STRENGTHS AND LIMITATIONS OF THIS STUDY

It is difficult to determine the causal relationship between dependent and independent variables, similar to the chicken-and-egg dilemma.

The tools used lacked an observational checklist.

The study acknowledges the possibility of social desirability bias and recall bias as limitations.

Introduction

The provision of nursing care is an important aspect of patient care, essential for the recovery and rehabilitation processes of patients.1 Nursing care involves duties performed by nursing personnel, including medication administration, posture correction, head-to-toe care, monitoring and recording vital signs, maintaining fluid input–output charts, educating newly admitted patients about nutrition and other aspects of health, and properly discharging patients.2 Missed nursing care, a type of error by omission, is defined as any element of necessary patient care that is omitted (completely or partially) or significantly delayed.3

According to a previous study, missed nursing care is common and widespread in different countries.4–8 Evidence from previous literature indicates that nurses’ age, highest level of education, workplace characteristics, working shift, healthcare provider communication, workload intensity, satisfaction with current employment and intention to continue working in their profession are the most significant determinants of missed nursing care.4 9 10 Other factors, including inadequate hospital resources, the working environment, nurse–patient ratios, a lack of effective communication, and their intention to remain in or leave their nursing profession or the institution, are also associated with missed nursing care.6 9 11 12

The incidence of missed nursing care varies widely, with reports indicating that it affects anywhere from 10% to as much as 74% of patient care scenarios.4 9 10 Various forms of missed nursing care have been identified as particularly prevalent and impactful.13 These include critical aspects such as planning and educating patients about their discharge, offering emotional support to patients and/or their families during initial assessments, conducting thorough physical examinations, diligently monitoring patients’ fluid intake and output, ensuring patients are turned every 2 hours to prevent bedsores, and assisting patients with ambulation to promote mobility and circulation.4 12 14 Each of these neglected care activities underscores the multifaceted nature of nursing work and the profound effect that missed care can have on patient health and recovery trajectories.13 15

Missed nursing care puts patients’ safety at risk and raises healthcare costs. Every shortfall in the nursing care process impacts the patient’s health.16 Additionally, studies have shown a link between missed nursing care and adverse patient outcomes, such as patient falls, nosocomial infections, pressure ulcers, increased risk of readmission after discharge, mortality and decreased patient satisfaction.13 This situation underscores the critical need to address the underlying factors leading to missed nursing care, emphasising the importance of adequate staffing, proper training, and sufficient resources to ensure high-quality patient care and mitigate avoidable healthcare costs.17 18 In Ethiopia, nurses face challenges that lead to the omission of critical patient care activities.19 Such scenarios have far-reaching consequences, notably in the improper placement of patients, the development of pressure ulcers and an overall increase in healthcare costs. Omissions can occur for various reasons, including staffing shortages, high patient-to-nurse ratios, inadequate training or resource constraints.20 21

Research efforts have been directed towards understanding the phenomenon of missed nursing care, including identifying the types of care most commonly omitted and the potential consequences these omissions can have on patient outcomes.22 23 Such studies have successfully highlighted the prevalence of missed nursing care and brought attention to its impact, ranging from delayed recovery to increased risks of complications and even mortality. However, despite these advances, a significant gap remains in our comprehension of the issue.19 Specifically, the existing body of research has not sufficiently explored or explained the root causes behind why nursing professionals regularly fail to administer certain crucial care elements to their patients.13 22

This gap in understanding points to a significant area ripe for intervention. Moreover, it appears that, within this specific field of inquiry, there has been a lack of research specifically focused on the factors contributing to missed nursing care.15 24 This oversight is particularly notable given the emergence of new, comprehensive specialised healthcare facilities, such as the Tibebe Ghion Comprehensive Specialized Hospital (TGCSH), which present unique contexts for examining such issues.

The introduction of this study aims to bridge these gaps by shedding light on the causes and predictive factors of missed nursing care, thus offering a fresh perspective on an old problem. By delving into these areas, the research promises to provide valuable insights for healthcare workers, equipping them with a deeper understanding of how to address and mitigate missed care. Furthermore, this study endeavours to explore how innovative solutions can tackle this issue, offering policymakers and health organisations, including health offices and the Ministry of Health, actionable evidence to inform their decisions.25 In doing so, the research could play a pivotal role in enhancing patient care quality, showcasing how new approaches and technologies might be harnessed to improve outcomes in the healthcare sector.26 This gap in knowledge is critical because, without a deep understanding of the factors that lead to missed care—whether they pertain to systemic issues within healthcare settings, such as staffing shortages and inadequate resources, or to more individual-level factors, like training deficiencies, burnout or the complexity of care needed—efforts to address and mitigate the problem may be misguided or ineffective.12 Identifying and understanding these underlying reasons are essential for developing targeted interventions that can support nurses in fulfilling all aspects of patient care, thereby improving patient safety and the overall quality of healthcare services. Therefore, the primary aim of this study was to assess missed nursing care and identify its associated factors.

Corrections and adjustments were made to enhance readability, consistency and grammatical accuracy, ensuring the text adheres more closely to British English standards.

Research question

What is the missed nursing care involved in public hospitals in Bahir Dar City, and what are its possible predictors?

MethodsStudy design, area and period

An institution-based cross-sectional study was conducted in primary and secondary-level public hospitals in Bahir Dar City from 16 March to 16 April 2023. Bahir Dar, the capital city of the Amhara region, is located 565 km northwest of Addis Ababa. The study was conducted in three government hospitals in Bahir Dar, incorporating all departments within each hospital: TGCSH and Felege Hiwot Comprehensive Specialized Hospital (FHCSH), both secondary level, and Addis Alem Primary Hospital (AAPH), at the primary level. The total number of nurses employed across these three hospitals was 819. TGCSH, situated in the southern part of Bahir Dar City, has the capacity to serve approximately 3.5–5 million people and employs 296 nurses. FHCSH, located in the northwestern part of Bahir Dar, serves 3.5–5 million people and has a staff of 470 nurses. AAPH, located in the northeastern part of the city, caters to 60 000–100 000 people and employs 53 nurses.27

Participants

Nurses who had worked in Bahir Dar City hospitals participated in the study.

Inclusion and exclusion criteriaInclusion criteria

All nurses who had worked in those hospitals were eligible for the study.

Exclusion criteria

Nurses with less than 6 months of work experience and nurses in administrative positions (not directly involved in continuous patient care) were excluded.

Data collection tools

Data were collected using a structured, self-administered survey tool adopted from the development of a psychometric tool to measure missed nursing care, with slight modifications applied.14 The tools, originally in English, were used because the participants were fluent in understanding, speaking and writing English. Three BSc nurses were involved in the data collection, under the continuous supervision of the principal investigator. The questionnaires contained a total of 47 questions, divided into three parts. Part one includes 20 questions on facility and respondent characteristics. Part two consists of five questions to assess the level of satisfaction, with responses ranging across four alternatives: 4 for very satisfied, 3 for satisfied, 2 for dissatisfied and 1 for very dissatisfied. For the satisfaction assessment, responses of very satisfied and satisfied were considered a ‘yes’ for satisfaction, whereas responses of dissatisfied and very dissatisfied were considered a ‘no’. Part three includes 22 questions designed to assess various types of missed nursing care, with responses based on a Likert scale: 1 for never, 2 for rarely, 3 for sometimes, 4 for frequently and 5 for always missed. For each question, missed care was defined as ‘not occurred’ (event=0) if the response was 1–2 (rarely or never) and as ‘occurred’ (event=1) if the response was 3–5 (sometimes, frequently or always missed). This tool has previously been used in Northern Ethiopia.14

Operational definition of key variables

Missed nursing care: nursing care was considered missed if the response of participants for each questionnaire was, sometimes missed or frequently missed or always missed. In terms of the whole questionnaire, out of 22 questions, if the score is >11, it is reported as missed to determine prevalence.12 14

For satisfaction assessment, very satisfied and satisfactory responses were considered satisfaction ‘yes’, whereas dissatisfied and very dissatisfied responses were considered satisfaction ‘no’.14

Perceived staff adequacy: perception of the respondents toward the adequacy of their nursing staff in their unit to accomplish nursing activities.11

An adequate nurse-to-patient ratio is considered to be 1:5 or less in general wards, 1:2 or less in the emergency room, gynaecology emergency unit, neonatal, paediatrics and adult intensive care unit, and 1:1 in the trauma unit; ratios exceeding these thresholds are deemed inadequate.28

Sample size

The actual sample size for the study was determined using the single population proportion formula n=[(zα/2)2p(1−p)]d2=sample size, zα/2=95% confidence level, and p=the proportion of missed nursing care, which was obtained from the previous study conducted in Tigray region, Ethiopia (33%),12 with a 5% margin of error, so the final sample size was 374. The authors considered the second objective to calculate the sample size using Epi Information software V.7 with the assumption of power 80%, 95% CI and ratio 1:1; however, the sample size calculated from the second objective (factors) was lower than that calculated using the single proportion formula. Therefore, the authors took the largest which was 374, using the single proportion formula.

Sampling method/techniques

A computer-generated simple random sampling method was used to select the study participants. To select the participants, the samples were allocated proportionally based on the number of nurses in each hospital (figure 1).

Figure 1

Schematic presentation of the sampling procedure for studying missed nursing care and its associated factors.

Data collection procedure

A list of nurses working in the wards of each hospital was then obtained from the nursing management office. Subsequently, using names generated by computer, the data collectors distributed the questionnaire to each participant. Three nurses collected data during the day shift, supervised by one MSc-qualified nurse, and two other nurses collected the data during the night shift, supervised by another MSc-qualified nurse.

Data quality control

To ensure the quality of data, a pretested and validated tool was employed. A pretest was conducted at Debre Tabor Comprehensive Specialized Hospital with 5% of the sample size (19 participants). Before the actual data collection, data collectors received training. The data collection was conducted by five trained data collectors, all holding BSc degrees in nursing, under the supervision of two nurses with MSc degrees. To minimise response or selective bias, methods such as randomisation and double-blinding were applied during data collection. Following a 1-day training session, face-to-face interviews were conducted to collect data. Consent and willingness were obtained from each participant before administering the questionnaires.

Data quality was further ensured by the initial training of data collectors. After the pretest and feedback, necessary corrections, including questionnaire modification and clarification, were made. Additionally, a reliability test (Cronbach’s alpha) was conducted, yielding a result of 0.892. Regular monitoring was carried out during data collection, with obtained questionnaires being reviewed for completeness and accuracy both during the interviews and at the end of each day. The tool was validated by two professional experts (content and language experts). Although this tool has previously been used in Northern Ethiopia, modifications were made based on the characteristics of the study population.

Data processing and analysis

The data were entered into Epi Data V.4.6 and then exported to SPSS V.25 for analysis. Descriptive statistics were performed to describe the sociodemographics, job-related items and instances of missed nursing care in terms of mean, frequency and percentage. The Hosmer and Lemeshow tests were used to assess the model’s goodness of fit, which was found to be 0.56. Multicollinearity was also checked using the variance inflation factor (VIF), with all values yielding between 0.4 and 0.85, which is normally considered acceptable if less than 4. A VIF greater than 4 is considered to indicate moderate multicollinearity, and values greater than 10 indicate significant multicollinearity. Binary logistic regression models, using both bivariate and multivariable analysis methods, were employed to assess associations between independent variables and the dependent variable. Variables with a p value less than 0.25 in bivariate analysis were considered candidates for multivariable analysis to control for confounders. A significance level of p<0.05 was used to declare the presence of a statistically significant association, with the adjusted OR (AOR) reported along with a 95% CI.

Patient and public involvement

No patients were involved in this study.

ResultSociodemographic and professional characteristics of the participants

Of a total of 374 samples, 369 nurses participated in the study, yielding a response rate of 98.7%. The mean age of the respondents was 30.7±4.7 years, with ages ranging from 23 to 45 years. Most (89.7%) of the participants held BSc degrees, and slightly more than half (51.5%) of them were female. More than half of the participants (53.7%) were married. Nearly half (46.1%) of the participants had 5–10 years of work experience (table 1).

Table 1

Sociodemographic characteristics of participants in Bahir Dar City public hospitals, 2023 (n=369)

Job-related characteristics of the nurses

The majority of the participants (80.5%) were dissatisfied with their salaries; however, 74.6% were satisfied with the level of teamwork. Approximately half (48.5%) of them had planned to leave the nursing profession. Most participants (88.3%) worked 40 hours or more per week, and 6 out of 10 (59.3%) had undergone job training in the last year (table 2).

Table 2

Job-related characteristics of nurses in Bahir Dar public hospitals, 2023 (n=369)

Missed nursing care among nurses

The prevalence of missed nursing care (completely and partially not performed or delayed) was 46.3% (95% CI 41.7% to 50.9%). The most commonly missed nursing care activity was the physical examination (head to toe), at 56.4%. In contrast, the least commonly missed nursing care intervention was bedside glucose monitoring, at 31.7% (figure 2 and table 3).

Table 3

Missed nursing care in Bahir Dar public hospitals, 2023 (n=369)

Figure 2

The magnitude of missed nursing care in Bahir Dar public hospitals in 2023 (n=369).

Factors associated with missed nursing care

A binary logistic regression model with multivariate analysis revealed that sex, job training, working shifts, satisfaction with teamwork and intention to leave the nursing profession were significantly associated with missed nursing care. Males were 2.9 times more likely to miss nursing care than females (AOR: 2.9; 95% CI: 1.8 to 4.8). Individuals who had not undertaken job training in the last year were 2.2 times more likely (AOR: 2.2; 95% CI: 1.4 to 3.6) to miss nursing care than those who had received training. Nurses working full 24-hour shifts were 3.7 times more likely to miss nursing care compared with those working only day shifts (12 hours) (AOR: 3.7; 95% CI: 2.0 to 6.5). Nurses with an intention to leave their profession had 1.8 times higher odds of missing nursing care compared with those who were stable in their profession (AOR: 1.8; 95% CI: 1.1 to 2.9). Nurses dissatisfied with teamwork were 4.6 times more likely to miss nursing care than those who were satisfied (AOR: 4.6; 95% CI: 2.8 to 7.6) (table 4).

Table 4

Factors associated with missed nursing care (MNC) among nurses in Bahir Dar public hospitals, 2023 (n=369)

Discussion

In this study, the prevalence of missed nursing care (completely and partially not performed or delayed) was 46.3% (95% CI 41.7% to 50.9%). This is in line with a study conducted in Rwanda at 46.7%7 and Nigeria at 42.5%.29 However, this finding is lower than that of a study conducted in Iran at 72.1%.4 This difference may be attributed to the study population and settings. Indeed, the study in Iran was conducted solely in the gynaecology and obstetrics unit, whereas this study included all inpatient units and all participants were nurses. The result of this study is much higher than those of other studies, such as in the USA at 36%,30 Gaza at 39%8 and Egypt at 41.1%.6 This variation may result from high patient flow, inadequate staffing and low resource accessibility in Ethiopia.14 This conclusion is supported by a previous study.6

This significant figure underscores the challenges within healthcare settings, pointing towards systemic issues such as inadequate staffing, high nurse-to-patient ratios, and insufficient resources or training. The activities most frequently reported as missed include comprehensive physical examinations (56.4%), discussing patient expectations (51.5%), patient discharge planning and teaching (50.9%), providing emotional support to patients and their families (50.8%), monitoring patient input and output (50.2%), ensuring patient ambulation as ordered (48.5%) and thorough documentation of necessary data (48%). These findings highlight critical areas of patient care that are neglected, potentially compromising patient safety, satisfaction and overall health outcomes. These results are in agreement with those of studies in Tigray, Ethiopia; North Shewa, Ethiopia; Iran and Australia.4 12 14 31

In nursing settings, when care tasks are inadvertently overlooked or left unattended, it often stems from an implicit hierarchy of task importance that nurses are forced to adopt as a coping mechanism to manage excessive workloads.32 This prioritisation process, though not always explicitly recognised, reflects the challenging decisions nursing professionals must make under the pressure of time constraints and resource limitations. The phenomenon of missed care highlights the complex interplay between the demands placed on nursing staff and the practical realities of delivering comprehensive patient care within the constraints of their working environment.32 33 Nurses may perceive physical examination as a physician’s task. In addition, nurses may miss these tasks because of their overdependence on family involvement in basic care. Some nurses may delegate nursing tasks to patient attendants and believe that patient families can accomplish tasks such as patient ambulation and monitoring input and output.34

Conversely, the aspects of nursing care least likely to be missed involve more procedural or routine tasks such as skin and wound care (26.8%), timely medication administration (27.1%, within 30 min of the scheduled time), assessment of vital signs as per orders (28.2%), administration of as-needed medication within 15 min of a request (28.2%) and bedside glucose monitoring as ordered (31.7%). These tasks, possibly due to their more immediate or visible consequences if neglected, or their routine nature, are prioritised over more holistic and time-consuming aspects of care.19 This discrepancy in care priorities suggests a need for systemic changes within healthcare institutions to ensure a more balanced approach to patient care, emphasising both the immediate and long-term needs of patients. Addressing the root causes of missed care, such as staffing and resource inadequacies, could improve the quality of patient care and enhance the overall healthcare experience for both patients and providers.13

The current study’s findings that male nurses are more likely to miss nursing care align with previous research conducted in Jimma, Ethiopia; Iran and Jordan.4 11 35 One plausible explanation for this trend is the observation that female nurses tend to be more committed to their caregiving roles, often engaging more deeply and empathetically with their patients. In contrast, male nurses are often found in roles requiring greater physical exertion, such as in operating theatres, which may influence the distribution of care tasks.36 In addition, female nurses interact more intimately with their patients.37 Male nurses tend to work in areas that require more energy, such as the operating room.38

Additionally, the study identified a higher incidence of missed care among nurses working 24-hour shifts compared with those on 12-hour day shifts, echoing findings from Tigray and North Shewa, Ethiopia and Jordan.12 14 35 The extended hours without sufficient rest likely contribute to fatigue, increasing the likelihood of omitted care. This underscores the critical need for adequate rest and recovery periods for nursing staff to maintain care quality.39

This finding revealed that those who had not taken job training in the last year were more likely to miss nursing care than those who had. The link between the absence of recent job training and increased missed care highlights the importance of ongoing education in nursing practice. Training not only updates nurses on best practices and new technologies but also reinforces the importance of comprehensive patient care, including emotional support. Thus, enhancing in-service training programmes could significantly improve nursing competence and patient outcomes.40 41

Those who had intentions to leave their position were more likely to miss nursing care than those who did not. This result is comparable with previous findings from Iceland, Saudi Arabia, and Tigray, Ethiopia.12 33 42 Those who intend to leave their institution may invest their time in searching for a vacancy or doing overtime work. This might deteriorate their concern about their care performance, which might then lead them to miss nursing care.

In this study, nurses dissatisfied with the level of teamwork were more likely to miss providing nursing care than their counterparts. This result is comparable with previous studies from Iran4 and Jimma, Ethiopia.4 11 Effective nursing care relies heavily on teamwork, and dissatisfaction in this area can lead to stress, burnout and decreased care quality. Enhancing teamwork through better communication, mutual support and shared goals could mitigate this issue, reducing the likelihood of missed care. These findings highlight several implications for healthcare management, including the need for targeted strategies to improve work conditions, professional development and the work environment. By addressing these factors, healthcare institutions can enhance the quality of nursing care, thereby improving patient outcomes and satisfaction.43

Limitations of the study

The study shares the limitations of a cross-sectional study design, which may make it difficult to distinguish the causal relationship between dependent and independent variables (akin to the chicken-and-egg dilemma). Additionally, the tools used lack an observational checklist. Social desirability bias and recall bias are limitations of the tool; however, the authors used blinding to minimise biases.

Conclusion

A significant proportion of nurses frequently missed essential nursing care. The participants’ male gender, absence of job training, working full days (24 hours), dissatisfaction with the level of teamwork and the intention to leave the nursing profession showed significant associations with missed nursing care. This indicates that coordinated actions are required to reduce the prevalence of missed nursing care and enhance the quality of nursing care. Developing a standard protocol to regularly monitor missed nursing care is critical for all hospitals.

Implications

This study demonstrated that a significant proportion of nurses frequently omitted basic nursing care (46.3%), which greatly impacted patient treatment outcomes. This implies the need for action-based interventions to address the problem. Hospital administrators and nurse managers should focus on strengthening nurses’ capacity through on-site training, enhancing professionals’ stability and recognising the importance of teamwork to improve nursing care. Nurse professionals should bolster their teamwork spirit and remain vigilant throughout their working schedules to minimise missed nursing care. Additionally, there is a need to consider mechanisms to promote better organisational settings and enhance nurses’ team spirit to increase their professional competency and satisfaction with teamwork. In Ethiopia, missed nursing care or omissions primarily stem from a range of factors, such as staffing shortages, elevated patient-to-nurse ratios, insufficient training and limited resources. Addressing these issues by tackling staffing challenges and ensuring the availability of essential equipment could significantly mitigate instances of neglected nursing care.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was ethically cleared and approved by Bahir Dar University College of Medicine and Health Sciences Institutional Review Board on 20 March 2023 (IRB 769/2023). Informed consent was obtained from each participant. All methods were carried out in accordance with relevant guidelines and regulations.

Acknowledgments

The authors are grateful to the data collectors and all study participants for their contributions to the study's success.