Factors affecting missed nursing care in hospitalized frail older adults in the medical wards: a qualitative study

Abstract

Background Frail older adults who are hospitalized, are more likely to experience missed nursing care (MNC) due to high care needs, communication problems, and complexity of nursing care. We conducted a qualitative study to examine the factors affecting MNC among hospitalized frail older adults in the medical units. Methods This qualitative study was carried using the conventional content analysis approach in three teaching hospitals. Semi-structured interviews were conducted with 17 nurses through purposive and snowball sampling. The inclusion criteria for the nurses were: at least two years of clinical work experience on a medical ward, caring for frail older people in hospital and willingness to participate. Data were analyzed in accordance with the process described by Graneheim and Lundman. In addition, trustworthiness of the study was assessed using the criteria proposed by Lincoln and Guba. Results In general, 20 interviews were conducted with nurses. A total of 1320 primary codes were extracted, which were classified into two main categories: MNC aggravating and moderating factors. Factors such as “age-unfriendly structure,” “inefficient care,” and “frailty of older adults” could increase the risk of MNC. In addition, factors such as “support capabilities” and “ethical and legal requirements” will moderate MNC. Conclusions Hospitalized frail older adults are more at risk of MNC due to high care needs, communication problems, and nursing care complexity. Nursing managers can take practical steps to improve the quality of care by addressing the aggravating and moderating factors of MNC. In addition, nurses with a humanistic perspective who understand the multidimensional problems of frail older adults and pay attention to their weakness in expressing needs, can create a better experience for them in the hospital and improve patient safety.

Unfinished nursing care reasons as perceived by nurses at different levels of nursing services: Findings of a qualitative study

“…Different factors may affect the poor leadership of the ward managers, from the scarce training received to the consequences of high stress lived daily (e.g., Martella, 2021) resulting in burnout (Kelly & Hearld, 2020). However, also in previous studies, the inadequate leadership has been documented (e.g., Rezaei-Shahsavarloo et al, 2021) as aggravating the unfinished nursing care:…”

“…However, two main new reasons have emerged: (a) the lack of nursing aides in their capacity to support nurses in concentrating their efforts on nursing care and (b) the quality of handovers in keeping priorities across shifts and teams. Also, at the nurses' level, some reasons have already been documented (increased age, education, experience and competencies, responsibility and motivation, stress and fatigue, time management skill, delegation skills, turnover, part time, time required for a nursing intervention and propensity to prevent legal/medicolegal issues; Arslan et al, 2022;Chiappinotto et al, 2022;Rezaei-Shahsavarloo et al, 2021). However, three elements seem to be new in this context: The progressive increase in the complexity and instability of patients, also due to their cognitive impairments (Rezaei-Shahsavarloo et al, 2021), triggers an additional demand for care: therefore, while on the one hand data should be continuously updated in the attempt to discover whether with the increased care demand the occurrence of unfinished nursing care will increase, and on the other more awareness should be devoted towards unfinished care, especially in the case of frail patients, in accordance with their increased risk of negative outcomes.…”

“…Also, at the nurses' level, some reasons have already been documented (increased age, education, experience and competencies, responsibility and motivation, stress and fatigue, time management skill, delegation skills, turnover, part time, time required for a nursing intervention and propensity to prevent legal/medicolegal issues; Arslan et al, 2022;Chiappinotto et al, 2022;Rezaei-Shahsavarloo et al, 2021). However, three elements seem to be new in this context: The progressive increase in the complexity and instability of patients, also due to their cognitive impairments (Rezaei-Shahsavarloo et al, 2021), triggers an additional demand for care: therefore, while on the one hand data should be continuously updated in the attempt to discover whether with the increased care demand the occurrence of unfinished nursing care will increase, and on the other more awareness should be devoted towards unfinished care, especially in the case of frail patients, in accordance with their increased risk of negative outcomes. Moreover, family restrictions due to the pandemic have further increased the incidence of unfinished care, and the role of nurses to compensate for them might be insufficient given the importance of family visits for the patients, the nurses and the entire care delivery system (Hugelius et al, 2021).…”

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States

“…While a geriatric hospital might not be able to increase nurse:patient ratios, it would be able to change many of the factors affecting missed nursing care among frail older patients. In one study, researchers identified lack of managers’ competence in establishing care guidelines, negative attitudes towards frail older adults, weakness in interdisciplinary care and lack of knowledge, skills, and experience of nurses in dealing with frail older patients as reasons for missed nursing care ( Rezaei-Shassavarloo et al, 2021 ). These areas of concern are some of the strengths of many geriatric models of care ( Ellis et al, 2017 ; Van Creen et al, 2010 ; Baztán et al, 2009 ; Hshieh et al, 2015 ; Grigoryan et al, 2014 ).…”

“…An architectural example of semicircular units within a geriatric hospital is seen in Figure 1. This structural design of a more efficient layout may help improve factors associated with missed nursing care by decreasing time spent walking between patient rooms in long hallways and increase time spent directly observing patients (Rezaei-Shahsavarloo et al, 2021). This open design may also assist efforts and improve attitudes towards reducing restraints (Gunawardena & Smithard, 2019).…”