Missed nursing care and stoma care: an Italian survey

In Italy, nursing research has paid special attention to ‘missed nursing care’ (MNC), a topic of priority interest for the profession and widely present in the international literature (Bagnasco et al, 2017; Bassi et al, 2018). MNC is defined as ‘any aspect related to patient nursing care that is omitted (partially or totally) or delayed’ (Kalisch et al, 2009). Other authors have proposed other terms such as ‘tasks undone’ or ‘implicit rationing’, making use of different conceptual assumptions and measurement tools but MNC is the most popular theoretical model in Italy (Bassi et al, 2018). MNC episodes are present within healthcare settings and can be an indicator of the quality of care provided and patient safety (Hessels et al, 2019).

Sist and colleagues (2017), in Italy, summarised the determinants for the development of the phenomenon, and subsequently the topic has been widely discussed in this healthcare context (Palese et al, 2018; Sasso et al, 2019). The studies carried out, varying in tools and settings, describe considerable percentages of missed care, including elements such as dialogue with patients (53%), patient/family education (41%), development or updating of care plans (42%) as described in the multi-country, multilevel cross-sectional RN4CAST study (Nurse Forecasting: Human Resources Planning in Nursing) (Ausserhofer et al, 2014; Sasso et al, 2017) or care planning (37.3%), emotional support (30.1%), patient/family interviewing (28.4%) (Muzzana et al, 2018) or patient ambulation (55%) (Parise et al, 2021) in other studies. Among the most prominent causes given for MNC have been unexpected increases in the number of patients, worsening clinical conditions, staff shortages, and increased admissions and discharges.

In the field of stoma care, clearly defined care pathways that adapt to new surgical approaches are crucial for ostomy patient education. The stoma care nurse (SCN) plays a central role in helping the patient to adapt to their new condition and achieving good care outcomes (Mineccia et al, 2022; Panattoni et al, 2023). Several authors have also described notable rates of stoma complications both early and late (Carlsson et al, 2016; Murken and Bleier, 2019) with an important impact on quality of life (Alenezi et al, 2021).

In stoma care nursing, the phenomenon of MNC has not been investigated to date. In 2022, at the AIOSS (Technical Scientific Association of Stomatherapy and Rehabilitation of the Pelvic Floor) national congress, MNC events were the main topic and various experiences were reported by patient associations and colleagues highlighting the need to investigate the issue in depth.

The purpose of the present study is to measure the prevalence of missed nursing interventions in the Italian population of ostomy patients and to describe what SCNs perceive to be the most relevant causes of missed care in their workplaces.

Materials and methods

A cross-sectional study was carried out with a quantitative approach. The measurement instrument was the Italian version of the MISSCARE survey, designed to measure missed nursing care (Kalisch and Williams, 2009).

The research team assessed the basic elements of the stoma care pathway from the literature and included some variations in the questionnaire, preserving the original structure, as already proposed in other studies (Parise et al, 2021). The questions included for the socio-demographic component were about the presence of dedicated stoma care services, the opening hours of these, and indicative volumes of activity. The requests for nursing interventions involved preoperative counselling and stoma site marking, choice of the right ostomy bag and assessment of self-care skills and educational aspects, in addition to surveillance on discipline-specific clinical aspects in the postoperative period and follow-up. The research team proposed the elimination of some questions not relevant for the specific care pathway (ie ostomy patients). Another group of experienced SCNs preliminarily evaluated the face validity and content validity. The instrument was then tested on another sample of 20 SCNs without any proposed changes. The final questionnaire consisted, in addition to the socio-demographic component, of 26 questions in the missed care section and 18 in the causes section, as well as an explanatory introduction that invited the SCN participants to focus on the correlated aspects of stoma care.

Approval was sought from and granted by the regional ethics committee of the study co-ordinating centre (Prot. No. 0083766 dated 07/28/2022). To ensure the anonymity of participants, an alpha-numeric code was assigned for each patient and the processing of data was conducted in aggregate form. The survey was targeted, via institutional email, at hospitals in Italy with dedicated services and/or pathways for ostomy patients and were addressed to the SCNs. Sample exclusion criteria were a failure to complete an entire section or more of the questionnaire. The platform used for the survey was REDCap, which participants accessed through a link sent via e-mail. Data collection took place between February and April 2023.

Data analysis

All the statistical analyses were performed using R (R Foundation for Statistical Computing, Vienna, Austria). Participants' characteristics are presented as median and interquartile range [IQR] for continuous variables, number and percentage for categorical ones. Frequency of MNC and reasons for MNC were scored on a 5-point and 4-point Likert scale, and evaluated as mean and confidence interval (CI) at 95%. Occurrence of MNC and reasons for MNC are expressed with descriptive statistics (mean and standard deviation) stratified by level of nurse education in the field of stoma care.

Results

A total of 461 email invitations to complete the questionnaire were sent out; 246 responses were collected and 214 (53.3%) were analysed, excluding those that had not been completely filled in in at least one of the sections (questionnaires were included if responses were missing from some but not all sections, and the number of missing responses are noted in the tables). As shown in Table 1, most of the participants were female (n=160, 76.2%) with a median age of 50 years (35.0-53.8). The most represented qualification was a bachelor's degree in 117 cases (54.9%) and work experience in the stoma care specialty was more than 10 years in 95 cases (50.3%).

As shown in Table 2, hand hygiene was the activity most frequently perceived as missed care (4.6, 95% CI: 4.47–4.73) followed by filling out nursing documentation (4.5, 95% CI: 4.34–4.66), hygiene/skin care (4.5, 95% CI: 4.37–4.63) and patient/family education (4.4, 95% CI: 4.24–4.56), also among the most frequently reported missed interventions in relation to stoma care.

The most widely perceived cause of MNC was an inadequate number of healthcare personnel (3.1, 95% CI: 2.95–3.25). Other more widely perceived causes of MNC were shortages of personnel with stoma care experience (3, 95% CI: 2.83–3.17) and unsuitable nurse–patient ratios for the level of care the patients needed (3, 95% CI: 2.85–3.15) (Table 3)

When comparing different levels of training and perceptions of MNC, it is evident that support for the choice of ostomy bag differs between those with postgraduate training (mean 4.5, SD 0.8) and those with lower-level training (mean 4.0, SD 1.3), as described in Table 4.

When comparing the perceived causes of MNC between different levels of participant education, no significant differences were observed, as shown in Table 5.

Discussion

MNC has been extensively studied over the past 20 years, with ever-increasing interest. To the best of the authors' knowledge, this is the first study attempting to identify MNC and its related causes in the Italian stoma care pathway and represents the perception of clinical nurse specialists. The demographic characteristics of the participants were in line with those of the Italian nursing profession generally and with other published studies on missed care (Palese et al, 2015; Sasso et al, 2019). The SCN has extensive experience in the field of stoma care and a level of education that represents the change that has taken place in Italy in recent years, moving towards postgraduate training.

A considerable number of basic and clinically relevant nursing interventions were perceived to be missed in this study, where patients with complex clinical, physical and psychological conditions go through their care journey in various settings. Particular attention must be given to hand washing: our finding is consistent with a previous study (Danielis et al, 2021) in which nurses were also more likely to miss high-priority care activities, which can have an immediate impact on patient safety. Palese et al (2015) in their study described different results in the medical field, describing these activities as rarely missing. Previous studies have documented frequencies and types of MNC in surgical and medical departments or in other settings (Friese et al, 2013; Palese et al, 2015; Sist et al, 2017). In this study, there is a significant level of missed care in other areas such as completion of nursing documentation, hygiene/skin care and patient/family education.

Other activities also demonstrate higher proportions of missed care than in other studies conducted in Italian settings, for example, the 50% level of missed care in emotional support described by Bagnasco and colleagues (2020) or PRN (as-needed) medication requests processed within 15 minutes, which were on average 30% in the study by Danielis and colleagues (2021). These differences could be justified by the different role of the SCN, who sometimes carries out consultation activities and is not involved in direct care.

The preoperative counselling on stoma formation/care and preoperative stoma site marking – performed at the time in many settings and usually the act of a SCN – showed significant rates of missed care despite a high degree of recommendation (Roveron et al, 2016). Arolfo and colleagues (2018) found that the preoperative stoma site was marked in 362 (63%) out of 779 patients who underwent elective surgery, confirming our study's findings.

Episodes of missed care in the patient's postoperative phase are even more relevant, as are educational aspects, clinical monitoring, and an adequate discharge plan followed by careful follow-up. The potential negative consequences of these for the patient can be peristomal complications (Maglio et al, 2021), lower levels of self-care (Giordano et al, 2020) and physiological and psychological distress (Kalayci and Duruk, 2022). For example, lack of support for the choice of ostomy bag and evaluation of its appropriateness can lead to leakage and discomfort, one of the main causes of the above.

Post-pandemic data reveals concerns: the clinical specialist nurse's role in patient safety may have heightened awareness of missed interventions, impacting patient safety. This suggests a need for ongoing nurse training to enhance their skills in meeting care needs and preventing occurrences of missed nursing care. These activities should be guaranteed for patient comfort, quality of life, and also for preventing increased dependency in daily activity at discharge.

This study finds MNC causes align with prior research, citing staff shortages, unexpected patient volume or acuity, and unsuitable nurse–patient ratios (Palese et al, 2015; Danielis et al, 2021; Parise et al, 2021). Notably, high percentages relate to general and specific educational gaps in stoma care, including inadequate experienced staff, lack of training, and knowledge deficits. To improve self-care skills, it has been recommended that education should be managed by health personnel experienced and trained in this area (Hendren et al, 2015) as well as the establishment of pathways managed by multiprofessional teams in which a recognised role is that of the SCN (Panattoni et al, 2023).

These data describe not only a series of tasks performed or not performed, as pointed out in the study by Palese and colleagues (2015), but also the impairment of the entire care process especially from an educational perspective, excluding some specific technical aspects such as preoperative planning. Educational interventions are indispensable elements in helping ostomy patients to adapt to their new condition, which has a major impact on quality of life.

Conclusion

Omissions of nursing care from a dedicated care pathway can increase the functional dependency of patients and have important consequences for their daily life. Clinically relevant interventions such as patient education, or clinical monitoring through to follow-up, can lead to the negative outcomes and impact on quality of life for these patients described in the literature and complained about by professional associations.

MNC episodes are a cross-cutting phenomenon in the various care settings and their frequency is mainly influenced by the number of nurses dedicated to care and the organisation of work. SCNs should offer training to ward nurses to help prevent MNC. Furthermore, further research is needed and should target a better understanding of the predictors involved in MNC. The emerging focus on the fundamentals of nursing care also has its place in these dedicated pathways, where the SCN should be the guarantor of the correct delivery of care.

KEY POINTS

• Missed nursing care (MNC) episodes are present within healthcare settings and can be an indicator of the quality of care provided and patient safety
• Elements of care commonly missing from a stoma care pathway included the educational aspects, clinical monitoring, discharge planning and careful follow-up
• Causes noted were staff shortages, unanticipated increase in volume and/or acuity of patients in the unit or unsuitable nurse–patient ratios, shortage of staff with stoma care experience, lack of training, and lack of knowledge
• Omissions of nursing care in the context of a dedicated care pathway can increase the functional dependency of patients and have important consequences for their day-to-day life
• The emerging focus on the fundamentals of nursing care also has its place in these dedicated pathways, where the stoma care nurse should be the guarantor of the correct delivery of care

CPD reflective questions

• What are the main factors that could contribute to episodes of missed nursing care (MNC) in your clinical practice?
• Reflecting on the most common omissions in the stoma care process identified in the study, what strategies could you adopt to ensure a more comprehensive and holistic approach?
• In light of the most frequently indicated causes for MNC, what actions could be taken to improve the quality of care provided to stoma patients?