Abstract
Background. Nurses’ systemic challenges drive missed nursing care (MNC), linked to adverse outcomes. Despite global MNC rates of 55–98%, old adult patients in emergency departments (EDs) are understudied. This study examines MNCs and their underlying reasons from the perspective of nurses and older adult patients referring to EDs.
Methods. This descriptive-comparative study enrolled 150 eligible nurses and 150 older adult patients from five teaching hospitals in Tabriz in 2024. Data were gathered using validated questionnaires on missed care and its underlying reasons (specific versions for nurses and patients) (Cronbach’s α = 0.90-0.95). Descriptive statistics, the t-test of independent groups, and one-way analysis of variance were used to analyze the data.
Results. Patients (50% female) prioritized unmet educational needs, while nurses (65.3% female) emphasized physical care and privacy lapses. The mean scores of MNCs were significantly higher in patients (75.02 ± 17.32 vs. nurses’ 51.66 ± 17.98, P < 0.001). The mean scores of underlying reasons differed significantly between groups (nurses: 52.17 ± 11.11; patients: 46.98 ± 7.38, P < 0.001). The shortage of nursing staff and unit overcrowding were identified as common MNC reasons in both perspectives.
Conclusion. This study revealed a perceptual divide between nurses and patients regarding MNCs and their reasons. Patients reported a greater extent of MNC, whereas nurses emphasized the contributing factors with greater intensity. Multifaceted interventions such as geriatric-specific skill training for nurses and optimized nurse-to-patient ratios are recommended to reduce MNCs.
Extended Abstract
Background
Missed nursing care, defined as the omission or delay of essential nursing interventions, constitutes a prevalent phenomenon threatening care quality, particularly among vulnerable populations such as older adults. This deficit may precipitate irreversible sequelae, including increased medical complications, hospital readmissions, and diminished patient satisfaction. Identifying and analyzing its underlying determinants—such as staffing shortages, excessive workload, occupational stress, and organizational-structural constraints represents a critical step toward designing effective mitigation strategies.
Emergency departments (EDs) are high-risk environments for MNC due to their unpredictable nature, high patient volumes, clinical urgencies, and time constraints. Reported prevalence rates in acute care settings range from 55% to 98%. Older adults face elevated risk owing to functional decline, multi-morbidity, complex care needs, and vulnerabilities such as communication deficits or cognitive impairment. Nevertheless, extant research predominantly focuses on general patient populations, with scant data on the extent and etiology of MNC specific to geriatric patients, particularly within Iranian EDs. This study was conducted to determine MNCs and the underlying reasons in old adult patients admitted to the EDs of hospitals affiliated with Tabriz University of Medical Sciences.
Methods
This descriptive-comparative study was conducted in the EDs of five teaching hospitals affiliated with Tabriz University of Medical Sciences in 2024. A total of 150 nurses working in the EDs and 150 older adult patients (≥60 years) were enrolled via proportional stratified random sampling and convenience sampling with proportional allocation among hospitals, respectively. Inclusion criteria for nurses were having at least a bachelor's degree in nursing, having at least 6 months of full-time work experience in EDs, and giving informed consent to participate in the study.
Inclusion criteria for older adults were age ≥60 years, stable physical, cognitive, and psychological status (as assessed by Mini-Mental State Examination score ≥24 and hemodynamic stability), and an Emergency Severity Index (ESI) triage level ≥3 indicating non-life-threatening conditions. Nurses or patients who left more than 10% of the questionnaire items unanswered were excluded from the study. In this study, three questionnaires were used to collect data, including MNCs for nurses, revised MNCs for patients, and underlying reasons associated with MNCs. The face and content validity of the questionnaires were verified by a panel of 15 nursing faculty members at Tabriz University of Medical Sciences. In addition, a pilot study with 20 eligible nurses and 20 patients was conducted to reassess reliability, and Cronbach’s alpha coefficients were calculated as 0.95 for MNCs (nurses), 0.90 for patients, and 0.92 for the reasons of MNCs questionnaires.
The sampling was conducted over 3 months, from August 2024 to the end of October. The nurses completed the MNCs and underlying reasons questionnaires, which were administered at the beginning of the shift and returned at the end. The researcher completed the MNCs questionnaire (patient version) and the underlying reasons while interviewing the patients at discharge from the ED. Descriptive statistics, the independent groups t-test, and one-way analysis of variance were used to analyze the data in IBM SPSS Statistics version 26.
Results
In this study, 50% of the old adult participants were female, 77.3% were married, and 54.4% were illiterate. Their mean age was 78.2 ± 5.2 years. The mean age of the participating nurses was 33.56 ± 8.14 years, and their mean work experience in the ED was 6.52 ± 5.79 years.
The overall mean score for MNCs from nurses' perspective was 51.66 ± 17.98, and from the old adult patients' perspective, it was 75.02 ± 17.32, compared to the obtainable score (0-130). The overall mean score of underlying reasons for MNCs from the nurses' perspective was 52.17 ± 11.11, and from older adult patients' perspective, it was 46.98 ± 7.38, compared to the obtainable score (17-68). The results of the independent groups t-test showed statistically significant differences between the mean scores of MNCs (P< 0.001) and their underlying reasons (P< 0.001) from the perspectives of nurses and older adult patients.
From the old adult patients' perspective, the highest mean score of MNC was related to the item "nurses explained skin care and pressure ulcer prevention" (mean 4.13 ± 1.05). From the nurses' perspective, the highest mean score of MNC was related to the item "provision of a private environment for old adult patients during history taking and examination" (mean 2.34 ± 1.14).
From the perspective of older adult patients, the highest mean scores of underlying reasons for MNCs were related to the items "unexpected rise in patient volume/unit overcrowding" (mean 3.38 ± 0.76), “lack of support from healthcare team members (mean 3.33 ± 0.87), and " inadequate number of nursing staff " (mean 3.0 ± 58.84). From the nurses ‘perspective, the highest mean scores of underlying reasons for MNCs were related to the items "inadequate number of nursing staff"(mean 3.58 ± 0.84), "unexpected increase in the number of patients or overcrowding in the ED" (mean 3.49 ± 0.83), and “insufficient ancillary staff " (mean 3.0 ± 33.86).
Conclusion
This study underscores a significant perceptual divide between nurses and older adult patients regarding MNCs and their underlying reasons. Results indicated that older adult patients emphasize unmet educational and communicative needs, while nurses focus more on physical and practical domains of care. The shortage of nursing staff and unexpected rise in patient volume/unit overcrowding were identified as common challenges in both perspectives, leading to increased MNCs and a decline in care quality. It is recommended that effective steps be taken to reduce care gaps by designing and implementing geriatric-specific communication skills training for nurses, reducing workload through health information technology integration, and improving supportive infrastructure, such as human resources, to optimize patient-to-nurse ratios.
Practical Implications of Research
- The perception of missed nursing care and its underlying reasons may differ between nurses and patients in the emergency department.
- Elder patients most frequently reported missed care in the educational and communicative domains of nursing care.
-Nurses tended to emphasize physical and practical domains as areas where care is most often missed.
- Elder patients reported a higher frequency of missed nursing care, whereas nurses placed greater emphasis on the contributing factors underlying such omissions.
- Staff shortages and emergency department overcrowding are associated with increased rates of missed nursing care.