Review of literature: Theoretical phase
Miss nursing care was first identified by Kalisch (2006) in a qualitative investigation(21). That study was conducted using five focus group discussions with nurses, nursing assistants, and secretaries in two hospitals. The results revealed nine frequently neglected nursing cares (assisting a patient to walk, Change position, delay in feeding or not feeding patients, training patients, planning for discharge, emotional support, oral hygiene, recording fluids entry and exit, and supervision) and seven themes about the reasons for negligence of these cares (shortage of staff, weak utilization of the staff resources, time required for nursing interventions, weak team work, inefficient delegation of authority, habits, and denial) (7).
Since missed nursing care a key measure for patient safety, a clear definition of missed care is required in order to determine what kind of care is neglected and how it is differentiated from the related concepts. Although miss nursing care occurs frequently, it has not been identified as an important nursing phenomenon.
Characteristics and definition of missed nursing care
Miss nursing care has been referred to as restricted nursing care, nursing care left undone, unmet patient needs, unfinished nursing care, and delayed nursing care. This concept points to essential nursing cares that have been delayed or any clinical, emotional, or prescriptive dimension of cares that have been forgotten for any reason (1). In the research conducted by Kalisch (2006) to analyze the concept of miss care using Walker and Avant’s approach, this concept was defined as any dimension of patient care neglected or considerably delayed by nursing staff due to frequent demands and insufficient resources (22). It has also been defined as an element of nursing care that has not been performed completely rather than a nursing care carried out incorrectly (23). Another study defined the concept as the intentional omission of care, long delay in care services provision, and irrecoverable measures (10). Indeed, the concept of rationed nursing care, which may be substituted with miss care, has been defined as not performing the necessary nursing responsibilities due to shortage of nursing resources (lack of time, staff, and combination of skills). In other words, a healthcare provider may ignore some nursing activities because of being faced with limited resources (24). Rationed nursing care occurs during the nurse’s relationship with the patient based on the nurse’s evaluations and results from her/his clinical judgement and decision-making (25). Organizational and social grounds are also effective in the incidence of rationed nursing care (26). In a previous study, delayed nursing care was defined as a combination of miss nursing care and rationed nursing care. This concept is used to describe a care that has not been carried out by the nurse and has been postponed to the next work shift (12). Experimentally, Sochalski (2004) defined unfinished care as some nursing responsibilities that had not been completed by the nurse in the previous shift (27). Review of the literature revealed no other definitions for miss nursing care. Moreover, most studies had explored the reasons for miss care, specific aspects of nursing care that had been neglected, and their consequences. These studies mostly dealt with the effective factors in miss care (28), postoperative mortality (29), urinary tract infection (30), hospital-acquired pneumonia (31) and patient falls (32), while less attention was paid to the concept of miss care. Besides, this concept has been usually evaluated using the Miss Care Survey, which contains two parts (nursing care elements and reasons for miss care) (3).
Attribute
More accurate investigation of the articles indicated that the concept of miss care had the following attribute:
Act of omission: This phrase has been referred to as a great error by the Patient Safety Commission and describes a dimension of nursing care that has been neglected , while it is expected to be done scientifically and technically. This error can have a considerable impact on the quality of care, patient safety, and nursing function (e.g., assisting a patient to walk). This type of error is more common and at the same time more serious. In fact, it focuses on the negligence errors that result in miss nursing care (33) and may occur in three forms as follows:
1) Not performing the essential nursing care for patients: Miss nursing care refers to the essential nursing cares in any clinical, emotional, and executive dimensions, which have not been carried out for any reason (1). It should be mentioned that essential nursing cares are determined based on nursing judgement, provider’s prescriptions, or professional standards (34). Some elements of nursing care that require more time and involvement tend to be neglected more. The most frequent miss cares have been reported to be primary care services, such as assisting the patient to walk, changing the patient’s position, oral hygiene, timely feeding the patient, providing emotional support for the patient and his/her family, training the patient, timely prescription of medications, documentation, and participation in interdisciplinary conferences, irrespective of situation and country (8).
2) Unfinished nursing care: Unfinished nursing care is a different kind of underuse and a growing concern in healthcare at the international level. Underuse occurs when healthcare services that are accompanied with desirable outcomes for patients are not fulfilled(33). This may include evaluation of patients, development of care plans, and provision of nursing cares required for patient care (35). Overall, unfinished care has been conceptualized as a three-dimensional phenomenon, including a problem (lack of time or resources), a process (clinical decision-making for prioritization and rationed care), and an outcome (care left undone) (33).
3) Delayed nursing care: Delayed care has been defined as miss care or rationed care. Various forms of delayed care depend on the accessibility of resources for care provision and refer to a set of nursing responsibilities or treatment measures accepted by clinical agreement and nurses’ cooperation and are important for patients in order to reach their intended outcomes. This phrase is normally used when a nurse accepts that s/he has not fulfilled a care and has postponed it to the next shift(12). Examples of this case include delay in feeding the patient (35). untimely admission for intensive care, delay in prescription of medications (36) and delay in diagnosis and treatment of serious complications (37).
Antecedents
According to the review of the literature, the antecedents of miss care could be classified into two categories:
1) Organizational restrictors
1-A) Human workforce for patient care: This deals with the number and characteristics of the staff (category, education level, job tenure, and work experience), which are associated with patients’ demands for nursing care (5). Evidence has indicated that a qualified individual reduces miss care and affects the care outcomes (38).
1-B) Available financial resources for helping the performance of the patients’ required measures: This refers to financial resources required for nursing care, such as medications, instruments, and equipment, whose accessibility affects the nurses’ ability in care provision (5). Old facilities, lack of disposable goods, and lack of access to new and advanced instruments have been considered to be a part of system failure. These factors could increase the time required for instruments preparation and cause fatigue and burnout among nurses, consequently endangering nurses’ safety. These, in turn, threaten patient safety and lead to patients’ dissatisfaction and disruption of the treatment process (39).
1-C) Organizational support for nursing function: This includes first-line managers’ support, sufficient resources, nurses’ involvement in organizational decision-makings, and cooperative relations with physicians. Organizational support can affect the nurses’ decision-making priorities. Thus, it is assumed to be effective in the care provided or not for patients (40).
2) Process restrictors
2-A) Nurse’s internal values: The antecedents of miss nursing care that are effective in the process of nursing function are affected by nurses’ internal processes and their consequences threaten patient safety (33). Nurses have internal values and beliefs about their role as a nurse, which affects their behaviors. The question is whether a nurse is not able to or does not want to carry out nursing cares at the standard level. Difference between a behavior and values can lead to the feeling of regret and guilt. Therefore, nurses’ values, attitudes, and beliefs affect their intention to neglect or delay some parts of patient care (5). Moreover, lack of responsiveness, lack of attention to patient needs, lack of follow-up, and frequent negligence can result in ignorance of usual cares, which is influential in miss nursing care (39). Overall, nurses’ decisions for fulfillment of particular care activities while eliminating or delaying other cares are mainly affected by their internal perceptions. Internal perceptions include team norms, decision-making styles, values, beliefs, habits, and attitudes based on which nurses understand their roles and responsibilities (41).
2-B) Nursing process: The five steps of the nursing process include evaluation, diagnosis, planning, execution, and evaluation. In each step, nurses can create an accurate structure for nursing care provision via performance of systematic and patient-oriented nursing measures. This informed, organized, and scientific approach requires thinking, knowledge, and judgement and can provide a common structure for nursing care (5). Miss care may occur in various known dimensions of nursing process; i.e., evaluation/diagnosis (evaluation of the risk of pressure ulcer), execution (perineal skin care), and evaluation (evaluation of skin integrity at the time of defecation) (42).
2-C) Inter-professional relations, relationships, and group work: Team work is an important component of work environments in healthcare. Effective group work is accompanied with positive outcomes for both staff and patients(8). In case a team lacks mutual trust, leadership, orientation, close relationships, and common mental models regarding task performance, it will have difficulty while encountering high workloads with the existing human resources (26). In fact, lack of coordination among healthcare team members exerts negative effects on the quality and continuation of care through weakening the nurses’ roles in patient care (39). Team work refers to a set of knowledge, skills, and attitudes in the members, which helps them operate as a team. The main components of this concept include leadership, supervision on the situation, relationships, and supportive behavior (43).
The outcomes of miss care were classified into two categories as follows:
a) Patient outcomes
1-a) Patients’ clinical outcomes: Various investigations have shown that patient falls, nosocomial infections, blood infection, urinary tract infection, pressure ulcer, medication errors, hospital-acquired pneumonia due to lack of oral hygiene, mortality, and readmission 30 days after discharge due to lack of patient training were associated with miss care (9, 21, 25).
2-a) Patient satisfaction: Satisfaction has been referred to as a feeling of happiness and tranquility perceived by patients resulting from the nurses’ emotional and intellectual acceptance (44). Nowadays, hospitals have found motivations for improving patients’ satisfaction by incorporating patient satisfaction in payment programs and general reports. Furthermore, patient care experience is a fundamental qualitative index associated with nursing (45). Studies have demonstrated that patients with worse experiences were admitted in the hospitals where essential nursing cares were neglected (9). These included not giving medications at due times, not explaining the medications complications, lack of pain control, not providing information at the time of discharge, not talking to patients, and not training the patients and their families, which resulted in the patients’ dissatisfaction. Yet, supporting the nurses’ capabilities for completion of necessary cares could promote patient care experiences (45).
b) Nurse outcomes
Nurses are committed to provision of comprehensive patient care based on essential nursing values, including provision of special technical care and training (12). In case this is not possible due to the nurses’ performance of non-nursing tasks such as answering the phone, transferring patients, and preparing the ward’s required facilities and materials as well as lack of facilities, nurses will not be able to fulfill their responsibilities completely (35). Nurses’ inability to provide high-quality patient care will in turn have a considerable impact on their job satisfaction and burnout (12). Job satisfaction points to achievement of success and satisfaction and consists of flexibility in work plan, independence, and educational opportunities (35). On the other hand, burnout has been described as a syndrome including emotional analysis, alienation, and reduction of personal success, which results in weakness in the quantity and quality of nursing care. It exerts negative effects, including fatigue, emotional fatigue, and shirking responsibilities, on most dimensions of individual, interpersonal, and organizational functions (46) ( Table 1).
Working definition: Based on the literature review, features, antecedents, and outcomes, the following working definition was proposed for the concept of miss care:
Miss nursing care is a healthcare error occurred due to a nurse’s negligence in performance of one’s duties. This phenomenon can occur due to organizational and process restrictors, which will have consequences for both the nurse and the patient.
Table 1: The final analytical Theoretical
Categories
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Theme
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Dimensions of definition
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negligence errors
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act of omission
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The attributes
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Not performing the essential nursing care for patients
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Breach of legal duty of care
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Delayed nursing care
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Human workforce for patient care
|
organizational restrictors
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The antecedents
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Available financial resources for helping the performance of the patients’ required measures
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Organizational support for nursing function
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Nurse’s internal values
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Process restrictors
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Nursing process
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Inter-professional relations, relationships, and group work
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Clinical outcomes
|
Patient outcomes
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The consequences
|
Patient satisfaction
|
Job satisfaction
|
Nurse outcomes
|
burnout
|
Field work phase results
The data were analyzed at the same time they were collected using inductive qualitative content analysis. In doing so, categories were extracted from the data and codes were extracted by reading the texts word-by-word for several times. At first, 65 codes were extracted and, they were integrated to eight categories and their relations were determined. After that, four main themes were extracted from the interviews’ texts as follows: unmanaged care, silent care, background factors, and patient outcomes.
Attributes of miss care: Silent care and unmanaged care were two features of miss care in the field work(Table 2).
Silent care: The nurses under the current investigation stated that considering the needs and tasks description, they had to neglect some cares. In fact, regarding time, tasks, and patient conditions, nursing cares are prioritized and some cares are omitted due to lack of time. For instance, prescription of medications is more important than assisting the patients to walk and building relationships with them. Therefore, based on the clinical judgement, a nurse decides to ignore assisting the patients to walk, which may result in unwanted complications due to chemotherapy medications.
Unmanaged care: This refers to a situation where patient needs are not well met due to lack of strategies for care provision, lack of team work, not using protocols and standards for care provision, and families’ lack of cooperation in care provision.
Antecedents:
Background factors: The antecedents of miss care identified in the theoretical phase were observed and explored in the field work phase.
A.Organizational restrictors: Based on the participants’ experiences, organizational restrictors, such as high workload, insufficient time, lack of on-arrival training, weak managerial support, inappropriate nurse-to-patient ratio, and unavailability of facilities and equipment, increased the incidence of miss care. The participants maintained that in case these factors were eliminated, more high-quality care could be provided for patients. Other background factors for the incidence of miss care identified in the field work phase included lack of responsibility and patients’ characteristics.
B.Nurses’ lack of responsibility: There is a wide a range of responsibilities in nursing, including respect for clients, maintaining the dignity of patients, empathy, adherence to professional commitments, responsiveness, responsibility, work conscience, and justice in service provision (47). In the field work phase in the current study, the participants considered a nurse’s responsibility as work conscience and lack of negligence, impatience, and inattention to dos and don’ts.
C.Patients’ characteristics: Among the present study participants, some believed that a patient’s or companion’s different culture and age could cause difficulty in provision of nursing care. In fact, patients’ or their companions’ cultural differences may cause the nurse not to have a real perception of the patients, not to take measures for reduction of their problems, and become indifferent towards them. Families’ lack of cooperation at the time of care provision was yet another reason mentioned by the participants. In this regard, patients’ disability to express their care needs, companions’ low education levels, and patients’ inability to take care of themselves were among the challenges encountered by nurses at the time of care provision, which resulted in negligence of or delay in care provision.
Patient outcomes: This was one of the major outcomes of the field work phase and consisted of undesirable incidents and patient dissatisfaction(Table 2).
Table 2.Examples of extracting of codes, sub categories, and categories from raw data
Meaning unit
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Code
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Subcategory
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Category
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Some things are likely to miss because the patients go and back to the ward a lot and we think that they know and we don't tell them.
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A realistic view that miss care is inevitable
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Conscious change of care
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Silent care
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Based on my priorities, I don't play with my patient. I say let me go and write nursing report. I can't play with he anymore. For example, in the morning shift I have to fill a box with chemotherapic drugs and Every drug has its own calculation , dilute and a Emptying the drugs bottle.
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Prioritize care
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Clinical Judgment
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From the beginning of patient admission,we have a series of special routines, such as mouthwash which is written by a doctor.
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Routine and non-use of protocols and standards
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No strategy for reducing miss care
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Unmanaged care
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Sometimes when we go to see the patient , she scaredof us and crying.his/her . Mother says youplease come back. I will give him/her medicine. When you come back to the patient again, she has not given the medicine yet.
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Lack of family participationin care
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After the injection of drugs such as Viennese Christian the patient must walk. Sometimes I don't get the patient to walk.therfore I'll ask his family to do thisand I emphasize that if you don't ,your feet will cramp. This may or may not be said at times. the first day that I want to give the medicine I will train.but the next day which I gana Prescribe the same drug, may not be trained and I only say this drug is as same as previous drug that I described for you yesterday.
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Sensory-motor dysfunction
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Adverse events
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Patient Outcomes
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We tell the visitor that you have to wash the baby in warm water in order to doesn,t get annalfischer , wound and Constipation, because of low immunity, it can cause infection.
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Skin infection
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Oral care is most important for oncology patients, especially for children
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Mouth fungus
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The visitor says somebody(stafe) comes and just give the medicine and go away. He/she doesnt talk to my child, especially patients who are hospitalized for a long time,say this.
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Lack of communication
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Patient dissatisfaction
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Undesirable incidents and patient dissatisfaction: The participants pointed to the undesirable incidents, which could result from the negligence of such cares as training the patients and their families, oral hygiene, and assisting the patients to walk after consuming vincristine. Experiences of participants also indicated that the incidence of these undesirable events as well as not building relationships with patients and their families could cause dissatisfaction among patients.
The final analytical phase
In this phase, the results of field work and theoretical phases were compared and integrated in order to produce a definition for miss care that will be supported by both the existing texts and the nurses. In so doing, all data were gathered in order to determine their content meanings. Then, use was made of a type of deductive analysis in which new experimental data were continuously compared to the primary definition of the concept. The new information could be employed for confirmation or revision of the hidden theoretical ideas in the operational definition. In fact, the data obtained from the interviews led to better recognition and insight towards the nature of the concept (48).
During the data collection process, simultaneous analysis and comparison were carried out. In so doing, the researcher went back and explored the details of the task by focusing on the initial theoretical findings. Further details have been presented in Table 3.
The final definition of miss care
Miss care is a healthcare error as a kind of negligence in which the nurse provides unmanaged patient care due to the adversity of organizational and process background factors, which results in the negligence of essential cares and leads to consequences for both the patient and the nurse.
In this stage, the results obtained in the theoretical and field work phases were integrated. Accordingly, the concept of miss care obtained in the theoretical analysis was redefined based on the insight gained through experimental observations. Analysis of the data obtained through the literature review and field work revealed four features for the concept of miss care as follows: unmanaged care, and silent care, healthcare error, negligence (Table 3).
Table 3.Comparison of the dimensions of miss care in the literature review to the features expressed in the participants’ experiences.
Dimensions
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Results of literature
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Results of participants’ experiences
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Final results
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Features
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Act of omission
|
Silent care
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Healthcare error as a kind of negligence
|
Breach of legal dut of care
|
Unmanaged care
|
Unmanaged patient care
|
Antecedents
|
Process restrictors
|
Background factors
|
Organizational and process background factors
|
Organizational restrictors
|
consequences
|
Patient outcomes
|
Patient outcome
|
Healths’Outcomes
|
Nurse outcomes
|
All subcategories related to the theoretical and field work phases were also integrated in the final analysis. Comparison of the antecedents of miss care in the theoretical and field work phases indicated that the antecedents mentioned in the texts were more focused on financial and human resources as well as relationships, which were in agreement with the antecedents of background factors such as organizational restrictors, nurses’ lack of responsibility, and patients’ characteristics, which were obtained in the field work phase. Besides, consequences related to patients and nurses were two main outcomes in the theoretical phase, which were in line with patient-nurse consequences revealed in the field work phase.