A Comparison of Nursing Activity Score Means for Missed Care Dimensions in Intensive Care Unit Patients

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Introduction
Te nursing workload is one factor that can afect patient safety and nursing care in the intensive care unit (ICU) [1].Because of the conditions of the patients in ICU, nurses working in the ICU spend more time directly caring for the patients and have various responsibilities [2,3].Nurse workloads are defned as the amount of performance required to carry out nursing activities.Te amount of nursing time; level of nursing qualifcation; direct patient care weight; the amount of physical activity; and the complexity of care are the attributes of nurses' workload [4].
Undesirable consequences, such as physical and emotional fatigue, nurse burnout, omission of nursing care, and reduction in quality, have been linked to workload in some studies [5][6][7][8].Missed care refers to the delay or omission of any aspect of patient care [9].Te review study revealed that a majority of nurses (55-98%) reported leaving at least one task incomplete [10].Te most important reported injuries related to missed care include phlebitis, pressure ulcers, skin ulcers, infection, bed falls, delirium, uncontrolled pain, and death [11,12].Patients can experience short-term and longterm efects when nursing care is intentionally or unintentionally omitted [13].
Toroughly examining all aspects of missed care during healthcare studies is challenging.In case of incorrect treatment, such as nonstandard bandaging, it can be detected and evaluated, but in the absence of treatment, detection is difcult without special tools like video recording or direct observation [14].Identifying factors related to missed care in the ICU and the efects of nurses' physical workload on the quality of care are important in any culture.Previous studies relied on nurses' self-reporting to investigate missed care.Te current research employed the observation method to evaluate the missed care for enriched data.Tis study aimed to determine the relationship between the nursing activity score and missed care in patients hospitalized in the ICU in Zanjan, Iran.

Study Design and
Setting.Tis observational and prospective study was carried out in Zanjan City, Iran, between April 3 and September 18, 2021.Tis study was conducted in a medical ICU of one of the training hospitals in Zanjan (Figure 1).

Sampling.
All patients who were admitted to the medical ICU during the study were included in the research.Te patient's legal guardian's consent was a necessary inclusion criterion for the study.To identify missed care, the nurses' performance was observed.Te study observed the performance of full-time nurses who will participate.Te sample size was estimated using the following formula according to Alizadeh et al., and the sample size needed to be 298 patients with α � 0.05, δ � 0.88, and d � 0.1 [15]. (1)

2.3.
Measures.Tis study employed three instruments: a questionnaire for patient and nurse profling, the Nursing Activity Score (NAS), and a missed care checklist.Tis tool has been confrmed as valid in various countries [15][16][17][18].Regarding the validity of the translation process, the NAS was translated based on the standards recommended in the guidelines [19].Te NAS was translated into Persian by two English-Persian translators using the forward-backward translation technique.(

Patient and
Te missed care assessment had 4 levels.A scoring range of 1-25 indicates a very high level of missed care, while 26-50 indicates a high level, 51-75 indicates a moderate level, and 76-100 indicates a low level.Te missed care checklist for 30 patients was scored by two researchers simultaneously to calculate inter-observer reliability.Tese two researchers achieved an 89% agreement in their scores.

Procedures.
Te NAS was compiled for each patient according to the reporting of the previous 24 hours by frst author.Missed care in patients was evaluated through direct 2 Nursing Forum observation using the missed care checklist.Missed care was observed in the patients whose NAS was calculated.Te nurse's care performance was observed on the patient to calculate their NAS.On average, each nurse participating in the study had their care performance observed eight times.Missed care in patients was observed by a nursing master's intern researcher in the same medical ICU.Nurses were aware of the aim of the study.Tey were aware their performance would be observed, but the exact timing and details were unknown.Te researcher's own presence in the ward allowed for natural observations of nurse behavior and performance.

Ethical Considerations.
Tis study was conducted after obtaining approval from Iran's National Committee for Ethics in Biomedical Research (IR.ZUMS.1397.324).
Written consent was obtained from the legal guardian of the patient and nurses participating in the study.Te purpose of the research was explained to the legal guardian of the patient and the nurses.
2.9.Statistical Analysis.Data were analyzed using IBM SPSS Statistics for Windows, version 24 (IBM Corp., Armonk, N.Y., USA).In this study, the kurtosis and skewness of the data were in the range (2, −2), so the data had a normal distribution.Descriptive statistics were reported as N (%) for categorical variables and the mean and confdence interval (CI) for continuous variables.Analysis of variance (ANOVA) was used to evaluate the mean diference based on the levels of missed care.Logistic regression was used to assess the association of variables with the level of missed care.Te regression analysis used the backward variable selection method because of the high number of variables included in the analysis.Te following variables were included in the regression analysis: NAS, patient-related variables (gender, age, patient diagnosis, level of consciousness based on GCS, and type of oxygen therapy), nurse-related variables (gender, age, marriage status, employment status, education level, work experience, working hours/months, and nurse-patient ratio).
To conduct a logistic regression, the high/low of missed care was summarized for each individual as follows.Te high-missed care group was defned as "very high missed care" or "high missed care," and the low-missed care group was defned as "moderate missed care" and "low missed care."Terefore, for each dimension, missed care was defned as "high missed" if the option was 0-1 and as "moderate missed" if the response was 2-3.Nurses provided written informed consents prior to the study.
Informed consent was obtained from the legal guardians of the patients.Nursing Forum 3

Frequency and Percentage of Missed Care Dimensions.
Motion and mobility had high missed care at 1.7%, while oxygen therapy, patient education, and urgency order implementation had low missed care.Missed care was moderate for responding to patient needs and alarms within 5 minutes, hand hygiene, infection control, and nutritional care.Te score for missed care was moderate.Table 3 shows that missed care did not happen in 59.3% of cases.

Te Comparison of Means of NAS Based on Levels of
Missed Care Dimensions.Te results of evaluating the mean NAS based on the levels of missed care showed that, except for the evaluation dimensions, hand hygiene, and infection control (p < 0.05), there was no mean diference in NAS in other dimensions and the total score of missed care (Table 4).Also, the results of the LSD post hoc test showed that, in the dimension of assessment (p = 0.018), hand hygiene (p = 0.013), and infection control (p = 0.016), the workload based on NAS at the medium level was signifcantly higher than the low level.

Factors Related to the Occurrence of Missed Nursing Care.
Work experience was the only remaining variable with R2 � 0.02 in the backward method of logistic regression.Te prevalence of missed care was signifcantly lower in participants with higher work experience (OR � 0.59, 95% CI: 0.37-0.94,χ2 � � 4.97, p � 0.026).Terefore, work experience is a protective factor for missing care.

Discussion
Results show that the mean NAS in medical ICU was 76. 31 Appropriately providing oxygenation according to the order 48 (  Nursing Forum  [30].Results of Haftu et al. showed that 299 (74.6%) nurses and midwives commonly missed at least one nursing care in the perinatal setting [31].Te study conducted by Ball et al. revealed that 86% of nurses could not complete one or more care activities because of insufcient time during their last shift [22].Ball et al. found that 74% of nursing care omissions occurred in general medical and surgical wards [32].Various settings have been used to conduct these studies.Most studies report a higher percentile of missed care than the present study.Tese studies have been conducted in diferent environments (wards and ICUs).Te results in all these studies were based on self-reporting [22,[30][31][32], which can lead to either overestimation or underestimation by participants.Although this study was conducted observationally, it made the data more objective than previous studies.
Te most missed care was mobility, motion, and hand hygiene dimensions, and the least missed care was the patient education dimension.A study showed that nurses had better hand hygiene practices with fewer instances of missed care, in contrast to our fndings [33].On the other hand, patient mobility is a crucial aspect of ICU recovery, and neglecting it may lead to complications and slow down the healing process [34].It is important for head nurses to supervise the careful administration of this care.Also, our result difers from the results of Chegini et al., who reported a high percentage of missed care in the dimension of patient education [30].Discrepancy in the results is attributed to the diference in the study setting.Due to low levels of consciousness, this dimension was inapplicable for most ICU patients in the present study.
Te results of evaluating the mean diference of NAS based on the levels of missed care showed that, except for the dimensions of assessment, hand hygiene, and infection control, there was no signifcant mean diference in NAS in other dimensions and the total score of missed care.
In the present study, infection control and hand hygiene were signifcantly related to NAS.Te increase in workload led to a loss of care.In a study, hand hygiene was associated with workload [35].Hand hygiene and infection control can shorten ICU patients' hospital stays, so it is necessary to teach ICU nurses about the importance of hand hygiene.
Unlike previous research [36][37][38], the current study found no association between missed care and the personal or professional characteristics of nurses or patient characteristics.Te present study has diferent results as Ball et al. observed a signifcant relationship between nurse-patient ratio and missed care [22].A review study found that missed nursing care reports were linked to low registered nursing staf [37].Tubbs-Cooley et al. found that missed care was associated with nurses' workload [36].In a review study, it was found that missed nursing care correlated with patient acuity, workload, work environment, and nurse characteristics, resulting in patients staying in the hospital for a longer period [38].Te fndings of previous studies varied because of diferences in nurse-to-patient ratios between general wards and the ICU.
Te study discovered that nurses' workload had little efect on the frequency and completeness of some routine care behaviors.Care that was not provided was sometimes documented in the nursing record, as noted in another study [39].De Marinis et al. found nursing records unsuitable for quality care evaluation [40].
In Iran, nurses have faced a high volume of documentation work [41].Although documenting care is vital, it may override patient care, causing nurses to unintentionally or intentionally exclude specifc care.Complications from not providing adequate patient care often develop slowly.All healthcare providers, not only the nurses, are responsible for these patient complications.Studies in most countries have reported missed care, indicating a lack of patient safety culture [22,[30][31][32].Missed care can be prevented by enhancing nurses' knowledge and changing the culture of patient safety, particularly among nursing managers [23,42,43].According to Tubbs-Cooley et al., system factors may be a contributing factor to missed care in this setting [33].
In line with Plein's research, our study found that work experience helps prevent missed care [44].Novice nurses, who had less work experience, were responsible for more patients.Tey also took care of patients who were far from the nursing station and the treatment room, requiring them to travel a long distance during their shift.Tese cases increased the workload of nurses.Appropriate stafng and fair work distribution prevent missed care.Missed care was found to be related to the work environment in prior studies [45][46][47].

Conclusion
Te study revealed a high incidence of missed care.Te study revealed that the mean workload was high in certain dimensions of care such as assessment, hand hygiene, and infection control.Te increase in workload for nurses results in lost care.Nonetheless, the utilization of experienced nurses can help mitigate this problem.To assess the factors related to ICU nurses' workload and patient care quality, additional studies are recommended.

Strength and Limitation
Te study's strength was in using the observation method to measure missed care.Compared to previous studies, the data in this study are richer.Altering participant behavior and invading personal privacy are factors that limit observations.Te Nursing Forum participating nurses were informed of the study's objectives but were not informed of case details to reduce behavior change.By trying to keep the anonymity of the hospital and nurses, the rights of the participants were respected.

Figure 1 :
Figure 1: Flow diagram showing the study design and sampling.

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Adjusting the feed pumpIt was not evaluated due to the absence of nutritional bag in the ward during the study Filling the bag connected to the feeding pump within 15 minutes after its completion Observing the semisitting position during feeding 134 To conduct this observational study, a medical ICU was selected from Zanjan teaching hospitals in the northwest of Iran.

Table 1 :
[29]77% (95% CI: −13.06-14.89).In the study byMomennasab  et al.in Shiraz (Iran), the mean NAS in the trauma ICUs was 65.3% ± 23.19%[26].Te mean NAS in 16 hospitals in Belgium was 68.6%[27].In the study by Camuci et al., the highest mean NAS was reported in the burn ICU at 70.4%[28].In 19 ICUs across seven countries, Padilha et al. observed a mean NAS of 72.8%, ranging from 44.5% in Spain to 101.8% in Norway[29].Te disparity in workload among studies may be because of distinctions in ICU typology.Te workload of nurses in the burn, trauma, cardiac, and medical ICUs difers, Personal and professional profle of the nurses participating in the study (N � 38).

Table 2 :
Frequency and percentage of missed care in each care (N �

Table 3 :
Te comparison of NAS means based on levels of missed care dimensions (N: 301).

Table 4 :
Te means and standard deviation of nursing activity score according to levels of missed care dimensions.In certain hospitals, ICUs are specialized for particular diseases, while in others, medical, trauma, and burn patients are admitted in one ICU.Te mix of patients with various illnesses afects the nurses' workload.Tis study showed that 40.7% of care was missed in 9 dimensions.Chegini et al.'s research discovered that 72.1% of nurses usually miss at least one nursing care during their last shift