Mental health nurses perceptions of missed nursing care in acute inpatient units: A multi-method approach.

Nurses have key roles in caring for hospitalized patients. Missed nursing care can lead to adverse outcomes, from minor discomfort to patient death. Mental health nurses have a significant role in advancing knowledge and practice due to missed, delayed, or unfinished nursing care. They are identifying, escalating, and managing warning signs of mental and physical health deterioration where the risk to patients is high in terms of compromised care quality and neglect and the evidence is scant. This study aimed to examine mental health nurses' perceptions of missed nursing care in acute mental health inpatient units in an Australian regional health service. A cross-sectional survey was undertaken using a modified Kalisch Phelan MISSCARE questionnaire and a qualitative content analysis was undertaken for narrative responses. Of 70 participants, the majority were aged 30-44 years, with >5 years of experience. The results indicated that care planning, safety audits, communication, and assessment of oral intake were perceived as care most frequently missed. Factors contributing to missed care need urgent exploration to ensure timely reduction of patient risk and enhancements to safe quality care.

BACKGROUND

The evidence on missed care in acute mental health care settings over the past 10 years appears to be scant. Missed nursing care can be considered as a failure to fulfil legal and ethical obligations as a nurse (Kalisch et al. 2009). For example, a nurse may miss teaching a patient about asthma management medications before discharge who then experiences respiratory distress and needs to be readmitted. Another example is a nurse may miss assisting a patient with the fitting of crutches before they need to ambulate to the bathroom post‐operatively, who falls and fractures their skull. The missed care is also referred to as nursing care that is delayed, partially completed, not completed at all (Kalisch et al. 2011) or unfinished (Blatter et al. 2021). Nurses play a critical role in coordinating care, assessing, planning, implementing, and evaluating health care interventions for hospitalized patients (Patient Safety Network 2019). Therefore, missed nursing care can lead to adverse outcomes ranging from minor discomfort to patient death (Kalisch et al. 2009). However, there is evidence that indicates issues regarding skill mix and the use of agency and casual nurses can also influence the quality of care and increase adverse events (Kalisch & Xie 2014). The above analysis highlighted that possible reasons for missed nursing care are under‐resourced settings, issues with teamwork, communication, decision‐making, habits, and values (Kalisch & Xie 2014). Other researchers also have found that missed care is not uncommon and lack of time, increased acuity, increased nurse–patient ratio, and lack of awareness can also be reasons for missed care (Kalisch 2014; Marven 2016; Verrall et al. 2015). The above studies also highlight that missed nursing care can influence staff morale, job satisfaction, and turnover (Kalisch & Xie 2014; Marven 2016; Verrall et al. 2015).

The first Australian study of missed care involved perceptions of 354 nurses and midwives on missed nursing care in South Australian Health services (Verrall et al. 2015). The study's findings highlighted competing demands that reduce the time for patient care, ineffective methods for determining staffing levels and inadequate skill mix and insufficient staff numbers as reasons for missing nursing care (Verrall et al. 2015).

Missed care in mental health care settings

Mental Health Nurses (MHN) are the largest workforce in the Australian mental health sector (Australian Institute of Health & Welfare 2019). Mental health nursing is a specialized field of nursing that focuses on working with consumers to meet their recovery goals. Mental health nurses consider the person’s physical, psychological, social, and spiritual needs within the context of that individual's lived experience and in partnership with their carers, family, and the broader community (Australian College of Mental Health Nurses 2019). While the largest workforce in mental health, MHN's shortage is well known (AIHW 2016). In 2015, approximately, 1 in 15 (6.9%) nurses employed in Australia indicated that they worked principally in mental health. Just under one‐third (31.1%) of mental health nurses were male, compared with around 1 in 10 of the general nursing workforces (Australian Institute of Health & Welfare 2019).

However, there is evidence on aged care and missed care in general ward settings (Ball et al. 2018; Winsett et al. 2016). Mental health nurses have a crucial role in advancing the state of the evidence on missed or unfinished nursing care (Blatter et al. 2021) identifying, escalating, and managing warning signs of mental and physical health deterioration. Missed nursing care occurs in mental health like other areas of health care and has not been extensively investigated before.

This study aimed to examine mental health nurses' perceptions of missed nursing care in acute mental health inpatient units in an Australian regional health service.

METHOD

A cross‐sectional survey was undertaken using a modified version of the Kalisch and Phelan MISSCARE questionnaire (Kalisch & Williams 2009; Phelan et al. 2018). Qualitative content analysis was undertaken for narrative responses. The setting was a medium‐size regional Australian public health service.

Instrument – modification, validation, and reliability

Authors ‘permissions were sought for modifications and use for this study. Staff nurses were invited to participate in a review of the instrument and to recommend modifications that were meaningful for the cultural and practice setting of mental health nursing in regional Australia. After a round table discussion and written responses, including email and handwritten contributions, there was agreement on amendments made to reflect the Australian context, including terminology, acronyms, shift times, and employment levels. The psychometric evaluation and validity of the missed care questionnaire was informed by Kalisch and Williams (2009) and was tested using measures of acceptability, item reduction and reliability (Lillian Dias Castilho et al. 2017). Content validity was tested locally, with six nurses working in acute mental health settings. Ethics approval was obtained from the hospital's Ethics Committee and then from the relevant university’s Human Research Ethics Committee.

Participant recruitment

The study and invitation to participate was advertised through staff meetings and displayed in the staff room. The paper‐based questionnaire was disseminated to nurses working in acute mental health inpatient units (aged persons and adults). The questionnaire was distributed mainly after in‐service meetings and after the shift handover following an information session.

Data collection

A convenience sample of 70 mental health nurses participated in this study. Participation was anonymous and voluntary; consent was implied. The questionnaire included questions about demographic characteristics (education, job experience, gender, age), work schedules (shift and hours worked), staffing levels, and mix. The questionnaire had two parts. Part 1 identified the types and frequency of missed care using a 5‐point rating scale. The frequency range was 1–5 (1 = never missed, 2 = rarely missed, 3 = occasionally missed, 4 = frequently missed, and 5 = always missed). Part 2 explored nurses’ perceptions of missed care in the form of narration (Appendix 1). Nursing care items were categorized into primary nursing care, physical health‐related care, mental health‐related care, documentation, discharge planning, and education. Completed questionnaires were inserted in a closed envelope and then dropped in the locked boxes in each unit.

Data analysis

Data analysis was undertaken using the statistical program SPSS Version 26 (IBM SPSS, 2020). Data analysis involved descriptive statistics summarizing the demographic data such as the area of work, years of experience, and qualifications. This was followed by the calculation of frequencies of missed nursing care and analysis of missed care items. Finally, the analysis of short narrations was undertaken on nursing staff's perceptions regarding reasons for missed nursing care.

FINDINGS

All nurses (n = 70, 100%) who were eligible to participate in the study completed the survey. Of these, 42 nurses were from the adult acute inpatient unit, and 28 nurses were from the aged inpatient unit, 80% (n = 56) of the participants were female. Most nurses (n = 24) were between the age of 30–44 years, with 6–15 years of experience. Approximately, half of the participants either had postgraduate classifications or were currently undertaking postgraduate courses (Table 1). More than half of the participants were working 0.8 to full time (10 shifts per fortnight) hours.

Table 1

Demographic details; (a) Qualifications; (b) Age; (c) Experience

(a)
Qualifications	Frequency	Percentage %
Diploma Nursing	12	17.7
Bachelors	20	28.6
Postgraduate Certificate/Diploma	20	28.6
Masters	18	25.7
PhD	0	0
Others	0	0
Total	70	100

Never missed and rarely missed nursing care items

Mental Status Examination (MSE), Risk Assessment (RA), and Visual Observation are three nursing care items ‘rarely’ or in some cases ‘never’ missed. The findings indicated that 69% (n = 49) of participants never or rarely missed doing RA during the shift. Similarly, 97% (n = 48) of nurses highlighted that they have never or rarely missed MSE during their shift. Visual observations (physically sighting the patient) are rarely missed by the participants (61%, n = 43).

Basic nursing care, including personal hygiene, is never missed, or rarely missed 61% of the time and 60% of the time for ADLs (Table 2).

Table 2

Care items

Items	Never missed Frequency Percentage	Rarely missed Frequency Percentage	Occasionally missed Frequency Percentage	Frequently missed Frequency Percentage	Always missed Frequency Percentage
Hygiene (shower, changing)	10 14.3%	33 47.1%	22 31.4%	5 7.1%	0 0%
Activities of daily living	16 22.9%	26 37.1%	24 34.3%	4 5.7%	0 0%
Therapies	18 25.7	24 34.3	23 32.9	0 0	5 7.1
Recovery plan	13 18.6%	25 35.7%	21 30.0%	0 0%	11 15.7%
Physical observations	25 35.7%	20 28.6%	20 28.6%	0 0%	5 7.1%
ECG	15 21.4%	28 40.0%	11 15.7%	16 22.9%	0 0%
BGL	30 42.9%	19 27.1%	10 14.3%	10 14.3%	1 1.4%
Weight	15 21.4%	28 40.0%	15 21.4%	6 8.6%	6 8.6%
Substance use module	18 25.7%	17 24.3%	17 24.3%	7 10%	11 15.7%
Progress notes	53 75.7%	3 4.3%	3 4.3%	0 0%	11 15.7%

Physical health‐related observations, including vital signs, are another item reported as never or rarely missed (64%), especially in the adult acute inpatient units. Approximately 28% (n = 40) of nurses said that they had missed vital signs occasionally. Further, 20% (n = 14) of nurses indicated that they occasionally miss checking the patients' bowel status under their care. Checking weight was occasionally missed by 15% (n = 11) of the nurses, while ECG was reported as never or rarely missed by 61% of nurses. ECG is usually done on admission if needed and after the administration of short‐acting antipsychotic medications (Table 2).

‘Communication’, including ‘therapies communication with the patients’, and ‘referrals’, are other nursing care items highlighted as occasionally missed. Again, 23% of participants reported that they ‘occasionally’ miss therapies (garden, group, individual and family therapy) with their patients. Furthermore, 21% of nurses indicated that they occasionally missed a recovery plan (like the discharge plan but included personal recovery goals and objectives) (Table 2). Safety audits are usually done once a shift in mental health inpatient units; 19% of participants stated that safety audits are occasionally missed.

Frequently and always missed nursing care items

The recovery plan was also reported as always missed by 15.7 (n = 11) nurses (Table 2). Frequently missed care (Phelan et al. 2018) in this research is care missed more than three times per week. Notably, the substance use module is reported as always missed by 11% of nurses, while 7% indicated frequent misses. The substance use module is usually completed on admission by the nurses (Table 2).

Another critical finding is on admission, and PRN ECGs are reported as frequently missed by 16% of nurses. Additionally, oral intake charts and Blood glucose monitoring are reported as frequently missed by 10% of nurses. Completion of progress notes as required is indicated as frequently missed by 11% of nurses.

Reasons for missed nursing care: mental health nurses’ perspectives

As mentioned prior, the last section of the survey was open‐ended narrative reflections of participants. Narrative reflections included a total of 280 short individual responses from 70 participants on reasons for missed care and feelings when knowing care was missed, actions, and suggestions for improvements. This allowed the participants to express their perspectives using their language. The responses were read and re‐read by the researcher. An analysis was performed to identified repeated words and phrases. The main idea was reviewed for the final report. The responses were either given as points or as short answers. The Four themes were identified from the responses: (1) an inadequate number of nurses, (ii) increased physical care needs, (iii) increased acuity, and (iv) low job satisfaction.

Inadequate number of nurses

Several respondents reported that there are days where the shift is managed with a smaller number of nurses than required. There can be shifts with additional staff requirements due to other reasons too. The participants appeared to recognize the reality of the shortage of mental health nurses.

We (mental health nurses) sometimes get more patient load due to various reasons with or even without replacement. If we get a bank nurse or a new nurse, also our (regular staff’s) workload will increase, and sometimes that can be the reason for missing care…, not enough mental health nurses. (Participant 9)

Interestingly, participants also added that additional requirements, such as reviews and meetings could lead to inadequate numbers in the ward, even on days with an adequate number of nurses.

We often don’t have enough staff on the floor, especially on the days of ward meetings, clinical review and other meetings. (Participant 70)

Similar points regarding low staffing and increased nurse–patient ratio were mentioned by other nurses too.

Increased physical care needs

Another theme identified from the reflections of the MH nurses is ‘increased physical care needs’. This was mainly raised by respondents working in the acute aged inpatient units. The aged inpatient units will usually have patients with relapse of mental illness, dementia with behavioural challenges and multiple other comorbidities. These patients need complete physical care, including full attention to personal hygiene.

There are times where we have four or five patients who need complete nursing care …those with dementia. This could take three nurses easily off the floor. Others often miss care. (Participant 2)

Other respondents mentioned the increasing pattern of physical care needs, especially in the aged mental health wards.

It becomes even harder when we have elderly with dementia…. (Participant 3)

Increased acuity

Several participants highlighted that ‘busy shift’, ‘more acutely unwell patients’, ‘high number of aggressions. The subtheme ‘increased acuity’ emerged from these reflections.

Nowadays, patients are more acutely unwell than before…. takes more time to manage them….. (Participant 23)

Another participant stated that

Some days, a single client can take my entire shift, and I will not get time to care for others (allocated patient load) … (Participant 34)

Similarly,

Now we get more acutely unwell patients…almost like the adult inpatient wards. (Participant 50)

Nurses in the adult inpatient units listed reasons for higher acuity as ‘clients with substance use issues’, ‘use of Ice’, ‘clients with behavioural and personality issues’, ‘physical health issues’, and ‘increased impulsivity’. Whereas nurses from aged inpatient units mentioned the reasons for higher acuity as ‘patients with dementia’, ‘patients with multiple comorbidities’, and ‘relapse of mental illness’.

Low job satisfaction

The final theme was low job satisfaction. The last question for reflection was ‘What are your feelings when you identify that care has been missed’? Participants’ responses were mainly indicated that they feel uncomfortable and anxious when they realize that the care was missed. Some stated the need for reporting missed care as a critical incident. Multiple respondents indicated ‘low job satisfaction’ or similar themes.

I get anxious and worried when I realise; I didn't do required nursing care. (Participant 37)

Another participant mentioned

When I remember I have not done something (nursing care), or when I don’t get time to care, I don’t get job satisfaction. (Participant 17)

Participant 56 stated, ‘I feel like I am not fulfilling my duty as a nurse’.

DISCUSSION

Missed care in mental health has not been extensively investigated previously. This study highlighted that missed nursing care occurs in mental health like other areas of health care. The participants articulated the reasons for missed nursing care and it is clear that nurses see themselves as with the potential for a therapeutic role in the ward environment, yet they are faced with a discrepancy between the expected outcomes of the role and what is actually happening (McAllister & McCrae 2017). Mental health nursing as a profession demands a variety of roles, functions, commitments, and ethical duties to fulfil the holistic care needs and uphold the rights of patients with mental illness (Australian College of Mental Health Nurses 2019). Practising in mental health requires the specific knowledge and skills of the specialty, caring and satisfaction. If caring is missed, unfinished, or delayed, what support is needed? Evidence indicates that there will be a shortage of more than 18,000 MHNs by 2030 (Australian Institute of Health & Welfare 2019). The study findings regarding mental health nurses' perceptions of missed nursing care are consistent with the existing literature. Inadequate skill mix, lack of experience of nursing staff were consistently echoed in missed care literature from general and aged care settings (Ball et al. 2018; Knopp‐Sihota et al. 2015; Moreno‐Monsiváis et al. 2015; Winsett et al. 2016). Additionally, the findings of this study support the original missed care conceptual model (Kalisch et al. 2009) developed to understand the concept of missed care and those factors were lack of resources, issues related to communication and teamwork. However, this research elicited new care items missed specific to mental health nursing. Narrative views highlighted the new theme ‘increased physical care needs’ mostly related to the increased number of clients with dementia and other chronic illnesses. Mental health nurses' enthusiasm apprehension and preparedness to attend physical care needs of patients with mental illness are highlighted in the literature (Dickens et al. 2019). The reasons for MHNs lack of confidence in attending physical health needs have been identified as inadequate skill, confidence, and insufficient knowledge (Olfson et al. 2015).

The results revealed that participants in this study rarely miss MSE and RA, two essential responsibilities in mental health. Visual observation is the process of sighting and observing the clients at designated intervals based on individual risks. These assessments, along with clinical judgment, are vital in ensuring the accurate diagnosis and safety of people with mental illness (Voss & Das 2020). However, communication with clients was identified as missing by nurses working in the inpatient units. Although missed nursing care in mental health has not been studied extensively worldwide, the results are supported by a study of Western Canadian nursing homes that found that the most frequently missed care was ‘talking with residents’ (Knopp‐Sihota et al. 2015). Care items such as primary nursing care, physical health monitoring, and other physical health monitoring have been reported as missed occasionally. Inequality in consumers' physical health care with mental illness compared with people without mental illness is noted previously in Australia (Happell et al. 2011). Also highlighted was the importance of training for mental health nurses, specifically around physical health care and physical health monitoring (Happell et al. 2011). In this study, the participants indicated that physical health‐related care, including assistance with hygiene, monitoring physical health, can be missed due to various reasons.

One indicator of acuity in mental health is an increase in the number of seclusions. In 2018–19, there were 7.3 seclusion events per 1000 bed days. This is an increase of 6.9 seclusion events per 1000 bed days in 2017–18 (Australian Institute of Health & Welfare 2019).

Evidence suggests that physical health issues including severe comorbidities are much higher in people with mental illness than in the general population (The Royal Australian & New Zealand College of Psychiatrists 2016). Additionally, it is not uncommon to have elderly with dementia requiring complete nursing care in the aged mental health units. Mental health disorders, such as depression and schizophrenia, are linked to a higher risk of dementia in later life (Oniyike 2016). On the other hand, people with dementia can present with mental health symptoms, such as anxiety, depression, and psychosis. Unfortunately, aged mental health units are not purpose‐built or resourced for caring for clients with dementia. The participants reported low job satisfaction when they realized that care was missed. The theme, ‘low job satisfaction was also reported because of missed care in previous research (Kalish et al. 2011).

Additionally, in this study, nurses highlighted that updating the nursing care plan and safety audits are frequently missed items due to the heavy workload in the inpatient settings. Documentation, a frequently missed care item was first reported by Phelan et al. (2018), and requires urgent attention, as ‘care not documented is not done’, not measured nor forming part of the evidence. It is essential to have a well‐supported organizational structure and a highly skilled workforce to meet the entirety of the nursing care needs of individuals with mental illness.

In this study, the participants suggested appropriate staffing as per the ward acuity, including nurse mix (hours, skills, and competencies, Plummer 2015), timely audits, education, and support for maintaining therapeutic engagement and workplace satisfaction and staff, patient and family feedback as strategies to prevent missed nursing care. Case studies of adverse events and near misses are to be analysed and presented for the prevention of recurrence. Time will be needed to reflect on and refine the items developed for the modified version of the instrument and trial again on different future populations.

A study of 11 Australian hospitals on medication safety and omission of doses also indicated that the medication list and audit tool's implementation significantly reduced omitted medication doses. Monitoring and providing timely feedback can reduce missed nursing care (Graudins et al. 2014).

LIMITATIONS

This study was conducted at a single site, and convenience sampling was used, limiting the generalizability of the findings.

CONCLUSION

Patients remain at risk of the impact of missed care. Future research on the influence of missed care on adverse events in mental health care settings is recommended. The development of workforce and clinical policies and procedures to support mental health nurses to practice safely is essential to address missed nursing care, thereby improving patient outcomes.

This research also has the potential to inform policy development, contribute to reform initiatives and operational practice policies, such as staffing, mandatory skill mix, and escalation protocols.

RELEVANCE FOR CLINICAL PRACTICE

The above study aims to identify missed care in the acute mental health inpatient units and examine the factors contributing to missed care. Previous studies in general health settings have identified several modifiable risk factors, which may be applicable in mental health settings also. Findings from this study can play a decisive role in enhancing patient care through changing policies, improving nursing care, and allocating resources.

Item	Rarely missed	Occasionally missed	Frequently missed	Always missed	Never missed
Personal Hygiene related care

Items	Rarely missed	Occasionally missed	Frequently missed	Always missed	Never missed
Daily routine/basic nursing care
Personal Hygiene related care, shower, bed making
Assistance with ADL
Vital signs once a shift
Escalation of deterioration
Monitoring for side effects after medications
Monitoring of oral intake
Bowel Chart
Therapeutic communication
Therapeutic relationship
1: 1 contact/time with the client
Visual observation
Client advocacy
MSE – every shift
Face to Face Handover
Follow up after PRN
Progress note
Therapeutic intervention (Safewards)
Care Plan
Psychoeducation
Education for clients
Support for carers and family
Education for family and cares
Recovery plan
Person centred need based care
Alcohol withdrawal scale
Substance use module
Pressure area care/monitoring
Blood sugar Monitoring
Referral to services eg. Dentist, dietician
FRAT
Reporting incidents (including misses and near misses)
Sensory Safety plan
On admission
ECG
ADD chart
PRAT
Initial Assessment
Admission Checklist
Weekly Nursing Care
Weekly weight
On discharge/discharge planning
Liaison with recovery clinician
Referral to PARC
Discharge Checklist
Professional development
Attending education
Clinical Supervision