Nursing Quality Indicators Research Articles

The Effect of a Certified Wound Ostomy Nurse Educational Bundle on Hospital Acquired Pressure Injuries in the Intensive Care Unit: A Quality Improvement Project

<i>Purpose:</i> Patients in critical care units are considered high risk for pressure injury (PI) development with reported rates in the United States topping 40% in some cases. Multiple factors contribute to the risk of this population including a knowledge deficit among nurses which often leads to a lack of assessment and prevention measures needed to reduce pressure injuries. This project was launched after data collected by the Wound, Ostomy and Continence Nurse (WOCN) team showed an increase in hospital acquired pressure injuries (HAPI) in the intensive care unit (ICU) in the first quarter of 2016. The rate was 11.56 per 1000 patient days. This data was collected as part of our quarterly prevalence study reported to the National Database of Nursing Quality Indicators (NDNQI). Although this rate is lower than the national average, our patients deserve process improvement to achieve 0% incidence. <i>Participants and Setting:</i> The setting was a 16-bed ICU at a tertiary care hospital in the Southeastern United States. Monthly data was collected over the span of a year to evaluate incidence rates of hospital acquired pressure injuries (HAPI) from Q1 2016 to Q 4 2017. <i>Approach:</i> The cornerstone of this project was to focus on nursing education surrounding pressure injury prevention (PIP) intervention selections. The overall goal was to heighten the quality of patient care by implementing an innovative PIP bundle that was supported by Certified Wound, Ostomy Nurse (CWON) education and knowledge sharing throughout the ICU. The Plan, Do, Study, Act (PDSA) methodology was used to monitor interventions and outcomes. <i>Outcomes:</i> The measurable goal of this project was to decrease the quarterly rate of hospital acquired pressure injuries in the ICU by 50% by 4Q 2017, as compared to a rate of 11.54 per 1000 patient days 1Q 2016. Subsequent quarters demonstrated incremental decreased HAPI rates of 0.9, 1.8, 1.7, 5.2, 4.3, 0.9 and 0 by 4Q 2017. This was a total reduction rate greater than 50% which was our goal. The PIP bundle highlighted by WOC nurse education resulted in significant and clinically relevant reductions in incidence of HAPI in the ICU. Our future goal is to continue with an ongoing PIP bundle and WOC nurse rounding as part of our best practice within this hospital setting. In addition, we continue to share knowledge gained by this QI project with our extended WOCN team working at our surrounding facilities.

Questionnaires to Measure Process and Structure of Quality Indicators for Pediatric Nursing.

Introduction:The quality of nursing care has a significant impact on the outcomes of care. The specific needs of children requiring hospital care make it essential to monitor and compare data not only on the medically oriented outcome measure but also on nursing care, structure, and process, requiring perspectives from registered nurses (RNs) and nurse managers (NMs). Thus, this project aimed to evaluate the structure and process of nursing quality indicators in pediatric hospital care with questionnaires distributed to RN and NM.Methods:We developed separate questionnaires for NMs and RNs to assess the process and structure of the quality indicators of breastfeeding, management of pain, venous access, medication management, and provision of a child-oriented environment. Nine NMs and 113 RNs from 9 pediatric wards answered the questionnaires.Result:Local guidelines were available for 3 out of the 5 quality indicators: pain management, venous access, and medication management. RNs reported varying levels of adherence to pain management (62%), and venous access management (72%). Satisfaction with the conditions for safe medication management was 90%. Approximately, two-thirds (67%) of RN reported sufficient knowledge regarding the impact of the child-oriented environment and less than half (44%) regarding how to support breastfeeding.Conclusion:Structure and process is a prerequisite for quality of care outcomes. This study discloses areas for quality improvement and offers instruments to compare structure and process in pediatric nursing care to discuss with consumers, managers, staff, and other stakeholders.

Posthospital Nursing Home Utilization and Quality Indicators Among Medicare Beneficiaries in Puerto Rico: Comparison With the United States

ObjectivesThe purpose of the study is to contribute to the literature regarding post-acute nursing home utilization and quality indicators among Medicare beneficiaries in Puerto Rico compared with the US mainland. DesignMedicare data from 2015 to 2017 was used to identify new discharges to skilled nursing facilities (SNFs) using the Minimum Data Set and the Medicare Provider Analysis and Review. Setting and ParticipantsPost-acute care patients admitted to SNFs in Puerto Rico and the United States. MethodsOur final cohort included 4,732,222 beneficiaries from Puerto Rico and the United States enrolled in Medicare fee-for-service or Medicare Advantage programs admitted to an SNF (N = 15,197) following an acute hospital stay. We compared demographic, clinical, and facility-level characteristics among patients in Puerto Rico and the United States. We also described 2 quality indicators among these groups: (1) 30-day rehospitalization rates and (2) successful discharge from the facility to the community. ResultsMedicare patients in Puerto Rico were physically and cognitively healthier than patients in the United States. Puerto Ricans were also more likely to be admitted to lower quality nursing homes than US patients (2.5 vs 3.4). Finally, Puerto Ricans had higher rates of successful discharge to the community [17.6, 95% confidence interval (CI) 13.0-22.3], but higher 30-day rehospitalization rates compared with US patients (11.2, 95% CI 6.2-16.3). These differences were consistent even when comparing these quality outcomes among Puerto Ricans to US Hispanics only. Conclusions and ImplicationsSNFs in the United States and Puerto Rico are now receiving financial penalties for high readmission rates. Currently, Medicare does not measure readmission rates for Medicare Advantage patients—even though some states, including Puerto Rico, have a high proportion of Medicare Advantage beneficiaries. As Medicare Advantage enrollment continues to increase, our results highlight the importance of measuring performance among Medicare Advantage patients and assessing disparities in quality of post-acute care among patients in Puerto Rico and the United States.

Examining the measurement invariance of the Practice Environment Scale-Nursing Work Index in the United States.

The increasingly diverse nursing workforce in the United States often creates challenges for researchers in meaningfully interpreting survey data from large samples of nurses with heterogeneous cultural backgrounds. Considering this, the purpose of this study was to determine the measurement invariance of the Practice Environment Scale-Nursing Work Index (PES-NWI) between registered nurses (RNs) reporting as Asian/Pacific Islander and those reporting as White. Data from the National Database of Nursing Quality Indicators®, collected in 2018 from RNs (N = 27,619) providing direct patient care, were used in this study. Multi-group confirmatory factor analysis was used to determine measurement invariance. Interpretation of the fit indices across models (configural, metric, and scalar) provides support for measurement invariance of the PES-NWI across the two groups. There is empirical support for pooling PES-NWI data and comparing it across these two groups.

The value of intentional self-care practices: The effects of mindfulness on improving job satisfaction, teamwork, and workplace environments

BackgroundBurnout rates among nurses have detrimental impact on job satisfaction, teamwork, and patient care. This costs millions of dollars in the healthcare system and challenges nurse leaders to address in order to keep up with the healthcare demands. Furthermore, burnout is especially relevant in our current healthcare climate, as frontline nurses have increased workload and multiple psychosocial stressors during the coronavirus disease (COVID-19) pandemic (Sultana, Sharma, Hossain, Bhattacharya, & Purohit, 2019). Literature also suggests that mindful self-care practices need to be reinforced in order to impact burnout long term (Chamorro-Premuzic & Lusk, 2017). Project7 Mindfulness Pledge© is an accessible and voluntary mindfulness tool that nurses can utilize in their individual practice to reduce burnout and does not require significant time commitment. ObjectiveTo evaluate the effectiveness of intentional self-care practices on nurse burnout and workplace environment by measuring job satisfaction and teamwork among nurses. MethodsComparisons between inpatient units on data from the National Database of Nursing Quality Indicators (NDNQI) with the Practice Environment Scale (PES), specifically on job enjoyment and teamwork, were done utilizing ANOVA. ResultsResults show that nurses in an inpatient unit that implemented Project7 has significantly higher job satisfaction as compared to units that did not implement Project7. ConclusionsThis suggests that this tool provides an effective and accessible mindfulness framework managers and directors can utilize to improve job satisfaction, teamwork, and thereby reduce burnout to create healthier work environments.

Research on the Application Value of Comfort Nursing Intervention in the Nursing of Senile Chronic Heart Failure

&lt;p&gt;&lt;strong&gt;Objective&lt;/strong&gt;&lt;strong&gt;:&lt;/strong&gt; To analyze the application value of comfort nursing intervention in senile chronic heart failure nursing. &lt;strong&gt;Methods:&lt;/strong&gt; The 120 heart failures discharged from our hospital in 2018 and 2019 were selected. The changes in nursing satisfaction, specialty nursing quality indicators and the incidence of pressure ulcers in hospitalized patients were compared and analyzed between the two groups. &lt;strong&gt;Results:&lt;/strong&gt; The average satisfaction degree of the two groups was 97.48% and 97.22% respectively, and the difference between the groups was statistically significant (P&amp;lt;0.05). The correct rates of acute left heart failure in the two groups were 99.56% and 98.13%, and the difference between the groups was statistically significant (P&amp;lt;0.05), and two groups of patients with cardiac Ⅲ class above intake control accuracy was 99.95% and 99.99%, and the difference between groups was statistically significant (P&amp;gt;0.05), and the incidence of pressure ulcer was 0.18‰ and 0, and there was no significant difference between the two groups. &lt;strong&gt;Conclusion:&lt;/strong&gt; Comfort nursing intervention has achieved good nursing satisfaction and clinical effect in elderly patients with heart failure.&lt;/p&gt;

Quality and Safety in Health Care, Part LXXX: The National Database for Nursing Quality Indicators and the Practice Environment Scale of the Nursing Work Index.

The National Database for Nursing Quality Indicators is an important source of information used to benchmark nursing by unit category in multiple areas related to not only structure and process but also outcome. It also provides some information regarding best practices and the cost to achieve certain results. The Practice Environment Scale of the Nursing Work Index is a frequently used way to measure the professional practice environment of nurses and the relationship of the latter to quality, safety, and other outcomes.

The relevance, feasibility and benchmarking of nursing quality indicators: A Delphi study.

To identify indicators of nursing care performance by identifying structures, processes, and outcomes that are relevant, feasible and have the potential for benchmarking in Swiss acute hospitals. A modified Delphi-Consensus Technique. We examined 19 indicators based on the current evidence and that were pre-selected by nursing scientists. Between August-October 2019, a consortium of experts (representatives of different cantons, hospitals, and healthcare roles in Switzerland) determined the relevance, feasibility, and suitability for benchmarking these indicators in two-round modus of digital survey. Consensus was defined a priori by at least 75% agreement on the highest level of a 3-point Likert-type scale. The response rate was 70.4% in the first and 68.4% in the second round. In round one consensus was reached for three indicators on relevance but for none of the indicators regarding feasibility or potential for benchmarking. For round two, the experts suggested two additional indicators (new total of 21 indicators). Of 21 indicators, consensus was reached on twelve regarding relevance, seven regarding feasibility, and two regarding the potential for benchmarking. A national expert consortium defined 12 of 21 nursing care indicators as relevant. Feasibility, however, was estimated only among seven indicators and a consensus on suitability for benchmarking was reached for two nursing-sensitive indicators. The results show how the indicators to evaluate nursing care performance, which have been identified as priority by Canadian nursing scientists, are assessed in a different setting. There are many overlaps, but also some differences in the assessment of the indicators between the different settings. Different health systems prioritize the indicators to evaluate nursing care performance differently, which is why national surveys are important for the compilation of their own (priority) indicator sets.

Falls in unilateral lower limb amputees living in the community. A Portuguese study.

Lower limb amputees present a high risk of falling. This study aims to characterise fall history in unilateral lower limb amputees that are autonomous in the community, identifying differences between transfemoral and transtibial amputees and assessing fear of falling between fallers and non-fallers. Descriptive, cross-sectional study of consecutive community-dwelling unilateral lower limb adult amputees of any aetiology, attending outpatient consultation in a Portuguese Physical and Rehabilitation Medicine central and university hospital department. a prior 12 week individualised rehabilitation program for prosthesis training; regular prosthesis use for more than one year with autonomous gait; and a Functional Independence Measure® score equal to or greater than 100. Injury severity was classified according to the National Database of Nursing Quality Indicators® injury falls measure. In order to assess walking performance over short distances and fear of falling we used the 10-meter walk test and the Falls Efficacy Scale, respectively. In a sample of 52 lower limb amputees, mainly men (80.8%) and of traumatic aetiology (63.5%), with a mean age of 57.21 ± 11.55 years, 36.5% reported at least one fall in the previous 12 months, all classified as minor injuries. Transfemoral amputees (n = 23) presented a higher number of falls (2.22 ± 3.23, p = 0.025) and lower gait velocity (0.77 ± 0.26 m per second, p < 0.001). Regarding fear of falling, we found no significant differences between fallers and non-fallers. The prevalence of falls was low and of minor severity. Transfemoral amputees fell more often and were slower. There were no reported differences in fear of falling between groups. This paper contributes information about Portuguese lower limb amputees, whose studies are scarce and are rarely dedicated to falling.

Nursing quality indicators for adult intensive care: A consensus study.

The selection of quality indicators demonstrating the efficiency and relevance of nursing practice in patient outcomes in the intensive care unit remains a challenge. The aim of this study was to develop a set of potential quality indicators to quantify nursing care provided to critically ill patients through a consensus method. This was a three-phase study including a European survey of intensive care unit (ICU) nurses (phase one) followed by a two-phase face-to-face consensus meeting of experts from Cyprus. Two distinct panels of experts were asked to rate each quality indicator using a 4-point Likert scale in phases one and two. The level of consensus was set at 60%. In phase three, scores of the content validity index for items and scales were considered for the final selection of quality indicators. The phase one survey included 139 ICU nurses from 13 European countries, and phases two and three included seven ICU experts from Cyprus. "Consensus in" was achieved for 12 items at the end of phase two. Three of the quality indicators were significantly different by country: (a) falls (P=.006), (b) accidental removal of nasogastric tube (P < .001), and (c) accidental removal of intravascular catheters (P < .001). Only falls was significantly correlated with higher academic qualifications of the participants (P=.002). Fifteen items have been identified as potential indicators for adult ICU nursing quality. These need to be prospectively studied to determine the extent to which they can accurately capture nursing care quality in this setting. The study provides a set of relevant quality indicators. A nursing set for the ICU may serve as the basis for nursing management and facilitate the strategy dedicated to the vision of health care quality assurance.

Constructing Inpatient Pressure Injury Prediction Models Using Machine Learning Techniques.

The incidence rate of pressure injury is a critical nursing quality indicator in clinic care; consequently, factors causing pressure injury are diverse and complex. The early prevention of pressure injury and monitoring of these complex high-risk factors are critical to reduce the patients' pain, prevent further surgical treatment, avoid prolonged hospital stay, decrease the risk of wound infection, and lower associated medical costs and expenses. Although a number of risk assessment scales of pressure injury have been adopted in various countries, their criteria are set for specific populations, which may not be suitable for the medical care systems of other countries. This study constructs three prediction models of inpatient pressure injury using machine learning techniques, including decision tree, logistic regression, and random forest. A total of 11 838 inpatient records were collected, and 30 sets of training samples were adopted for data analysis in the experiment. The experimental results and evaluations of the models suggest that the prediction model built using random forest had most favorable classification performance of 0.845. The critical risk factors for pressure injury identified in this study were skin integrity, systolic blood pressure, expression ability, capillary refill time, and level of consciousness.

Patient Falls Prevention: Assessing the Use of an Innovative Color-Coded Flag System in an Outpatient Oncology Infusion Center.

The National Database of Nursing Quality Indicators (NDNQI, 2020) defines a patient fall as an unplanned descent to the floor with or without injury. A fall occurs in 30%-50% of hospitalized patients with cancer in the United States (Jatoi, 2017). According to the Joint Commission (2015), the average cost of each fall with injury in the United States was about $14,000 to the healthcare system, averaging about $50 billion annually (Kartiko et al., 2020). Fall-related injuries to patients can result in additional treatment, hospital admissions, prolonged hospital stays, delays in cancer treatment, immobility, pain, emotional distress, caregiver fatigue, and depression (Joint Commission, 2015). Patients with cancer are highly susceptible to falls because of the neurologic deficits caused by chemotherapy treatments, medications given to prevent side effects, allergic reactions to the chemotherapy medications, increasing age, cognitive status, disease site, and cancer- and treatment-related fatigue (Jatoi, 2017). The high financial costs to patients and healthcare providers, as well as the physical and mental impact on patients, led to this pilot project.

Patient Falls and Injuries in U.S. Psychiatric Care: Incidence and Trends.

The goal of this study was to estimate the incidence of falls (total, injurious, and assisted) in U.S. psychiatric care across 6 years (April 2013-March 2019). Data on falls among patients of adult and geriatric psychiatric units of general, acute care, and psychiatric hospital inpatient units from the National Database of Nursing Quality Indicators were used for this 6-year study. Total falls, assisted falls (i.e., falls broken or slowed by staff), and injurious falls were calculated, along with trends in total and injurious fall rates. The sample included 1,159 units in 720 hospitals. Of the 119,246 falls reported, 25,807 (21.6%) resulted in injury. Only 7.0% of the total falls in psychiatric units were assisted by a staff member. Falling unassisted was associated with a higher likelihood of fall-related injury (adjusted odds ratio=1.69, 95% confidence interval=1.59 to 1.80). The total fall rate (8.55 per 1,000 patient-days) and injurious fall rate (1.97 per 1,000 patient-days) were highest for geriatric psychiatric units in general hospitals. Total and injurious fall rates in psychiatric units in general hospitals declined during the study (total fall rate declined by 10% for adult psychiatric units in general hospitals). There was no clear trend in total or injurious fall rates for units in psychiatric hospitals. Falls are a persistent problem in psychiatric care settings. Few fall-prevention programs have been tested in these settings, which have unique risk factors for falls. Additional research is needed to develop fall-prevention interventions in psychiatric care.

Assessment of the Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) database using a data quality index

A comprehensive data quality assessment is necessary to expand a nursing database that is designed for evaluating the impact of implementing Best Practice Guidelines (BPG) developed by the Registered Nurses' Association of Ontario (RNAO). This case report presents a method to standardize data quality assessments of the Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) database by developing a data quality framework (DQF) and assessing key dimensions of the framework using a data quality index (DQI). The data quality index is a single key performance metric for assessing the quality of the database. The aims of sharing this case report are 2-fold: (1) to promote best practices for assessing data quality by developing and implementing a data quality framework and (2) to demonstrate an unprecedented method of assessing the data quality of a nursing database.

Development of a perioperative nursing quality evaluation indicator system for lobectomy patients with Da Vinci robotic under enhanced recovery after surgery

Objective To develop nursing quality evaluation indicator system for perioperative patients with Da Vinci robotic under enhanced recovery after surgery(ERAS), in order to provide references for clinical evaluation of nursing quality for lobectomy patients. Methods Based on the theory of structure-process-outcome quality model and ERAS, literature review, semi-structured interviews were adopted to determine nursing quality indicator system for perioperative patients. Delphi method was used in two rounds of consultation among 21 experts. Results The positive coefficient was 100%, authority coefficient was 0.839,0.901, and the coefficients of concordance were 0.317,0.335. The final indicator system consisted of 3 first-level indicators, 14 second-level indicators, and 52 third-level indicators. Conclusion The nursing quality evaluation indicator system for lobectomy patients with Da Vinci robotic was scientific and reliable, which can provide scientific references for evaluating nursing quality for perioperative patients with Da Vinci robotic under ERAS. Key words: Lung neoplasms; Perioperative period; Enhanced recovery after surgery; Quality assessment; Delphi technique

Methods and Processes Used to Collect Pressure Injury Risk and Prevention Measures in the National Database of Nursing Quality Indicators® (NDNQI®).

Previous research found that reliability estimates for chart-extracted quality of care data vary. The purpose was to examine methods and processes used to gather data on the National Database of Nursing Quality Indicators (NDNQI) pressure injury (PI) risk and prevention measures to identify factors that may influence their reliability. Study participants (N = 120) from 36 hospitals completed a 35-item online survey. Included were the NDNQI PI Survey Team member with the most experience and/or skill in patient record review from each hospital (n = 36) and 84 other NDNQI PI Survey Team members. In general, participants followed NDNQI PI data collection guidelines. However, deviations were noted such as 60 (50%) participants collected PI data on units where they work, and 92 (76.7%) determined whether moisture management was performed by direct observation of patients rather than chart documentation. Findings provide insight on how to improve the reliability of hospital-acquired PI risk and prevention measures that includes clarification of the data collection guidelines.

Parent Satisfaction With Care and Treatment Relates to Missed Nursing Care in Neonatal Intensive Care Units.

Background: The satisfaction of parents of infants in neonatal intensive care is important to parent-infant bonding and parents' ability to care for their baby, including after discharge. Given the principal caregiver role of nurses in this setting, parent satisfaction is influenced by high quality nursing care. Nursing care that is required but missed, such as counseling and support, might influence parent satisfaction. How missed nursing care relates to parent satisfaction is unknown.Objective: To describe the satisfaction of parents of infants in neonatal intensive care and to determine how satisfaction relates to missed nursing care in a sample of USA nursing units.Methods: The design was cross-sectional and correlational. Thirty neonatal intensive care units that participate in the National Database of Nursing Quality Indicators were recruited. To maximize sample variation in missed care, the highest and lowest quartile hospitals on missed nursing care, measured by nurse survey, were eligible. Ten parents of infants who were to be discharged were recruited from each site to complete a survey. Parent satisfaction was measured by the EMPATHIC-38 instrument, comprising five subscales: information, care and treatment, organization, parental participation, and professional attitude, and a total satisfaction score. Multivariate regression models were estimated.Results: Parent satisfaction was high (5.70 out of 6.00). The prevalence of missed care was 25 and 51% for low and high missed care units, respectively, and 40% for all units. On average, nurses missed 1.06 care activities; in the low and high missed care units the averages were 0.46 and 1.32. Over 10% of nurses missed activities that involved the parent, e.g., teaching, helping breastfeeding mothers, and preparing families for discharge. One standard deviation decrease in missed care activities at the unit level was associated with a 0.08-point increase in parent satisfaction with care and treatment (p = 0.01).Conclusion: Parents in USA neonatal intensive care units are highly satisfied. Neonatal intensive care nurses routinely miss care. Parent satisfaction with care and treatment is related to missed nursing care. Nursing care that is missed relates primarily to the care of the baby by the parents, which could have long term health and developmental consequences.

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study

BackgroundTo guide fall prevention efforts, United States organisations, such as the Joint Commission and the Agency for Healthcare Research and Quality, have recommended organisational-level implementation strategies: leadership support, interdisciplinary falls...

Efficacy of Using Available Data to Examine Nurse Staffing Ratios and Quality of Care Metrics.

Nurse staffing ratios impact both the quality and safety of care on a particular unit. Most hospitals have access to a large volume of nurse-sensitive outcomes. We hypothesized that these data could be used to explore the impact of changing the nurse-to-patient ratio on patient-reported outcomes, nurse satisfaction scores, and quality of care metrics. Retrospective data from hospital resources (eg, Press Ganey reports) were linked to daily staffing records (eg, assignment sheets) in a pre-post study. Before September 2017, the nurse-to-patient ratio was 1:1.75 (pre); afterward, the ratio was reduced to 1:1.5 (post). Press Ganey National Database of Nursing Quality Indicators scores were improved, staffing turnover rates were reduced, and falls were linked to periods of high nurse-to-patient ratios. This study shows the efficacy of using readily available metrics to explore for associations between nurse staffing and nurse-sensitive outcomes at the nursing care unit level. This provides a unique perspective to optimize staffing ratios based on personalized (unit-level) metrics.

Missed care relates to nurse job enjoyment and intention to leave in neonatal intensive care.

To determine relationships among missed nursing care, job enjoyment and intention to leave for neonatal nurses. Being unable to provide required nursing care to infants could contribute to poorer neonatal nurse job outcomes, which may exacerbate staffing challenges. Little evidence exists about how missed nursing care relates to neonatal nurse job outcomes. The design was cross-sectional. Secondary data from the 2016 National Database of Nursing Quality Indicators Registered Nurse Survey were used, which included nurse ratings of job enjoyment, intention to leave and missed nursing care. American Hospital Association data from 2016 were used to describe hospitals. Linear and logistic regressions were calculated. There were 5,824 neonatal nurses. Mean nurse job enjoyment was 4.26 out of 6 (SD=0.97). On average, 15% of nurses intended to leave their position. Each one unit increase in missed nursing care was associated with a 0.26 decrease in job enjoyment and a 29% increased odds of intention to leave after controlling for nursing and hospital characteristics. Missed nursing care can influence nurse job enjoyment and intention to leave in neonatal care units. Neonatal nurse managers should address missed nursing care to improve neonatal nurse job outcomes.