and evidence-based role in healthcare organizations.During recent years, research has focused on the patient safety movement in relation to missed nursing care (MNC; Recio-Saucedo et al., 2018) which is defined as any aspect of required nursing care that is omitted (in part or in whole) or delayed (Kalisch, Landstrom, & Hinshaw, 2009).As RNs are at the forefront of delivering nursing care, the reports on MNCs are important for patients as well as for healthcare organizations and their patient safety work.There are several factors that contribute to variations in reported MNC, including individual nursing characteristics (e.g., nurses' educational level and nursing role), hospital characteristics (e.g., teaching hospital and number of hospital beds) unit characteristics (e.g., resources and communication) and work environment (e.g., supportive and/or ethical climate, collective efficacy, and teamwork; Mandal et al., 2020).
Consequences of MNC impact patient outcome, liked increased occurrence of infections, pressure ulcers, and mortality rates (Recio-Saucedo et al., 2018), and nursing staff outcomes, like decreased job satisfaction, burnout, and increased intention to leave (Albsoul et al., 2019;Cho et al., 2020).
Evidence-based practice (EBP) is one way to improve patient safety from the nursing perspective (Mazurek Melnyk & Newhouse, 2014).However, research on activities for basic nursing care, for example, bathing, dressing, communication, mobility, and nutrition care that is fundamental to all patients' health and wellbeing regardless of healthcare settings, is still scarce (Zwakhalen et al., 2018).Therefore, it is imperative that RNs actively work to improve their research knowledge so that the gap between theory and practice continues to close.RN EBP use has been reported to be modest (Melnyk et al., 2018;Saunders et al., 2019).RN use of EBP is associated with individual factors like educational level (Rudman et al., 2020) and years of practice (Saunders et al., 2019), and organizational factors such as supportive leadership, workload, organizational climate, and access to resources (Teixeira et al., 2023).Rudman et al. (2020) findings also show that RNs working in outpatient care and home care reported significantly more EBP use than RNs working in inpatient care (24/7 care).
Since 1993, nursing education in Sweden has been part of higher education.Since 2007, there has been a three-year study program leading to both registration as a nurse and a bachelor's degree according to the national education system (The Swedish Higher Education Act, 1992).Thereafter, one or two-year study programs at the advanced level, that is, 60-120 ECTS credits according to The European Credit Transfer and Accumulation System to achieve a master's degree are available in line with the European standard (Eurydice, 2022).Subsequently, a licentiate or doctoral (PhD) program in nursing is accessible.The well-established higher education system in Sweden gives unique research opportunities to examine the associations between educational levels in nursing for both EBP and MNC.
Therefore, we hypothesized that EBP capability beliefs and EBP use would be reported as higher among RNs with higher educational levels and that this would also be reflected in reported MNC.The aim of this study was to examine associations between RNs educational level, the capability beliefs, and use of EBP, and MNC.

Design, setting, and sample
This study had a cross-sectional design and was conducted at a university hospital (tertiary referral hospital with 1000 beds), providing acute and specialized care for severe injuries, urgent medical conditions, and care in connection with surgical procedures.A total of 1619 permanent employed RNs were invited to participate in the study.The inclusion criteria were all eligible RNs working at adult inpatient wards, which comprised medical and surgical wards including mixed, short-stay, and high-dependency units as well as intensive care units and emergency departments.Nurse assistants, contract RNs, and units within the children's division were excluded.

Measurements
To collect data on MNC, the MISSCARE Survey-Swedish version was used (Nymark et al., 2020).The background section of the survey includes questions on demographic data such as age and sex, educational level (i.e., bachelor, master, licentiate, or doctoral level according to the European level of education (Eurydice, 2022)), and experience in the role and at the current unit.Section A comprises 24 questions on elements of MNC, answered using a five-point Likert scale which in this study was coded numerically: never missed = 1, rarely missed = 2, occasionally missed = 3, frequently missed = 4, and adult health/adult care, advanced practice/advanced, education, evidence-based practice, missed nursing care, nursing practice, nursing practice, patient safety, quantitative methodology | 3

MNC AND EBP IN RELATION TO ACADEMICS IN NURSING
Data on the practice of EBP were collected using the Evidencebased Practice Capabilities Beliefs Scale (EBPCBS) which assesses the two concepts of self-reported capability beliefs of EBP and the use of EBP (Wallin et al., 2012).The six items reflect the EBP process as follows: (1) formulating questions about clinical practice to search for new research-based knowledge, (2) using databases to search for knowledge, (3) using other information sources, for example books, journals, or asking colleagues, (4) appraising research reports, (5) contributing to change in clinical practice by implementing research knowledge, and (6) participating in evaluating whether clinical practice is based on research knowledge (evaluating practice).To assess the respondent's beliefs concerning EBP capability they were asked to rate how confident they were about performing each step of the EBP process.They did this using the scale: 0-30: No, I cannot manage that; 40-70: I might manage that; and 80-100: I'm sure I can manage that.Furthermore, the EBPCBS also includes a section asking the respondents how often they carry out the six EBP activities in their daily work.The respondents were asked to rate the activities on a scale from 1 to 4: seldom or never = 1, about once every 6 months = 2, about once a month = 3, and several times a month = 4.The validity and reliability have been tested in all types of healthcare settings (Wallin et al., 2012).

Data collection
The eligible participants received an email with an individual link to the web survey in which they were asked to participate.Two reminders were e-mailed to non-responders.The data collection was concluded in November 2021.

Data analysis
MNC was defined as when items regarding care were reported as occasionally, frequently, or always missed.All MNC items were subsequently treated dichotomously.Similar to Kalisch, Landstrom, and Williams (2009), the items in the MISSCARE Survey were divided into four broader care groups: (1) Basic Care, (2) Assessment, (3) Individual Needs, and ( 4) Planning.The study by Kalisch, Landstrom, and Williams (2009) was based on an older version of the MISSCARE Survey (23 items), where the item Wound Care was not included, and in this study, it was incorporated into the care group Basic Care.The MNC item Handwashing (meaning nursing staff's handwashing) was included in this study in the Basic Care group, contrary to Kalisch, Landstrom, and Williams (2009), who included the item Handwashing in the care group Assessment.
Indices were generated from the MISSCARE Survey care groups to measure the respondent's ratings within each care group.The items in the respective care group were summarized and divided by the number of included items in each care group: Basic Care (8 items), Assessment (7 items), Individual needs (6 items), and Planning (3 items).Similarly, an overall MNC index was generated to measure the respondent's overall rated MNC.The 24 items on the MISSCARE Survey were summarized and divided by 24.All items were equally weighted.Thus, each index was in the range 1-5, where 1 represented never missed and 5 always missed.
From the EBPCBS, two indices were generated; one to measure the respondent's capability beliefs concerning the EBP process, and another to measure the respondent's use of the EBP process.The six items in the respective indices were summarized and divided by six.
Thus, the EBP capability index was in the range 0-100, the higher the value the higher the capability beliefs.The EBP use index was in the range of 1-4, where 1 represented seldom or never and 4 several times a month (Wallin et al., 2012).
Group comparisons were made between four groups based on low/high educational levels and low/high EBP use.A lower educational level meant holding a bachelor's degree, including a nursing diploma.A higher educational level included 1 and 2-year master's degrees, or licentiate or a PhD degree.For answers on the EBP use index, the median value (2.5) constituted a cut-off for RNs who were low EBP users (scoring median or below the median value) versus high EBP users (scoring above the median).
A chi-square test was used to explore differences in background characteristics between groups and missed elements of care.An independent samples median test was used to compare ages between groups.When presenting MNC items, valid percentages were used thus missing data were excluded from calculations.An independent samples t-test was used to compare means on EBP capability beliefs, EBP use scales, and MNC care groups between educational levels.A one-way ANOVA was used to compare means on subscales and overall MNC between low/high EBP users at educational levels.A Pearson correlation coefficient test was used to assess the relationships among the MNC total scale, MNC groups, the EBP use index, and the EBP capability beliefs index.The interpretation of the value of the correlation coefficient differs between studies (Overholser & Sowinski, 2008); in this study, r was interpreted as weak when r was <0.10-0.20;fair when 0.21-0.40;fair and good when 0.41-1.0.Multiple stepwise regression analysis was used to study how overall MNC and MNC group subscales (dependent variables) varied with the EBP capability beliefs index, the EBP use index, experience in the role, and educational level.Statistical analyses were performed with SPSS 25, and statistical significance was set at 0.05.

Ethical issues and approval
The study followed the principles outlined in the "Declaration of Helsinki."Written information about the study was given as an introductory text to the survey, where voluntariness was emphasized, and confidentiality guaranteed.The participants consented to participate by answering the questionnaire.The study was approved by the National Ethical Review Authority (reference number 2019-04080).

RE SULTS
A total of 228 RNs answered the questionnaire (response rate 14.1%).Data were missing on EBP for 10 RNs and on an educational level for an additional 5, thus, 213 RNs were the final sample.Most RNs were female with a bachelor's degree.RNs with higher educational levels, that is, master to a doctoral degree compared to bachelor's degrees, had significantly more experience in the role and their current working unit (Table 1).
Most MNCs were reported within the care group Planning, followed by Basic Care.The overall MNC index mean value differed significantly between groups, where RNs holding a higher degree scored more MNC, independent of high or low EBP use.This was also evident for the care group indices Basic Care and Planning (Table 2).When comparing MNC solely between educational levels the same pattern was viewed (Table S1).
The overall EBP capability beliefs index for the total sample was 82.9 indicating a rather high EBP capability beliefs with a variation between the six items of 91.9 for searching other sources and 75.4 for appraising research reports.The overall EBP use index was 2.5 indicating an EBP use at least once a month with a variation between the six items of 3.3 for searching other sources and 1.9 for appraising research reports (Table 3).
RNs with a higher educational level scored significantly higher on the EBP capability beliefs index and within all aspects of the EBP capability beliefs scale except for the item Search Other Sources.They also scored significantly higher on the EBP use index and within the EBP use items formulate questions, appraise research reports, implement knowledge, and evaluate practice (Table 3).between Overall MNC and the EBP capability beliefs indices were found in RNs with higher educational levels (Table S2).
The variation in the overall MNC and care group indices was analyzed with multiple stepwise regression, which showed a limited explanation of the variance (Table S3).Non-significant models were found within the care group Assessment and Individual needs indices (data not presented).In all significant regression models, only two independent variables were significant; the EBP use index and academic degree.In the significant models (where the dependent variables were overall MNC, Basic Care, and Planning indices), being a high EBP user indicated less reported MNC.All models also showed that having a higher educational level (i.e., master to doctoral degree) meant more MNCs reported on the overall MNC, Basic Care and Planning indices, in comparison to RNs with a lower educational level (bachelor's degree).

DISCUSS ION
Most of the RNs (68%) had a bachelor's degree in nursing and one-third had a master to doctoral degree in nursing.In Sweden, graduating from nursing programs provides a nursing diploma with a bachelor's degree.In 2021, the National Academies of Sciences made a recommendation that an 80% proportion of RNs with a bachelor's degree in nursing to provide safe care (National Academies of  (Boström et al., 2018).
The reasons could be that our study was conducted in a university hospital where the mission was to perform care but also to provide education and clinical training for students and conduct clinical research.Significant associations between a higher academic degree and a greater extent of EBP use were identified in this study, which is in line with previous studies (Furuki et al., 2023;Rudman et al., 2020).However, nearly half of the RNs with a higher academic degree were classified as low EBP users.Being trained to use EBP does not mean that RNs can practice these skills after education.Another explanation could be that the prerequisite for EBP activities such as resources for searching databases for evidence is not supported for RNs in 24/7 clinical settings, despite working at a university hospital.
Other reasonable explanations could be individual factors, although previous research points to organizational factors, such as lack of leadership in the development of nursing practice (Bianchi et al., 2018;Orton et al., 2019).Research has also suggested that staff working in units with a more positive work environment were less likely to report missed care tasks, therefore the work environment (e.g., teamwork, communication, and accountability) should be considered as a modifiable factor to improve the quality of care (Cordeiro et al., 2020;Song et al., 2020).Furthermore, previous research has shown that, in contrast to the case of RNs working in outpatient care and home care, working in an inpatient context in hospitals (24/7) is not supportive of RNs' use of EBP (Rudman et al., 2020).This might be because of the RNs ability to engage in continuous professional development or may be due to other unknown reasons in inpatient settings.
The findings of this study indicate that RNs holding higher educational levels and who also were low EBP users reported significantly more MNC on the overall total MNC scale and in the subscales Basic Care and Planning compared to the three other groups.
This result may seem inconsistent but could possibly be explained by that the MISSCARE Survey is answered in the perspective of all the MNCs at the ward (i.e., not only the MNC performed by themselves), and the RNs with higher education have the knowledge and skills necessary for the nursing practice that should be performed for the patients.However, if they do not have the authority or mandate to influence the nursing care for the patients, they might report MNC to a higher extent than RNs with a lower educational level.Thus, to decrease MNC in hospitals, managers need to employ and help RNs with higher educational levels to become high EBP users.Our findings, together with previous research (Bianchi et al., 2018;Crawford et al., 2023;Furuki et al., 2023), emphasize that the organizational context (including teamwork), where quality improvement and patient safety are prioritized, is crucial to achieving better patient outcomes.

Limitations
This study has some limitations that need to be addressed.
Irrespective of the level of educational level, most RNs (54.5%, n = 116) were low EBP users (scored the median value of 2.5 or below on the EBP use index).When examining relationships between the overall MNC and the EBP use index, fair correlations were found between the EBP use index and the Planning index, irrespective of educational level.Additionally, fair correlations were found between the EBP use index and the Basic Care and Overall MNC indices for nurses holding a higher educational level.A significant but weak correlation was found between the EBP capability beliefs and the overall MNC indices in RNs with a bachelor level, and a fair correlation between the Planning and the EBP capability beliefs indices.No significant correlations 17416787, 0, Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/wvn.12681by Sophiahemmet University, Wiley Online Library on [13/10/2023].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

Total sample, n = 213 Bachelor level, low EBP user, n = 84 Bachelor level, high EBP user, n = 60 Master-doctoral level, low EBP user, n = 32
Characteristics of participating RNs and total sample by educational level and EBP use.Missed nursing care by educational level and EBP use with numbers and valid percentages, mean for overall MNC, and care group indices.Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/wvn.12681by Sophiahemmet University, Wiley Online Library on [13/10/2023].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: EBP, Evidence-based practice.The Bold values are significant.17416787, 0, Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/wvn.12681by Sophiahemmet University, Wiley Online Library on [13/10/2023].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 TA B L E 2

Items by care group Bachelor level, low EBP user, n = 84 Bachelor level, high EBP user, n = 60 Master-doctoral level, low EBP user, n = 32
(Aiken et al., 2014;entages given per item represent respondents reporting the element of care occasionally, frequently, or always missed.The higher mean score in care group indices and overall MNC index, the more MNC.Registered nurse scoring on the EBP capability beliefs scale.Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/wvn.12681bySophiahemmet University, Wiley Online Library on [13/10/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)onWiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Sciences, 2021), which is also supported by research showing that such a proportion leads to significantly reduced odds of in-hospital mortality, seven-day readmission, and 30-day readmission, and a shorter length of stay in the acute care hospital(Aiken et al., 2014; The representativeness is limited due to the nature of the sample since a single-center sample from a tertiary hospital providing acute and specialized care was used.Thus, only the acute care context was included.However, the sample was considered representative of the hospital since the largest proportion of included RNs mirrored the largest care areas at the hospital, and the largest proportion of RNs had a first-cycle degree.The authors recognize that reported MNC differs between settings nationally and internationally, and that the use of EBP is affected by educational degree and organizational factors at the specific units.The sample size is also a limitation, based on a low response rate.Web-based surveys generally have lower response rates in comparison to paper surveys, but there is no agreed norm on acceptable response rates in academic surveys, and response rates have historically decreased over time.Another factor to consider is whether returned questionnaires are usable, that is, to consider the amount of missing data.In our study, all but 15 questionnaires were considered usable, and we present missing data in each MNC item.A strength of this study is that validated surveys have been used.17416787, 0, Downloaded from https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/wvn.12681by Sophiahemmet University, Wiley Online Library on [13/10/2023].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