An Analysis of Research in Missed Nursing Care

An Analysis of Research in Missed Nursing Care

Evidence based practice is the core of the nursing process, and the decisions we make in the field are backed by researcher’s ability to collect and interpret data. Researchers have many tools and methods available to accomplish this, and each method has its place and purpose. Whether to gather information about the emotional tone and impact of a subject or to extrapolating a statistical analysis to quantify a phenomenon, research is applied to continually move nursing forward in ways that are scientifically based and relevant. While this is true of research conducted, not all studies are executed flawlessly, and may come under scrutiny by other researchers.

This paper will analyze the execution of such a research project. The evaluation of the article will be measured through the researcher’s ability to analyze material gathered and applied to the topic, as well as the level of appropriate application the projects design is constructed for subject being explored. The analysis will delve into the specifics of the populations evaluated and how statistically relevant the data is to the project, as well as evaluate for potential bias, and how it is relevant and applicable to the nursing practice for future improvement.

Article Selection

Nursing is a field that many go into with the intention of helping others, and with that intention aid in the treatment of the whole person as they experience the processes of illness. While this is true for many, even with the best intention to help others as they go through what may be the most difficult time of their lives many nurses will admit that despite their best efforts, some activities meant to promote wellness or prevent harm may be missed on any given shift. The factors that contribute to this are the subject of this study, and this is research that hits the heart of the nursing profession. If good intentions were the only driving force determining if all nursing tasks were accomplished, research in this area would not be needed, as the issue of missed nursing care would not be a factor that needed examination.

Research and Learning Goals

The research article by Park, Hanchett, and Chenjuan, “Practice Environment Characteristics Associated with Missed Nursing Care” is a project that explores what factors are behind nursing care that is not accomplished (2018). The authors reviewed current data that had been collected on the subject and formulated their own research to expand upon this knowledge. The research project is an exploration into the varied environmental factors and seeks to find a commonality in these factors by examining medical surgical settings as a baseline.

I no longer practice nursing in the area that is the focus of this study, however the foundation of my nursing career began on such a unit. While intensive care units (ICU’s) are a specialty that function with the common practices of medical surgical unit, nursing is still a driving force in the care and advocation for patients’ rights and wellbeing. The issues faced in one specialty of nursing can echo in another, and although the goals and tasks may differ, some basic structural difficulties may persist. As the knowledge base of this area grows, the application into other specialties can be explored, and the concepts of the data collected that can add to this are of great value to nursing.

Research Question

The researchers asked a twofold question to address their study’s focus. They question whether there is a correlation between certain work environments and missed nursing care. The next aspect studied is the distinct characteristics of environments in which nursing care was missed in higher rates than others.

Research design

Park, Hanchett, and Chenjuan designed a correlational non-experimental, quantitative study which provides level IV evidence (LoBiondo-Wood & Haber 2018). Data was collected from previously gathered survey for secondary analysis, and no randomization and manipulation is possible with this method. The survey was in the form a questionnaire used to determine if any relationships exist, although no cause can be determined at this level (LoBiondo-Wood & Haber 2018).  This method of research collects statistical information and allows the researchers a measurable result to analyze from the specific timeframe in which the data was collected.

Researcher’s description

The researchers described their correlational approach as a study that used secondary analysis of data previously collected from the National Database of Nursing Quality Indicators (NDNQI) 2015 survey (Park, Hanchett, and Chenjuan, 2018). The data was collected for this purpose to provide a look at characteristics on the unit level based upon a comprehensive study and investigation


Park, Hanchett, and Chenjuan, 2018).

Choice of design

This quantitative approach to the research question is an apt choice to examine the problems presented. The researchers intended to fill in the gaps of data already collected from previous studies, yet the nature of the research questions is restrictive in the methods available. The research attempted to determine what the natural environment’s effect on nursing care is and this cannot be replicated in a laboratory setting. The variables are ones that cannot be manipulated by the researchers, as this would interfere with the practice environments and the integrity of the independent variable would be at risk. The choice to use a correlational design allowed for the researchers to determine if the variables co-vary in this environment (LoBiondo-Wood & Haber 2018). The researchers also identified gaps in current literature, and the research conducted by this design can provide a foundation for further research studies to build a data pool for evidence-based research.

Foundations of the Study

The theory is easily identified by the authors, who based their research upon the Structure Process Outcome model introduced by Avedis Donabedian (Naranjo, & Kaimal, 2011). This module was introduced to provide a framework for improving the quality of patient care and is an applicable theory to structure the concepts of this research around. The model is based upon a correlation between improvement in the structure and process of the nursing environment and improvement of patient outcomes (Kobayashi, Takemura, & Kanda, 2011)

Literature Review

Park, Hanchett, and Chenjuan conducted a review of current literature to determine the current knowledge base regarding the correlation between what is defined as missed nursing care which can affect patient outcomes and associated environmental factors. Their review discloses weaknesses in current literature linking these two factors and stated that little research is available. The review also determined that the specifics of environmental factors which influence missed nursing care is not clearly defined in current data.


The article does not have a section directly labelled a literature review, however, the introduction of the article contains the information gathered for this purpose. The articles reviewed do not appear in chronological order and is presented in a concept-based manner.  The article begins with the definition of missed care, as applied to current research and practice, which is considered either an omission or significant delay to required patient care, and this section subsequently ends with the bifold research questions posed by the project (Park, Hanchett, and Chenjuan, 2018).

Review depth.

The articles referenced for research in the literature review did not stray far from the research question. Many of the articles were primary sourced nonexperimental cross-sectional studies providing level IV evidence directly related to missed nursing care in a variety of clinical environments. The authors identify gaps in collected data existing on a unit level and detail the differing opinions on factors which lead to missed nursing care. They offer examples such as personnel type and absenteeism versus adequacy of resources and teamwork (Park, Hanchett, and Chenjuan, 2018).

Review Clarity.

The literature review does successfully build upon the studies conducted in the past, and the sequence is logical in presentation based upon concepts (LoBiondo-Wood & Haber 2018). The authors succeed in answering a clinical question of missed nursing care environmental factors and can use this information to refine their own research for their target area. No hypotheses were presented by the authors however, although much of the research presented discusses a positive correlation between a poor care environment and missed nursing care.

Conduct of Research

The researchers derived their sample from the National Database of Quality Indicators (NDNQI) taken in 2015. The information gathered from the NDNQI is acquired from about 2000 hospitals with voluntary participation by nursing staff who provides at least 50% of the patient care for intersystem quality improvement (Park, Hanchett, and Chenjuan, 2018).  The information collected was repurposed in a secondary analysis by the researchers for this study.

Sample Characteristics

Park, Hanchett, and Chenjuan (2018) further refined the sample from the NDNQI to fit in to the criteria for the research question. The survey used for the information the authors analyzed included the responses from 31,650 nurses spread across 371 hospitals and sampled 1583 units. For the purpose of providing a homogenous base to draw upon as a standard representation of a typical nursing unit, the sample was taken from either medical, surgical, or medical surgical units (Park, Hanchett, and Chenjuan 2018). With this consideration in mind, the units did not include information gathered from specialty units such as obstetrics or intensive care due to the variation in the working environment and experience of the staff in these locations.


The survey analyzed by the authors and used by the NDNQI included the Practice Environment Scale of the Nursing Work Index (PESNWI) as a basis for measurement of the nursing environment. The survey included questions regarding 16 areas of nursing care that was missed during a shift, and for the purpose of the research, removed the question related to breastfeeding as related to the obstetrics specialties. The descriptive correlational nature of the data allowed for the researchers to gather information from the variables discussed to create a correlation coefficient (Dang, & Dearholt, 2018).

Characteristics of data collected.

The nature of the secondary analysis is reliant on the NDNQI for its data, and the timeframe the survey was given is not specified in exact detail, although the year this information was gathered was 2015. The NDNQI is a confidential survey whose results are stored in a public database. The NDNQI gives instruction on how to avoid identification and includes a statement citing nurses’ hospital of employment will not have access to individual responses, as the information is collected directly by the NDNQI and the hospital is given a summary report of the responses (NDNQI: A Press Ganey solution, n.d.). Although a statement is made by the NDNQI regarding the voluntary and confidential nature of anonymity in the survey is available, it is unclear if refusal is possible after the survey has been conducted.

Analysis and Reporting

The study used descriptive statistics and the information was measured through the multilevel regression statistical analysis to interpret the information (Park, Hanchett, & Chenjuan, 2018). Descriptive statistical analysis allows the researchers to quantify what degree the variables within the study influence the research questions, and broadening this analysis is the addition of multiple regression statistics, which is a method that can be applied to more than two variables (LoBiondo-Wood & Haber 2018). This type of analysis allows the researchers a more in-depth investigation to how much the independent variable influenced the dependent variable, as well as which independent variable had a greater degree of influence in the case where multiple factors are in play (Fisher, & Bloomfield, 2019).

Generalizability, Reliability, and Validity

The sample population is an adult medical, surgical or combination style of unit, and the authors recognize this as a factor that may limit generatability. The samples were also derived from specific demographics of the hospitals themselves, as they were described as magnet, teaching and metropolitan in nature, which had the potential for further limitation (Park, Hanchett, and Chenjuan, 2018).

The authors also recognized the reliability of the results was also a weakness of the study due to the nature of the questionnaire. The data collected relies on the reporting of those who answer the survey question, which leaves it vulnerable to bias as well as reduced reliability due to dependence upon the memory of the nurses who reported those findings (Park, Hanchett, and Chenjuan, 2018).

The authors discussed the validity of the PESNWI scale used in the NDNQI survey

(Park, Hanchett, and Chenjuan, 2018).  The authors stated that this scale is a validated tool which has been verified by the National Quality Forum (NQF) as a common research tool. It is described as a method which is high in internal consistency and validity (Park, Hanchett, and Chenjuan, 2018).

Ethical Review

The anonymity of the participants is protected by the NDNQI, and participation is voluntary. The authors used secondary analysis of the information gathered by the NDNQI, and this information is devoid of identifying characteristics of the participants. There is no evidence of a breach of ethics with the collection and distribution of this data.

Article Conclusions and recommendations

The authors concluded that their research supports the concept in which good working environments were negatively correlated with missed nursing care. The conclusion was that emphasis on a good working environment will lead to fewer poor outcomes and events, with a specific emphasis on adequate staffing and resources for the nursing staff (Park, Hanchett, and Chenjuan, 2018).  The authors stated the future research in this area should be directed toward connecting the link between structure and missed care, as well as the outcomes associated with it, as missed care is not currently considered and adverse event (Park, Hanchett, and Chenjuan, 2018).

This research provided level IV evidence toward the topic and provided a basis for future research and clinical practice guidelines (Dang, & Dearholt, 2018). The gaps in research detailing the link between missed nursing care and poor outcomes is one that could feasibly be refined into increasingly higher levels of evidence. This article successfully provides groundwork for future research to both expand and refine the current knowledgebase of these variables.

Researchers contact information

The researchers provided the University of Kansas School of Nursing as the supporter for the study. The acknowledgment states that Ms. Hanchett is a student in the BSN program, but does not discuss the other authors. Though not explicitly stated as a method to contact the authors, the University is acknowledged as a potential for contact of the researchers.


The article by Park, Hanchett, and Chenjuan (2018) is a nonexperimental, correlational quantitative research article that investigates the impact environment has on missed nursing care in the nursing field. The researchers use descriptive statistical analysis to quantify the information gathered through secondary analysis of the NDNQI survey, and this provides level IV evidence as a foundation for practice guidelines and future research. The authors successfully gathered and analyzed data to support previous research and open new areas for future investigation regarding missed nursing care and poor patient outcomes.


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