THE CORRELATION AVAILABILITY NURSES AND EQUIPMENT WITH ACUTE MISSED NURSING CARE AT HOSPITALS

Background: One of the nurse’s roles is to provide nursing care regards of patient safety, consistently and timely. The availability of nurses and equipment can be considered as a primary constraint contributing to acute missed nursing care. Aims: This study aimed to determine the correlation between the availability of nurses and equipment with incidences of acute missed nursing care in medical and surgical wards at hospitals. Methods: This study used quantitative research with a cross sectional approach. This research was conducted at six private hospitals in Malang from October 2020 to November 2020. The population in this study were selected using consecutive sampling, and the study sample consisted of 206 nurses. The acute MISSCARE Survey was used to collect data. The relationship between the availability of the number of nurses and equipment with acute missed nursing care was analyzed by applying SPSS version 26 with the Spearman test. Results: The relationship between the availability of nurses and acute missed nursing care yielded results of ρ = 0.016 (<0.05) and R = -0.168. Equipment availability and acute missed nursing care had values of ρ = 0.026 (<0.05), and R = -0.155. This shows correlation between the availability of the number of nurses and equipment with incidences of acute missed nursing care. Conclusion: The availability of the number of nurses and equipment are the reasons for the incidence of acute missed nursing care. Therefore, nursing managers are needed in managing and allocating the necessary number of nurses and equipment.


Introduction
One of roles is to provide nursing care to patients without missing or delaying care (Nilasari, Hariyati, and Anisah, 2020). Missed nursing care is a form of negligence towards patients (Duffy, Culp, and Padrutt, 2018). Previous study stated that missed nursing care occurs in individual interventions such as indications of patient mobilization needs, drug administration, and oral care (Winsett et al., 2016). Missed or delayed nursing care occurs in the nursing care process (assessment, diagnosis, planning, implementation, and evaluation) because of the patient care environment (level of patient care needs, allocation of labor resources, allocation of material resources, and relationships or communication) and the nurses themselves (team rules, decision-making priorities, internal values and beliefs, and habits) Dabney, Kalisch, and Clark, 2019;Hessels et al., 2019).
A study at 168 hospitals in the USA by VanFosson, Jones, and Yoder (2016) reported that missed nursing care in nursing interventions they occurred during these stage as follows: individual needs interventions, basic needs interventions, and planning. Missed nursing care has occurred in several countries, with as many as 86% of nurses in Britain and 74% of nurses in Sweden having missed nursing care at the end of their shift (Ball et al., 2018). Missed nursing care occurs during activities such as patient mobilization or ambulation, taking care of personal hygiene, and patient education. When this happens, emotional support for patients is eliminated or postponed in various care units (Vryonides et al., 2018). Meanwhile, there is no research on the incidence of acute missed nursing care in Indonesia.
The most frequently missed or delayed treatments in the medical surgery room occur during ambulation of patients, medication administered within 30 minutes, and oral care (Jones, Hamilton, & Murry, 2015).
Missed care occurs due to increased patient volume, the number of patients being admitted and discharged, inadequate assistants, inadequate staff, unavailable medicine, administrative tasks, and patient care (dos Reis Dutra, Salles and Guirardello, 2019). Another study stated the nursing actions most often neglected in the medical room were entertaining or talking to patients (66%), educating patients (52%), and developing or updating nursing care plans (47%) (Duffy, Culp and Padrutt, 2018).
Meanwhile, data in Indonesia shows that as many as 80% of nurses underperformed in several nursing interventions (Asmirajanti, Hamid and Hariyati, 2019). Meanwhile, in the medical surgery room, there is no research on the incidence of acute missed nursing care.
Missed nursing care is a phenomenon that can threaten patient safety and have a direct impact on the quality of patient care (Srulovici and Drach-Zahavy, 2017a;Kim, Yoo and Seo, 2018;Rabin et al., 2019;Cho et al., 2020). Missed nursing care also has consequences for nurses, such as decreased personal accountability of nurses, job satisfaction, and intention to resign or turn over (Srulovici and Drach-Zahavy, 2017b).
Missed nursing care that the patient needs is not implemented or delayed occurs in the nursing care process, and is determined by allocation of labor resources and allocation of material resources (Hessels et al., 2019). Several studies have stated that the variables of nurse availability and of medical tool availability were important factors in the occurrence of missed nursing care (Ball et al., 2016;Dabney, Kalisch, and Clark, 2019). Nursing staff composition and missed nursing care were significantly associated with an increase in nurse workload by one patient. A 10% increase in missed nursing care was associated with 7% and 16% increases in the likelihood of a patient dying within 30 days of admission to care (Ball et al., 2018).
Provision of equipment and means of care can be considered the greatest factors impacting the quality of healthcare, as it is impossible to provide high-quality care if equipment is not provided safety (Rabin et al., 2019). Nurses are essential to providing safe and effective care, but the insufficient number of nurses lead to heavy workloads, which can subsequently lead to missed nursing care (Gathara et al., 2020). Research has shown that insufficient hospital staff resources or a lower number of nurses leads to heavy workloads during shift periods (Junttila et al., 2016;Jansson, Syrjälä and Ala-Kokko, 2019).
According to several studies, the incidence of missed nursing care in the medical and surgical wards to the availability of personnel and equipment, and this has a negative impact on patients and nurses. Research has not investigated acute missed nursing care in the medical and surgical wards in Indonesia. This study aimed to determine the relationship between the availability of nurses and equipment with acute missed nursing care in medical and surgical wards at private hospitals in Malang.

Method
This quantitative research used an observational-descriptive design with a cross sectional approach. The population in this study was all nurses in the surgical and medical wards at private hospitals in Malang. This study used consecutive sampling with a sample of 206 registered nurses. It was conducted at six private hospitals supported by having a medical surgery room. All the hospitals were located in Malang and investigated from October 2020 to November 2020 consisting of four type B hospitals with 174 nurses, and two type C hospitals with 32 nurses.
The study used the acute MISSCARE Survey tool containing 15 question items; namely focused review, assessment, monitoring blood sugar, documentation, monitoring vital sign, managing treatment effectiveness, skin and wound care, emotional support, monitoring of incoming and outgoing fluids, administering drugs if necessary, hand washing, intravenous access care, patient education, toileting, and schedule of drug administration.
Respondents were asked to report how often certain elements of nursing care were missed using a Likert scale: A = Always Missed (1), OM = Often Missed (2), SM = Sometimes Missed (3), RM = Rarely Missed (4), and NM = Never Missed (5) (Dabney, Kalisch, and Clark, 2019). The reason MISSCARE survey tool containing 8 question item namely focused review on the availability of nurses: nurse assistants are not on duty or absent; drugs are not available when needed; the number of nurses is inadequate; the emergency condition of other patients; an unexpected increase in patients; insufficient or absent number of nursing assistants; the number of other tasks outside of nursing performed by nurses; and the number of administrative tasks; and 2 question items: focused review on the availability and functions of equipment to support nursing care . Respondents were asked to indicate the reasons for missing elements of nursing care using a Likert scale: 1 = not a causative factor, 2 = a causative factor, but at a minimum, 3 = a partial causal factor, and 4 = the main causative factor (Bragadóttir, Kalisch, and Tryggvadóttir, 2017;dos Reis Dutra, Salles and, Guirardello, 2019). The research instrument has tested the validity and reliability of the 10 respondents with the results rcount = 0.68 and α = 0.6.
Respondents used an o nline form link to fill out the research survey, which was forwarded by the nursing managers of each hospital over a two-week period. The relationship between the availability of nurses and tools with acute missed nursing care was analyzed using the SPSS application version 26 for Windows 14. The differences in the incidences of acute missed nursing care and the demographic characteristics between the two types of hospitals were analyzed using the Wilcoxon test. The relationship between the availability of nurses and tools with acute missed nursing care was analyzed using the Spearman test. All statistical analyses were performed at the 0.05 significance level.
This study has obtained ethical eligibility from the Health Research Ethics Committee of the Faculty of Medicine, Brawijaya University Number 183/ EC/KEPK/10/2020 and a research permit from six private hospital in Malang. In accordance with the research ethics protocol, the ethical principles included informed consent, beneficence, respect for anonymity, confidentiality, and respect.

Result and Discussion
The nursing process is also beneficial for patients because they participate in determining nursing planning and build cooperation in implementing nursing actions. The nursing process prevents the occurrence of duplicated actions and insufficient action, and improves high quality nursing care (Budiono, 2016;Pérez et al., 2017). Proper nursing care impacts both nurses and patients, and prevents duplicated actions and missed care.
The relationship between the availability of nurses and equipment with acute missed nursing care was analyzed using the Spearman test, as shown in Table  1. There was a relationship between the availability of nurses and acute missed nursing care with a negative strength (ρ value = 0.016 (<0.05),; (R) -0.168 (± 0 to ± 1)). Availability of equipment with acute missed nursing care had with a negative strength (ρ value = 0.026 (<0.05),; (R) -0.155 (± 0 to ± 1)), which indicates that there is a negative relationship between tool availability and incidences of acute missed nursing care. This shows a relationship between the availability of nurses and equipment with incidences of acute missed nursing care.
Inadequate staff resources or a lower number of nurses lead to heavy workloads during shifts (Junttila et al., 2016;Jansson, Syrjälä and Ala-Kokko, 2019). The results in Table 1 showed that there was a relationship between the availability of nurses and incidences of acute missed nursing care. The increasing unavailability of nurses is the main factor causing patient care to be missed or delayed, and it increases the incidences of acute missed nursing care. The insufficient number of nurse personnel can hinder nursing practice, and this is consistent with the results of the study that states factors in the care environment (e.g., workload due to lack of personnel) can facilitate or hinder nursing practice (Rabin et al., 2019). Research on hospitals in France and Finland showed that insufficient staff resources or a lower number of nurses led to heavy workloads during shift periods (Junttila et al., 2016;Jansson, Syrjälä and Ala-Kokko, 2019). Therefore, nursing managers need to plan for personnel requirements and handle workload problems related to nursing work in order to increase nurse productivity and satisfaction, as well as reduce turnover, work stress, and provide adequate staff for patient care needs (Alghamdi, 2016;Qureshi et al., 2019;Bagnasco et al., 2020).
Management of nursing workload and staffing is needed, especially in creating and maintaining a healthy work environment, setting practices that maximize the health and well-being of nurses, and ensuring quality patient care (Hovenga and Lowe, 2020). The components of the nursing workload identified in terms of patients, nurses, and health institutions have been divided into five main categories: total nursing time, nursing competency level, weight of patient care required, the amount of physical exertion, and complexity of treatment (Alghamdi, 2016). Effective staffing requires comprehensive nursing workload measurements to determine staffing needs, handle increased workload volume, and manage the impact on nursing services at any given time (Swiger, Vance and Patrician, 2016). The high workload of nurses increases the occurrence of missed nursing care, which results in patients having a longer length of stay (Tubbs-Cooley et al., 2019). When nurses' resources are insufficient (e.g., insufficient practice environment and time), nurses may minimize their standard of care or share of attention across nursing activities or even across patients. This can increase the risk of adverse outcomes for patients, thereby threatening patient safety and reducing the quality of care. Nursing care priorities can be described in terms of implicit offering, in which nurses decide to withhold or not carry out the necessary nursing duties when they are deprived of nursing resources through clinical decision making and judgment.
Inadequate material resources, such as facilities and infrastructure, cause nurses to skip or delay patient nursing care (Haftu et al., 2019;Tou et al., 2020). The results of the study showed a relationship between the availability of equipment and incidences of acute missed nursing care, as shown in Table 1. The unavailability of tools is the main factor causing patient care to be missed or delayed, and it increases incidences of acute missed nursing care. The availability of physical tools and functions when needed can facilitate or can become a barrier to nursing services (Henderson et al., 2016;Rabin et al., 2019). Therefore, it is necessary to fulfill the need for tools optimally in terms of their existence and function by the hospital as a health service provider, in order to prevent the occurrence of acute missed nursing care (Ogboenyiya et al., 2020;Dutra and Guirardello, 2021).
The relationship between the availability of nurses and tools with incidences of acute missed nursing care is negative. This means that if nurses perceive that the availability of nurses and tools is the main factor causing patient care to be abandoned, incidences of acute missed nursing care increase. Health services are an integral part of hospitals or health clinics. Maximum service can be achieved if the availability of resources in the service center is adequate. However, the availability of adequate resources cannot be ascertained, and excessive availability of resources can also result in waste. The problem that often occurs is the lack of optimal services provided to patients due to limited available resources. Optimal barriers to service include the repetition of unpermitted services, uncertain service distances, and service time (Pardede et al., 2019). The hospital must procure the equipment needed to develop and support the health system (Nkwanyana and Voce, 2019).
The work environment of nurses is associated with quality of care, mortality during patient care, and missed nursing care. The missed nursing care model shows that missed nursing care can occur at any stage of the nursing process. The model also describes the internal processes and factors that guide nurses in deciding what elements of care should be given priority, and thus resolved or overlooked (eliminated or delayed) until resources are enough available. Missed nursing care can occur due to human resources and material resources (infrastructure) factors. Missed nursing care can be caused by the factor of human resources, specifically when the number of staff members is inadequate. More staff members increase sufficiency and level of teamwork, and it reduces incidents of missed nursing care. Material resources contribute to missed nursing care when supplies or equipment do not function properly when needed, supplies or equipment are unavailable when needed, and medicine is unavailable when needed. Unbalanced patient assignment also affects missed nursing care, especially when other departments do not provide the needed care (e.g., physical therapy is not running, inadequate handover from previous shift or sending unit, lack of support from team members).
Missed nursing care is the negligence of nursing care that is needed by patients (Pérez et al., 2017). Missed care occurs when a nurse is asked to perform various activities at the same time, but some activities are not carried out or are delayed (Cho et al., 2020). Assessment of nurses, which includes missed nursing care related to the primary assessment of nurses, which can be in the form of incomplete care, or care that is deliberately not given (Srulovici and Drach-Zahavy, 2017b).
Missed or delayed nursing care causes morbidity and mortality of patients in the surgical ward (Ball et al., 2018). Missed nursing care is a phenomenon that can threaten patient safety and have a direct impact on the quality of patient care (Srulovici and Drach-Zahavy, 2017a;Kim, Yoo, and Seo, 2018;Rabin et al., 2019). This can lead to negligence and commission errors in nursing actions, which is failure to take action correctly. The MISSCARE survey instrument identifies these action as lost or overlooked. The negligence of agreement forms in therapeutic transactions by health personnel can result in overlooked and unfulfilled content on the forms. This has a broad impact not only on patients and families, but also on hospitals, individual nurse perpetrators, and on the profession in the form of criminal or civil lawsuits.
The elements of nursing care in missed care have been classified into four groups: nursing assessments, basic care interventions, individual needs interventions, and planning. The planning category includes nursing assessment procedures, and the assessment procedures most frequently missed by nurses in medical and surgical wards are complete documentation of all data needed, monitoring fluid intake and output, and assessing vital signs in order. The nursing procedures most often missed in the basic care-intervention category are ambulation, changing the patient's position every two hours, and oral care. The interventions associated with individual needs that are most often missed by nurses are emotional support for the patient and family, treatment effectiveness assessment, medication given within 30 minutes before or after the scheduled time, and PRN treatment requests followed up within 5 minutes. The most frequently overlooked items of nursing care related to planning are attendance at interdisciplinary care conferences, and patient education about diseases, tests, and diagnostic procedures .
Missed nursing care is influenced by internal and external factors Hessels et al., 2019). Internal factors come from the individual nurses themselves and their perceptions and internal values. External factors come from the work environment, teamwork, communication, organizational learning, workload, management support for patient safety, and available infrastructure (Bragadóttir, Kalisch, and Tryggvadóttir, 2017;Cho et al., 2020). The main reasons for missed nursing care in the medical surgery room are the insufficient number of nurses, the emergency condition of the patient during work shifts, and the unavailability of drugs, materials, or equipment when needed (dos Reis Dutra, Salles, and Guirardello, 2019). Low work environment accountability leads to acute missed nursing care. Factors in the care environment can facilitate or hinder nursing practices. Table 2 shows that the nurses in the medical and surgical wards consisted of 206 nurses from 6 private hospitals in Malang. The demographic data shows 31 male nurses (15%) and 175 female nurses (85%). As many as 144 nurses (70%) were aged 30 and under, while 62 nurses (30%) were above the age of 30. Besides, 151 nurses (73%) had D3 degrees, while 55 nurses (27%) had S1 degrees in nursing. Regarding their work, 128 nurses (62%) were permanent employees, and the remaining 38 were contract nurses (40%). Furthermore, 191 nurses (93%) worked on shift schedules, while 15 nurses (7%) worked on non-shift schedules. Lastly, 117 nurses (57%) had worked for five years or less, and 89 nurses (43%) had worked for over five years. In terms of marital status, 139 nurses (67%) were married, and 67 nurses (33%) were unmarried. Table 2 shows the demographic characteristics data obtained from the respondents. There was a difference of ρ value = 0.016 (≤0.05) in incidences of acute missed nursing care between permanent and contract employees. Incidences of acute missed nursing care was higher among permanent employees (mean = 41.19) than contract employees (mean = 35.38). Hospital unit characteristics and nurse characteristics may be indicators of the acute missed nursing care phenomenon. Staffing competence is a key mechanism that affects the quality of patient care.
There is a difference that can be seen in the occurrence of acute missed nursing care from the demographic data of employment status. The incidences of acute missed nursing care based on permanent employment status is greater than that of contract employees, as shown in Table 2. This is in accordance with the results of research that associated missed care with several factors from the perception of nurses based on demographic data, namely the number of nurses' children, years of experience working as a nurse, the assignment unit, and the level of satisfaction with the profession (Bragadóttir, Kalisch and Tryggvadóttir, 2017;Alshammari et al., 2020). Therefore, nurse managers must plan actions to reduce the nursing workload through teamwork, as well as improve patient safety culture and job satisfaction by developing solutions for nurses to feel empowered (Metcalf, Wang, and Habermann, 2018;Bacaksiz et al., 2020;Dutra and Guirardello, 2021). Nurses' decisions to eliminate or delay certain care activities are also influenced by nurses' intrinsic perceptions of the process in terms of team norms, decision-making practices and embedded values, beliefs, habits, and attitudes through which nurses perceive their roles and responsibilities. Low personal accountability leads to the occurrence of missed nursing care (Srulovici and Drach-Zahavy, 2017b). When the level of competency of nursing staff is low, the potential for acute missed nursing care increases due to a lack of time in patient management experience. The foundations of nursing ethics are to save human lives, to protect patients from harm, to respect human rights, and to create patient safety, high quality service, and dignified, caring, and comprehensive care for patients without discrimination (Vryonides et al., 2018). Patient safety culture is a vital health component in the quality of care, characterized by a healthcare provider's perspective on the importance of safety, and a belief in the effectiveness of patient care outcomes and remedial actions.

Conclusion
Missed nursing care occurs when nursing care is postponed, partially completed, or not completed at all. The occurrence of missed nursing care is determined by human resources and material resources (equipment availability). This study shows that there is a relationship between the availability of nurses and tools with incidences of acute missed nursing care in the medical and surgical wards. Heavier workload and unavailability of tools are considered by nurses as the main causes of patient nursing care being missed, and these factors increase incidences of acute missed nursing care.
Proper nursing care will impact both the nurse and the patient, for example preventing duplicated actions and missed care. Provision of care can be considered an indicator of the quality of health services. It is impossible to provide high quality care if both manpower and equipment are not available enough. Therefore, it is the duty of every health institution to reduce the likelihood of injury to patients by providing adequate care. Nursing quality is an important factor in ensuring patient safety because nursing care that is below standard directly leads to the occurrence of missed nursing care during treatment. This shows the need for human resource management interventions in the form of nursing managers allocating appropriate workloads to reduce the occurrence of acute missed nursing care. The availability of tools determines the quality of patient care, therefore the availability of physical and functional tools is also expected to reduce the occurrence of missed nursing care.

Ethics Approval and Consent Participant
The respondents used an online form link to submit the consent forms, which were forwarded by the nursing managers of each hospital.

Conflict of Interest
The author states that there is no conflict of interest in this article.