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DOI:
10.4103/sjhs.sjhs_74_21
The Interrelation between nurse‑ to‑ patient
ratio, nurse engagement, and missed nursing
care in King Saud Medical City: Basis for
development of nurse–patient quality of care
Mary Rosaclaire Tenorio, Waleed Tharwat Aletreby1, Batla Al
Shammari2, Basel Almuabbadi2,
Huda Mwawish3, James Montegrico4
Department of Nursing, 1Department of Critical Care Quality,
2Nursing Office, 3Department of Critical Care, King Saud
Medical City,
Riyadh, Saudi Arabia, 4School of Nursing, University of North
Carolina at Charlotte, Charlotte, North Carolina, USA
Address for correspondence:
Ms. Mary Rosaclaire Tenorio,
Nursing Department, King Saud Medical

City, Riyadh, Saudi Arabia.
E-mail: [email protected]
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Original Article
How to cite this article: Tenorio MR, Aletreby WT, Al
Shammari B,
Almuabbadi B, Mwawish H, Montegrico J. The Interrelation
between
nurse-to-patient ratio, nurse engagement, and missed nursing
care in King
Saud Medical City: Basis for development of nurse–patient
quality of care.
Saudi J Health Sci 2021;10:116-24.
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Background: Healthcare is a substantial industry globally,
where nurses comprise the
largest percentage of the healthcare system. There is a global
nursing shortage and
nursing staff retention has become a major human resource
challenge. One of the critical
indicators of quality of care is nurse‑ to‑ patient ratio (n:p
ratio), but due to the extreme
shortage of nurses, the quality of nursing care may have been
affected leading to low
nurse engagement results and substantial missed on aspects of
nursing care. Identifying
these key areas among nurses in King Saud Medical City
(KSMC) will contribute to the
improvement of staffing conditions at any levels. Aim: The
primary objectives were (1) to
investigate the impact of patient‑ to‑ nurse ratio (p:n ratio) on
satisfaction and (2) to explore
the impact of p:n ratio on missed care. The secondary objectives
were (1) to compare the
nurses’ satisfaction categories, missed care categories across
different hospitals included
in our medical city, different age categories, and different
education levels and (2) n:p ratio
will be compared across hospitals. Methods: This was a
cross‑ sectional analytical study.
Setting: This was conducted at KSMC, Riyadh, Saudi Arabia,
specifically in areas of main
general hospital, medical tower, pediatric and maternity
hospital. Outcome Measures:
(n:p ratio), nurse engagement/satisfaction, and missed nursing
care. Results: Of the total
of 384 responses (96% response rate), the majority of
respondents were satisfied (n=155,
40.4%), followed by Neutral (n=124, 32.3%), very unsatisfied
category included only 17

responses (4.4%) and very satisfied were 35 nurses (9.1%).
While responses to the missed
care section revealed that overall the majority of missed care
opportunities were in the
category of never missed (278, 72.4%). As for the p: n ratio, the
average was 4.2 (patients)
± 1 (nurse). Furthermore, the ratio of patients‑ to‑ nurse was
not found to significantly impact
overall satisfaction, neither in the univariable model nor in the
multivariable model adjusted
for age, education, and experience. Interestingly, age category
was a significant predictor
of nurse satisfaction (higher odds of satisfaction category with
higher age category)
yielding an adjusted odds ratio (OR) of 1.4 (95% confidence
interval [CI]: 1.01–1.8;
P = 0.04) although this was a post hoc finding. As for the
impact of n:p ratio on missed
care, it was significantly associated with missed care in the
univariable model, with OR of
1.3 (95% CI: 1.01–1.6; P = 0.037) and an OR of 1.3 (95% CI:
1.02–1.6; P = 0.032) in the
multivariable model. When the categories of satisfaction were
compared across different
hospitals of KSMC, different age groups, and education, there
were no differences in Submitted: 19‑ May‑ 2021
Accepted: 09‑ Jul‑ 2021 Published: 16‑ Aug‑ 2021
Tenorio, et al.: Nurse to patient ratio, nurse engagement, and
missed nursing care
Saudi Journal for Health Sciences ‑ Volume 10, Issue 2,
May‑ August 2021 117

INTRODUCTION
Over the years, nurses were known to be advocates in health
care, caring, and supporting their patients. Nurses dealt with
various health‑ care professionals in providing the best patient
outcome. They are known to spend most of the time dealing
with patients’ needs and even in the worse situations, nurses
will always be there to alleviate pain and suffering as well as
provide the best nursing care needed. Quality care is essential
in nursing care and this is a priority in every health care
facility.
However, nursing shortage has been a human resource concern
that nurse staff retention is identified as a major challenge.
An increasing evidence indicates deficient nurse‑ to‑ patient
ratio (n: p ratio) may lead to low patient outcomes, this is
a problem that we need to look into. The American Nurses
Association Principles for Nurse Staffing (2020) describe that
appropriate nurse staffing is a critical requisite for delivering
safe, quality health care at every practice level, and in every
settings.[1] Evidence demonstrates that nursing care has a
direct impact on the overall quality of services received, and
when nurse staffing is appropriate, adverse events decline
and overall outcomes improve.[2] An initiative was made by
the Saudi Patient Safety Center (SPSC) during the 4th global
ministerial Patient Safety Summit in 2019 to develop safe nurse
staffing levels. This is needed to achieve the highest levels of
safe nursing care and to meet the national transformational
goals for 2030 that supports the nursing profession in the
kingdom.[3] Despite these initiatives, King Saud Medical
City (KSMC), Riyadh, is still experiencing an alarming issue
related to nursing shortage, which may affect patient outcomes,
and nurses work environment and nurse satisfaction. The
notion of this research study was to evaluate the present n: p
ratio, missed nursing care, and Nurse Engagement among
Nurses in KSMC, at the same time identifying its significant

differences. The study is focused on bedside nurses who
handle patient and implement nursing care, thus excludes
the outpatient department and the head of the department.
Specifically, it attempted (1) to investigate the impact of
patient‑ to‑ nurse ratio (p: n ratio) on satisfaction, (2) to
explore the impact of p: n ratio on missed care, (3) to make
comparisons of nurses’ satisfaction categories, missed care
categories compared across different hospitals included in our
medical city, different age categories, and different education
levels, and (4) n: p ratio was compared across hospitals.
This research was approved by the IRB in KSMC with
registration number KACST, KSA: H‑ 01‑ R‑ 053, dated
May 20, 2020.
Objectives
Under the hypothesis that a high p: n ratio may negatively
impact either overall satisfaction or missed care opportunities,
the primary objective of the study was the impact of p: n
ratio on satisfaction, and separately the impact of p: n r atio
on missed care. Secondary objectives were comparisons
of nurses’ satisfaction categories, missed care categories
compared across different hospitals included in our medical
city, different age categories, and different education levels,
while n:p ratio will be compared across hospitals.
METHODS
This research used a cross‑ sectional analytical research
design, which utilized an electronic survey to investigate the
study objectives. The study was carried out in KSMC, Riyadh,
Saudi Arabia. KSMC is a tertiary referral center, with 1200
beds, and over 6000 employees. It is the largest Ministry of
Health hospital in the central region of Saudi Arabia. The
nursing staff is composed of 4500 nurses divided over four

different hospitals, namely maternity, pediatric, main general
hospital, and medical tower.
The survey method was the main data collection procedure
used in this study divided into two sections, the first section
was similar to the nursing engagement and satisfaction survey
administered by Health Cluster 1 in Riyadh city, this section in
addition to demographic data inquires about the nurses’ level
of engagement and satisfaction, it includes nine questions
to be answered according to a 5‑ point Likert scale, the scale
is interpreted as 1 = strongly disagree/very unsatisfied,
2 = disagree/unsatisfied, 3 = neutral, 4 = agree/satisfied,
and 5 = strongly agree/very satisfied. The average of each
person’s score was calculated and used to derive the overall
satisfaction category according to the following ranges:
0 ≤ very unsatisfied ≤1, 1< unsatisfied ≤2, 2< neutral ≤3,
3< satisfied ≤4, 4< very satisfied ≤5 [details of section 1 in
Table S1, Supplementary File], so eventually each respondent
is placed in one of five categories of satisfaction.
The second section of the survey is adopted with permission
from the missed nursing care survey devised by[4] commonly
known as MISSCARE. The survey requires respondents to
report the hospital’s unit in which they practice, then it
proceeds to questions related to missed opportunities of
nursing care divided into missed opportunities regarding
patients’ assessment (8 questions), missed individual needs
interventions (6 questions), missed basic needs interventions
(7 questions), and missed planning interventions, giving a total
any of the Chi‑ square tests performed. Similarly, there were no
statistically significant differences when the missed care was
compared
across the same subgroups; moreover, it was distinguished that
p: n ratio was significantly higher in the maternity hospital.
Conclusion:

A higher p:n ratio negatively affects missed care opportunities.
Keywords: Missed nursing care, nurse engagement/satisfaction,
patient‑ nurse ratio
missed nursing care
118 Saudi Journal for Health Sciences ‑ Volume 10, Issue 2,
May‑ August 2021
of 24 questions [details in Table S2, Supplementary File]. Each
question is answered according to a 5‑ point Likert scale with
the following interpretation: 1 = never missed, 2 = rarely
missed, 3 = occasionally missed, 4 = frequently missed, and
5 = always missed, while a value of 0 indicates not applicable.
Responses are averaged (excluding inapplicable values) and
the average is used to categorize missed opportunities
of care as follows: 0.5< never missed ≤1.49, 1.5≤ rarely
missed ≤2.49, 2.5 ≤ occasionally missed ≤3.49,
3.5≤ frequently missed ≤4.49, and 4.5≤ always missed ≤5;
accordingly, overall responses of each individual are placed
in one of the five categories. The second part of MISSCARE
survey includes 16 questions pertaining to perceived
reasons of missed care, divided into three categories of
communication, materials, and labor intensity.
The survey included a statement at the beginning that
outlines the current study and informs that responding to
the survey will be considered as the responder’s consent to
participate in the study; furthermore, the study was reviewed
and approved by the institutional review board of KSMC.
Data management

To facilitate data interpretation, demographic variables
such as age, gender, and level of education were considered
as categorical data. Age was described as 18‑ 30, 31‑ 40,
41‑ 50, 51‑ 60, and more than 60 years old, while level of
education was classified as diploma, bachelor’s, and master’s
degrees. Similarly, the level of experience was in categorical
order of <2 years, 2–5 years, 5–10 years, and more than
10 years. Likewise, overall satisfaction and missed nursing
opportunities were arranged in categorical order, while
p: n ratio was considered as a continuous whole number
variable, rather than n: p ratio for easiness of calculations
and comprehension.
Sample size calculation
KSMC employs 4500 nurses in different hospitals of the city,
we estimated that for a 95% confidence level and 5% error
margin of the survey, a sample size of 354 responses is
required, we inflated the sample size to 400 to account
for nonresponses. Nurses were chosen randomly by a
computer‑ generated random numbers list of 400 from the
4500 total nurses using their ID card number.
Chosen nurses were contacted via the official KSMC E‑ mail,
offered a summary of the study, and provided with an
electronic form of the survey, they were sent two E‑ mail
reminders a week apart.
Statistical method
Survey results were summarized as count (percentage) for
categorical variables, whereas continuous variables were
summarized as mean ± standard deviation (SD), each variable
with a corresponding 95% confidence interval (CI).
For the purpose of the primary objective, an ordered logistic
regression model was used with n: p ratio as an independent
factor while overall satisfaction as the dependent in one

model, and missed opportunities of care in the second.
Each logistic regression model was univariable once and
multivariable once adjusting for age, education, and
experience. Results of the models were reported as odds
ratios (ORs) along with corresponding 95% CI and P values.
Secondary variables were analyzed by Chi‑ square test or
Fisher’s exact test as appropriate when comparing categorical
variables, and by ANOVA test when comparing continuous
variables, each presented with corresponding 95% CI and P
value.
All statistical tests were two‑ tailed, and considered statistically
significant with P < 0.05. A commercially available statistical
software package was used (StataCorp. 2015. Stata Statistical
Software: Release 14. College Station, TX, USA: StataCorp LP)
to analyze the data.
RESULTS
The survey response rate was 96% (n=384). The majority of
respondents were females (n=382, 99.5%), mostly in the age
category of 31–40 years (n=235, 61.5%), as for experience the
category of 5–10 years included the highest number (n=155,
40.4%), followed by more than 10 years (n=125, 32.6%). The
majority of responses came from diploma holders (n=290,
75.5%), and were mostly divided between the pediatric
hospital (n=176, 46.2%) and the maternity hospital (n=155,
40.7%). Table 1 provides details of demographic data.
The majority of respondents were satisfied (n=155, 40.4%),
followed by neutral response (n=124, 32.3%). About 4.4 %
(n=17) were very unsatisfied while 9.1% (n=35) very satisfied.
Responses to the missed care section revealed that overall the
majority of missed care opportunities were in the category
of never missed (n=278, 72.4%). As for the p: n ratio, the
average was 4.2 ± 1 [Table 2 and Figure 1].

Primary outcomes
The ratio of patients to nurse was not found to significantly
impact overall satisfaction, neither in the univariable
model nor in the multivariable model adjusted for
age, education, and experience. Adjusted OR was 1.13
(95% CI: 0.9–1.4; P = 0.26). Interestingly, the age category
was a significant predictor of satisfaction (higher odds of
satisfaction category with higher age category) yielding an
adjusted OR of 1.4 (95% CI: 1.01–1.8; P = 0.04) although this
was a post hoc finding.
As for the impact of n:p ratio on missed care, it was
significantly associated with missed care in the univariable
model, with OR of 1.3 (95% CI: 1.01–1.6; P = 0.037) and an
OR of 1.3 (95% CI: 1.02–1.6; P = 0.032) in the multivariable
model. In this analysis, no other variable showed a significant
association with missed care opportunities [Table 3].
missed nursing care
The p: n ratio was significantly higher in the maternity
hospital (ANOVA P < 0.001) [Figure S7, Supplementary File].
DISCUSSION
Remarkably, the impact of n: p ratio on missed care was
significantly associated with missed care in the univariable
model, with OR of 1.3 (95% CI: 1.01–1.6; P = 0.037) and an
OR of 1.3 (95% CI: 1.02–1.6; P = 0.032) in the multivariable

model. In this analysis, no other variable showed significant
association with missed care opportunities [Table 3]. Hence,
the higher the n: p ratio, it can negatively affect the missed
nursing care, yet the ratio of patients to nurse was not
found significantly impact overall satisfaction neither in the
univariable model nor in the multivariable model adjusted
for age, education, and experience. Interestingly, age
category was a significant predictor of satisfaction (higher
odds of satisfaction category with higher age category).
The result of the study similar to the research of Kalisch,[5]
a qualitative study specific to missed nursing care, used
a semi‑ structured focus group interview with nursing
medical‑ surgical units in two hospitals with a 210‑ bed
hospital in the southern region and a 458‑ bed regional
medical center in the northern region of the United States.
A total of 107 registered nurses (RNs), 15 licensed practical
nurses, and 51 nursing assistants working in medical–surgical
patient care units were interviewed in 25 focused groups.
The study revealed that important elements of nursing care
are being missed on a regular basis in acute care hospitals
in medical‑ surgical units. These findings shed light which
may contribute to poor patient outcomes. In addition,
Kalisch and Lee[6] highlighted the missed nursing care on
Magnet versus non‑ Magnet Hospitals disclosed that Magnet
Hospitals had significantly less missed care and Magnet
Hospital staff reported less staffing and communication
problems.
In our study, age was a significant predictor of satisfaction,
but the ratio of patients was not found to significantly
impact the overall satisfaction; nonetheless, the results in
the study of Al‑ Faouri I et al. (2021)[7] indicate that “missed
nursing care” is negatively associated with job satisfaction
and the number of RNs per shift, and positively with the n: p
ratio. The results of this study indicated that there was a
significant relationship between “missed nursing care” and

the age of the participants; this result could be explained
by the fact that the majority of nurses in Jordan are young;
wherein, younger nurses might be more enthusiastic about
work and they might work with caution to prove themselves.
The results also indicated a negative relationship between
“missed nursing care” and participants’ satisfaction. In
terms of missed care and unit characteristics associated
with intention to leave by Tschannen D. et al., (2010),[8] four
variables were found to be significantly related to nursing
turnover missed care, skill mix, absenteeism, and gender.
Larger amount of missed care was associated with higher
Table 1: Demographic data
Variable n (%) 95% CI
Age category (years)
20‑ 30 14 (3.6) 2‑ 6
31‑ 40 235 (61.2) 56.1‑ 66.1
41‑ 50 92 (24) 19.8‑ 28.6
50‑ 60 39 (10.2) 7.4‑ 13.7
Above 60 4 (1) 0.3‑ 2.6
Gender
Female 382 (99.5) 98.1‑ 99.9
Male 2 (0.5) 0.06‑ 1.8
Experience (years)
<2 38 (9.9) 7.1‑ 13.3
2‑ 5 66 (17.2) 13.6‑ 21.4
6‑ 10 155 (40.4) 35.5‑ 45.5
>10 125 (32.6) 27.9‑ 37.5
Education
Diploma 290 (75.5) 70.9‑ 79.7
Bachelors 84 (21.9) 17.9‑ 26.4
Masters 10 (2.6) 1.3‑ 4.7

Hospital
Pediatrics 176 (46.2) 41.1‑ 51.3
Maternity 155 (40.7) 35.7‑ 45.8
Medical tower 30 (7.9) 5.4‑ 11.1
Main general hospital 20 (5.2) 3.2‑ 7.9
CI: Confidence interval
Table 2: Overall satisfaction, missed care opportunities,
and patient‑ to‑ nurse ratio
Variable n (%)/mean±SD 95% CI
Overall satisfaction
Very unsatisfied 17 (4.4) 2.6‑ 7
Satisfied 53 (13.8) 10.5‑ 17.7
Neutral 124 (32.3) 27.6‑ 37.2
Satisfied 155 (40.4) 35.5‑ 45.5
Vary satisfied 35 (9.1) 6.4‑ 12.4
Missed care
Not‑ applicable 1 (0.3) 0.01‑ 1.5
Never missed 278 (72.4) 67.6‑ 76.8
Rarely missed 70 (18.2) 14.5‑ 22.4
Occasionally missed 16 (4.2) 2.4‑ 6.7
Frequently missed 11 (2.9) 1.5‑ 5.1
Always missed 8 (2.1) 0.9‑ 4.1
p:n ratio 4.2±1 4.1‑ 4.3
CI: Confidence interval, SD: Standard deviation, p:n: Patient:
nurse
Secondary outcomes
When the categories of satisfaction were compared across
different hospitals of KSMC, different age groups, and
education, there were no differences in any of the Chi‑ square

tests performed [Supplementary File, Figures S1‑ S3].
Similarly, there were no statistically significant differences
when the missed care was compared across the same
subgroups [Supplementary File, Figures S4‑ S6].
missed nursing care
May‑ August 2021
turnover rates which state that the more missed nursing
care, the higher the dissatisfaction with current position
and with their occupation. Alharbi et al., (2020)[9] revealed
that the current shortage of nurses jeopardizes the quality
and safety of patient care globally, and is particularly serious
in Saudi Arabia with respect to nurse outcomes, 64.4% of
participants reported being moderate or very satisfied with
their jobs, although the mean score of emotional exhaustion
was 25 (SD 13.28) which is suggestive of moderate levels of
burn out Maslach et al., (1996)[10] and 56.1% reported being
somewhat to very likely to leave their current jobs within
the next year.
CONCLUSION
Since the result of the study shows that a higher p: n ratio
negatively affects missed care opportunities, the management
may look into the implementation of the appropriate n: p ratio
according to the unit patient acuity and the Nurse Staffing
Levels for Patient Safety and Workforce (2019). The white
paper explains in detail the significance of the appropr iate
P: N ratio and its relationship to the quality of care. Moreover,

further research on nurse staffing and nursing care in tertiary
hospitals in Saudi Arabia are needed to support our nurses
and the organization in creating evidence‑ based programs in
intensifying nurses’ retention, improve job satisfaction and
patients’ outcomes.
Limitation
The majority of the respondents were coming from pediatric
and maternity hospitals. There was less percentage of
respondents coming from other hospitals such as main general
hospital and medical tower; hence, this is the limitation of
this study. A specific research on those hospitals on p: n ratio,
missed nursing care, and satisfaction may consider as those
areas include critical units so that comprehensive results may
be gathered and definite recommendation and outcome can
be made in details to those units.
Acknowledgment
The authors would like to thank Dr. Beatrice Kalisch and
co‑ author Dr. Reg Williams for allowing us to utilize the
MISSCARE Survey in our Medical City.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. ANA’s Principles for Nurse Staffing 3rd Edition 2020.
American Nurses
Association www.Nursingworld.org. Available from:
https://cdn2.
hubspot.net/hubfs/4850206/PNS3E_ePDF.pdf. [Last accessed on
2021

Jul 01].
2. Aiken LH, Sloane D, Griffiths P, Rafferty AM, Bruyneel L,
McHugh M, et al. Nursing skill mix in European hospitals:
Cross‑
sectional study of the association with mortality, patient ratings,
and
quality of care. BMJ Qual Saf 2017;26:559‑ 68.
3. Saudi Patient Safety Center, International Council of Nurses,
Nurse
Staffing Levels for Patient Safety and Workforce Safety. SPSC
and ICN
White Paper. Riyadh, Saudi Arabia; 2019. Available from:
https://spsc.
gov.sa/English/Documents/Joint%20Statement%20from%20SPS
C%20%20
ICN%20on%20World%20Patient%20Safety%20Day%202019.pd
f. [Last
accessed on 2021 Jul 01].
4. Kalisch BJ, Williams RA. Development and psychometric
testing of a
tool to measure missed nursing care. J Nurs Adm
2009;39:211‑ 9.
5. Kalisch BJ. Missed nursing care: A qualitative study. J Nurs
Care Qual
2006;21:306‑ 13; quiz 314‑ 5.
6. Kalisch BJ, Lee KH. Missed nursing care: Magnet versus
non‑ Magnet
hospitals. Nurs Outlook 2012;60:e32‑ 9.
Table 3: Ordinal logistic regression of nurse‑ to‑ patient
ratio association with overall satisfaction and missed

care
Variable Univariable model Multivariable model
OR (95% CI) P OR (95% CI) P
Overall satisfaction
n:p ratio 1.11 (0.9‑ 1.4) 0.3 1.1 (0.9‑ 1.4) 0.3
Age 1.3 (1.05‑ 1.7) 0.02 1.4 (1.01‑ 1.8) 0.04
Experience 1.13 (0.94‑ 1.4) 0.2 0.98 (0.77‑ 1.2) 0.8
Education 1.2 (0.8‑ 1.7) 0.3 1.1 (0.76‑ 1.6) 0.6
Missed care
n:p ratio 1.3 (1.01‑ 1.6) 0.037 1.3 (1.02‑ 1.6) 0.032
Age 0.9 (0.7‑ 1.2) 0.4 0.9 (0.7‑ 1.3) 0.7
Experience 0.9 (0.7‑ 1.1) 0.4 0.9 (0.7‑ 1.2) 0.5
Education 0.9 (0.6‑ 1.5) 0.8 1 (0.6‑ 1.6) 0.99
n:p: Nurse: patient, CI: Confidence interval, OR: Odds ratio
Figure 1: (a) Overall satisfaction. (b) Missed care
b
a
missed nursing care
7. Al‑ Faouri I, Obaidat DM, AbuAlRub RF. Missed nursing
care, staffing
levels, job satisfaction, and intent to leave among Jordanian

nurses.
Nurs Forum 2021;56:273‑ 83.
8. Tschannen D, Kalisch BJ, Lee KH. Missed nursing care: The
impact on
intention to leave and turnover. Can J Nurs Res 2010;42:22‑ 39.
9. Alharbi AA, Dahinten VS, MacPhee M. The relationships
between nurses’
work environments and emotional exhaustion, job satisfaction,
and intent
to leave among nurses in Saudi Arabia. J Adv Nurs
2020;76:3026‑ 38.
10. Maslach C, Jackson SE, Leiter MP. Maslach Burnout
Inventory Manual.
3rd edition. Mountain View, CA: CPP, Inc.; 1996.
missed nursing care
May‑ August 2021
Figure S1: Satisfaction by hospitals: Insignificant differences of
satisfaction categories across hospitals (Chi-square P = 0.7)
Figure S3: Satisfaction by education: Insignificant differences
of satisfaction categories across levels of education
(Chi-square P = 0.9)
Figure S2: Satisfaction by age group: Insignificant differences
of
satisfaction categories across age groups (Chi-square P = 0.5)

Figure S4: Missed Care by Hospital: Insignificant differences of
missed care across hospitals (chi square P = 0.5)
SUPPLEMENARY FIGURES AND FILE
missed nursing care
Figure S7: N:P ratio by Hospital: P < 0.001, Scheffe pairwise
test shows significant difference between Maternity and
Pediatric
hospitals, and between Maternity and hospital and medical
tower.
Figure S5: Missed care by age category: Insignificant
differences of
missed care across age categories (chi square P = 0.7)
Figure S6: Missed care by education: Insignificant differences
of
missed care across levels of education (chi square P = 0.7)
missed nursing care
May‑ August 2021

Table S1: Questions of engagement and satisfaction survey
Age group: 18‑ 30, 31‑ 40, 41‑ 50, 51‑ 60, more than 60.
Gender: Male ‑ Female.
Years of experience: <2, 2‑ 5, 6‑ 10, more than 10.
How happy are you at work? Very unhappy, unhappy, Neutral,
Happy, very happy.
I have a clear understanding of the next steps in my career:
Strongly disagree, disagree, Neutral, agree, and strongly agree.
How do you rate your work‑ life balance? Very unsatisfied,
unsatisfied, neutral, satisfied, very satisfied.
I am encouraged to come up with new and better ways to
perform
my job. Strongly disagree, disagree, Neutral, agree, and
strongly
agree.
I am given opportunities to participate in forming decisions
related
to my work.
I understand how my role relates to the hospital/center’s
success.
My work is well recognized. Strongly disagree, disagree,
Neutral,
agree, and strongly agree.
My supervisor and co‑ workers respect me as part of the team.
I am satisfied with the facilities provided to enhance my social,
physical, emotional and personal well‑ being. Very unsatisfied,
unsatisfied, neutral, satisfied, very satisfied.
Would you recommend the hospital/center as a place to work to
your
friends and family? Very unlikely, unlikely, neutral, likely, very
likely.
What are the greatest strengths of the hospital/center? Open
Response.

20. Skin/wound care
21. Setting up meals for patients who feed
themselves
Indicators
IV. Planning
22. Patient teaching
23. Attend interdisciplinary care conferences whenever is held
24. Ensuring discharge planning
Part II. Indicators
I. Communication
1. Unbalanced patient assignment
2. Inadequate hand‑ off from previous shifts
3. Other departments did not properly provide the care
needed. (e.g. PT, dietician, RT)
4. Lack of back up support from team members
5. Tension or communication breakdowns with other ancillary/
support departments
6. Tension or communication breakdowns within the nursing
team
7. Tension or communication breakdowns with the medical staff
Indicators
II. Material Resources
8. Medications were not available when needed
9. Supplies/equipment not available when needed
10. Supplies/equipment not functioning properly
11. Electronic Nursing documentation not available
Indicators
III. Labor Resources

12. Inadequate number of staff
13. Urgent patients situations (deteriorating patient condition)
14. Unexpected rise in patient volume and/or acuity in the unit
15. Inadequate number of assistive and/or clerical
personnel (e.g. nursing assistants, ward clerks, porters)
16. Heavy admission and discharge activity
IV: Intravenous, NA: Nursing assistants, PRN: When Necessary,
PT: Physiotherapy, RT: Respiratory Therapy
Table S2: MISSCARE survey questions
Part I. Indicators
I. Assessment
1. Full documentation of all necessary data
2. Focused re‑ assessment according to patient condition
3. Patient assessments performed each shift
4. Proper handwashing
5. Vital signs assessed
6. Monitoring intake/output
7. Bedside glucose monitoring as ordered
8. IV site care and assessment according to hospital policy
Indicators
II. Interventions ‑ Individual Needs
9. Assess effectiveness of medications
10. PRN medication request acted on within five minutes
11. Medications administered within 30 minutes before or after
scheduled time.
12. Assist with toileting needs within five minutes of request
13. Response to call light is provided within five minutes
14. Emotional Support to patient and/or family
Indicators
III. Interventions ‑ Basic Care

15. Ambulation three times per day or as ordered
16. Turning patients every 2 hours
17. Mouth Care
18. Feeding patients when the food is still warm
19. Patient bathing/skin care
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Heriot-Watt University
C10IB1 International Business
Coursework 1: Country Based Analysis – Portugal
Wordcount: 2,685 words

Introduction
Portugal is an EU and Schengen area member state located on
the West coast of the Iberian Peninsula (European Union, 2020).
Although Portugal is a developed country, its economy heavily
depends on EU funds, and its GDP and income per capita are
among the lowest in Europe (Pinto da Costa, 2020). The
International Monetary Fund (2019) defines Portugal as a small,
open economy without an independent currency, as the country
became a member of the Euro-area in January 1999 (European
Commission, n.d.).
The purpose of this briefing report is to highlight the conditions
of business in Portugal and the opportunities and threats
presented by operating in this market. The report will firstly
outline the political scenario in Portugal; secondly, the
country’s operational structure and business regulations will be
discussed. Thirdly, the essay will provide an overview of the
Portuguese economy, comparing the economic situation pre- and
post-COVID-19 and analysing Brexit’s potential consequences.
Finally, Portugal’s current social issues will be examined, and
the risk involved with operating in Portugal will be assessed.
Country analysis
1. Political scenario
Portugal is an independent, semi-presidential parliamentary
democracy, whose legislative power lies within the Parliament
(DFK International, 2018). Its Head of State is the President
Marcelo Rebelo de Sousa, a Social Democrat elected in January
2016 (GOV.UK, 2018). In October 2015, the current Prime
Minister, António Costa, was asked to form a left-wing
coalition government between socialists, communists and left-
wing MPs (GOV.UK, 2018). Despite the core differences
between these parties, the coalition has been successful in
leading the country through a period of slow but steady
economic recovery after the austerity imposed by the €78
billion bail-out fund negotiated with the European Commission,
the European Central Bank and the International Monetary Fund

after the European debt crisis of 2009-2013 (ibid.). The
resilience shown by this coalition highlights the ability of the
Portuguese government to lead the country out of financial
hardship, which will be helpful in recovering from the current
COVID-19 crisis.
A presidential election will be held in January 2021 (ibid.). In
May 2020, the President declared that the Portuguese people are
too worried about the economic recovery to be concerned about
the 2021 presidential election (Cabrita-Mendes, 2020).
However, the socialist candidate Ana Gomes openly argued that
democracy should not be put on hold (Plataforma Media, 2020).
This suggests that a socialist victory would see the
government’s focus shift towards addressing social issues,
while the current President would focus his action towards
economic recovery. Polls show that 55% of Portuguese would
be inclined to vote for Rebelo de Sousa should he run again
(Público, 2020). Although the presidential elections of January
2021 could cause some political unrest within the country, this
information demonstrates that the population seems to have
favourable opinions towards the current government. A likely
re-election of the current President could entail a faster
recovery, therefore entailing low political risk for businesses.
Regarding the tackling of the COVID-19 crisis, in April 2020
the European Commission approved two €13 billion Portuguese
aid schemes to help businesses face the financial loss caused by
COVID-19 (European Commission, 2020a). Furthermore, in
March and April 2020 nine Euro-area governments, including
Portugal, called for the issuance of joint European debt in the
form of social bonds (also called ‘corona bonds’) to help
member states fight the financial hardship caused by the
pandemic (Financial Times, 2020). The Portuguese government
has also authorised bank loan repayments to be postponed until
September 2021 for individuals and businesses affected by the
crisis (IMF, 2020), allowing consumers to have a larger
disposable income for the short-term, which could increase
consumer demand in the short-term.

2. Economic overview
According to DFK International (2017), Portugal’s connections
and free trade with the EU, as well as its strategic location,
make it an excellent country for the expansion of foreign
businesses. Portugal also offers low labour costs compared to
other European countries (ibid.), which may be an appealing
element for MNCs expanding their operations. On the other
hand, this presents social issues such as strong income
inequality and low worker productivity.
Portugal’s economic and social environment was badly hit by
the 2009-2013 European debt crisis, when the government was
forced to negotiate a €78 billion bail-out fund with the
European Commission, the ECB and the IMF (GOV.UK, 2018).
However, in February 2019 it was observed that Portugal’s
economic conditions had steadily improved, with the
unemployment rate declining 10% since 2013 and the GDP
growing by 2% a year (OECD, 2019). In fact, the Portuguese
economy had largely recovered from the 2009-2013 crisis (ILO,
2020). However, although the debt-to-GDP ratio reached its
lowest point of 117.7% at the end of 2019 (CEIC Data, 2020),
this was still a very high figure, which highlighted the
government’s inability to respond to potential economic shocks
(OECD, 2019); this was further proved by the heavy
repercussions COVID-19 is having on Portugal’s economy
(ILO, 2020).
Even before the pandemic, Portugal was still facing social,
financial and structural issues as a result of the previous crisis
(ILO, 2020); although these issues were slowly being addressed,
the country was characterised by relatively low wages and
strong income inequality, as well as job insecurity and high
public and private debt (ibid.). As a result of the pandemic, the
Portuguese economy is expected to enter a recession and its
GDP is expected to fall by up to 8% in 2020 alone (ILO, 2020).
This will not only have negative consequences for the economy
but also for the people, which were already facing several social

issues before the pandemic. On one hand, the nation's economic
history indicates that the Portuguese government has already
been able to recover from an economic crisis in the past and is
on track to address its many weaknesses. However, Portugal has
already been severely affected by the coronavirus crisis and is
likely to take relatively more time to recover than other
countries due to the legacy of the previous crisis.
Regarding Portugal’s international trade activity, the country’s
top exports are cars, vehicle parts, petroleum, leather footwear
and uncoated paper, while its main imports are crude petroleum,
cars, vehicle parts, packaged medicaments and petroleum gas
(OEC, 2020). In May 2020, Portugal’s trade balance presented a
year-on-year deficit of €908 million compared to 2019, as well
as a decrease of 39% in exports and 40.2% in imports (ibid.).
This is another important indicator of the financial loss caused
by the COVID-19 pandemic, as well as the job insecurity caused
by reduced trade and economic activity. The debt-to-GDP ratio
was also severely impacted by the current coronavirus crisis. A
pre-pandemic report by the European Commission (2019)
forecasted the debt-to-GDP ratio to decrease and reach 116.8%
by 2020; however, in June 2020 the ratio accounted for 127.2%
of Portugal’s nominal GDP, as shown by Figure 1 (CEIC Data,
2020). Portugal’s high debt-to-GDP ratio could cause the
domestic and international market to face severe uncertainty
and increases the country’s risk of default if unable to pay back
its debt. This poses a problem for Portugal-based companies,
because high levels of government debt creates long-term
uncertainty and high risk.
Figure 1:
Government debt-to-GDP ratio (September 1st, 2017 – June 1st,
2020)
(CEIC Data, 2020)
Brexit also poses a severe threat for Portugal and although it is
difficult to evaluate its economic consequences on EU
countries, including Portugal, Brexit will entail an increased

level of uncertainty on both ends. Firstly, Britain will stop its
contribution of 15% to the European Fund, which will result in
Portugal’s share of the fund decreasing by 7% for the 2021-
2027 budget (Pinto da Costa, 2020). This will negatively impact
on Portugal’s economy, which largely relies on EU funding.
Although economic activities are four times more at risk in the
UK than they are in the EU (Confederation of Portuguese
Business, 2018), Portugal will be the second most hit country
by the uncertainty caused by Brexit, as the UK is Portugal’s
fourth biggest foreign market accounting for $4.79 billion of its
product exports in 2018 (OEC, 2020). Depending on the future
trade relationships established following January 2021, the
Portuguese export of consumer goods and services may decline
by up to 26% (ibid.). Furthermore, consumer goods companies
are the most high-risk with regards to Brexit (Confederation of
Portuguese Business, 2018). The post-Brexit political and
economic environment will certainly impact imports and
exports, notably for consumer goods, which will face stronger
regulations and stricter customs controls. Hence, this may
represent an obstacle for multinational consumer goods
companies, as their trade to and from the UK will face severe
issues, such as increased costs and time-consuming paperwork –
the extent of which depends on the nature of the nature of the
trade relationship established between the UK and the EU after
Brexit.
3. Operational structure
A World Bank (2018) report which investigated the cities of
Braga, Coimbra, Évora, Faro, Funchal, Lisbon, Ponta Delgada,
and Porto, assessed the business regulatory environment in
Portugal and its impact on Portuguese entrepreneurs. The
study’s areas of interest were starting a business, dealing with
construction permits, getting electricity, registering property
and enforcing contracts. The report assesses that entrepreneurs
can register their companies and complete the tax, social
security and labour registrations at a single contact point taking
up to 3 hours, making Portugal one of four countries in the

world allowing the creation of a business with only one
interaction (World Bank, 2018). This highlights the ease of
founding a business in Portugal. However, this information
mainly refers to small and medium enterprises; hence, it might
not be entirely relevant for big, multinational companies.
According to Lavinder (2018), several multinational companies
are opening technological hubs in Portugal thanks to the
policies which have been implemented by the Portuguese
government to make business easier and attract foreign capital.
This could suggest that the conditions of doing business for
foreign companies are favourable, for example due to low
corporate tax rates and reduced labour costs. Another factor
which has brought these companies to operate in Portugal is the
vicinity of leading universities and other institutions (Lavinder,
2018). The cost of living and renting premises in Portugal is
also cheaper than in other European countries (ibid.), making
Portugal appealing for foreign companies, as the cost of moving
both operations and staff there would be reduced compared to
other EU countries. The fact that other multinational giant
companies have expanded their business to Portugal in the past
is also proof that business regulations are advantageous for
foreign investors.
Portugal’s ability to attract foreign investments is shown by the
corporate tax rate being 21%, much lower than in other
European countries, such as Italy (24%), Spain (25%), France
(28%) and Germany (30%), as highlighted in Table 1 (KPMG,
2020).
Table 1:
(KPMG, 2020)
Operating in Portugal would allow foreign MNCs to benefit
from lower corporate tax than in other Western European
countries, making the country attractive for expansion.
However, Portugal’s tax rate is slightly higher than the
European average of 19.12% in 2020, demonstrating that other
European countries, such as Easter European, could have more

favourable tax rates than Portugal.
4. Social issues
The OECD (2020) states that the labour force participation rate
in Portugal fell from 58.60% in the first quarter of 2020 to
56.30% in the second quarter (Trading Economics, 2020). This
indicates that the Portuguese labour force has decreased as a
result of the current pandemic; this suggests that the financial
hardship has led Portuguese companies to furlough or lay-off
staff. In fact, the unemployment rate is estimated to reach
between 9.7 and 13.9 percent by the end of 2020 (ILO, 2020).
The European Commission has established a temporary
instrument called SURE (Support to mitigate Unemployment
Risks in an Emergency) to provide financial support in the form
of loans to EU member states facing severe economic and social
issues as a result of the COVID crisis Portugal will receive a
loan of €5.9 billion (European Commission, 2020b). This
programme will be financed by the issuance of social bonds
under the Social Bond Framework (ibid.).
Despite the mixture of uncertainty, job losses and decrease of
income causing consumption to drop, especially in March and
April 2020, the registered number of job losses in the wholesale
and retail sectors was far less severe than the average for the
country as a whole (ibid.). Portuguese consumers are generally
concerned about the economic effects of COVID-19 and are
cutting their spending on all categories, even though the
pandemic’s damaging impact on the population’s disposable
income, spending and savings is decreasing overall (McKinsey
& Company, 2020). This suggests that, even though job loss in
the retail sector was minimal, Portuguese consumers are willing
to spend less and less on consumer goods as a result of the
COVID crisis; this may pose a problem for consumer goods
businesses, as low demand may negatively impact sales and
cause unemployment in the retail industry to rise.
Another social issue which is currently representing a key
challenge for Portugal’s business performance and growth is
low productivity due to poor investment on human capital,

heavy regulatory inflexibilities and difficulty in accessing
capital especially for small businesses (European Commission,
2019). Moreover, the Portuguese workforce is lacking education
and expertise; in fact, 50% of the country’s population lacks
basic digital skills and school drop-out rate is higher than the
EU average (European Commission, 2019); however, some
progress regarding these issues has been made, following
policies which have encouraged enrolment into higher education
and the enhancement of digital skills (ibid.). The Human Capital
Project (World Bank, 2020) has determined that students in
Portugal score 509/625 on a scale of attainment. This shows that
the Portuguese government needs to make further investment on
human capital in order to improve productivity and generate a
better-skilled labour force; although progress is being made to
face this issue, the current Portuguese workforce is poorly
skilled and does not meet the required productivity standards.
This may represent an issue for MNCs expanding to the
Portuguese market, as cultural differences, as well as a poor
level of expertise and productivity, may lead to lower efficiency
for the business and increased costs, as more time will have to
be invested to address the cultural barriers.Risk assessment
After analysing the current economic climate in Portugal, it can
be inferred that Portugal has great potential to become a
flourishing developed economy. However, although the
country’s economic situation had steadily recovered from the
2009-2013 European debt crisis, it is now experiencing strong
setbacks due to the COVID-19 crisis which has entailed a strong
decrease in GDP and income per capita, as well as an increase
of the debt-to-GDP ratio, increasing the chances of Portugal
entering a recession and defaulting. Moreover, Portugal heavily
relies on the European Union for funding; however, the UK’s
withdrawal from the European Union will cause Portugal to
receive less funding, hence increasing economic risk for the
country.
Portugal’s political scenario is also facing some challenges,
with the next presidential elections taking place in early 2021;

although the political scene is generally stable, government
changes could potentially lead to political unrest, especially as
Brexit could have a significant impact on the Portuguese
economy, depending on the nature of the trade relationships
which will be established in early 2021. Moreover, consumer
sentiment is low, resulting in decreased demand for consumer
goods and therefore creating issues for companies, increasing
unemployment rates and income inequality. Social risks also
include low productivity and lack of digitally skilled labour,
due to low investment on human capital and relatively low
levels of education.Conclusion
After taking into consideration the threats and
opportunities and all political, social, economic and social
issues currently faced by Portugal, it can be inferred that the
risks involved with operating in Portugal do not create the ideal
conditions for foreign investment. Therefore, it can be
concluded that investing in Portugal at this given moment is not
suggestable, but, as the country presents great potential for
growth, it is recommended to further investigate the country’s
economic, political, social and operational climate in the future,
once the COVID-19 crisis is resolved and after the relationship
between the UK and the EU has been established.
References
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Corporate tax rate (2020)
European average
2020 19.12 Portugal
2020 21 Italy
2020 24 Spain

2020 25 France
2020 28 Germany
2020 30
2

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