Missed Nursing Care: Concept Analysis Using the Hybrid Model

Background and Objectives: Miss care is a quality index, which has been identied for nursing care and patient safety recently. However, no precise denition is available for the clinical dimensions and features of this concept. Thus, the present study aimed to analyze the concept of miss nursing care based on the hybrid model. Design: A concept analysis was conducted using a three-phase(theoretical phase, eldwork phase and nal analysis phase) hybrid method. Methods:In the theoretical phase, the concept of miss care was explored in reliable databases from 1998 up to 2018. Using COREQ guidelines ,in the eld work phase, in-depth interviews were conducted with six nurses and the data were analyzed using content analysis method. In the last phase, the nal analysis was carried out. Results: The results indicated miss care as 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. Conclusion: Based on the present concept analysis, unmanaged care was the main feature of miss care, which had not been included in the previous denitions. Nurses can create an accurate structure for nursing care and reduction of miss care through performance of process-based care and determination of nursing care priorities. Further studies are recommended to compare this concept to similar ones to determine the clinical distinctions.


Introduction
The quality of nursing services is a major factor in patient safety. Patient safety in healthcare centers requires continuous quality promotion (1). This concept is dependent on nursing performance and is affected by errors in any aspect of patient care (2). Thus, assurance of patient safety and nursing care quality is an important challenge for nursing managers. In order to intervene in the methods for increasing safety and care quality, nursing managers should rst understand the opportunities that improve care as well as the barriers against care provision (3).
One of the objectives of patients' rights charter is assurance of the health system's responsiveness to patient needs. However, lack of time and personnel could lead to the ignorance of key points in patient care (4). In other words, patients' numerous care demands in a healthcare environment with lack of resources may cause nurses to prioritize the demands (5). Under such circumstances, the nurse decides which responsibilities to carry out or ignore (4). Consequently, some nursing responsibilities are missed (5). The neglected responsibilities may be different depending on various reasons, such as pressure for prioritization, teamwork, and the nurse's internal value system (6). However, what occurs during nursing care provision has not been well identi ed. In other words, the speci c outcomes of what nurses do or do not have not been well determined. In this context, negative outcomes seem to be associated to what Kalisch has called miss care (7).
Miss care is a quality index identi ed for nursing care and patient safety recently (8). This concept encompasses all dimensions of clinical, emotional, and prescriptive nursing care that have not been completed or have been delayed (9). It has also been de ned as the arbitrary omission of care, long delay in health services provision, and irrecoverable measures (10). Hence, miss care refers to inaccurate performance of healthcare. In this regard, safety specialist James Reyes believes that miss care is a common reason for the problems that can affect the quality of care and lead to the incidence of undesirable outcomes for patients (11). Evidence has revealed that miss nursing care or cares that have not been completed or have been postponed to the next shift are quite usual (12). In developed countries, it has been estimated that one out of every ten hospitalized patients is hurt due to care negligence (7). In this regard, a previous study demonstrated that miss nursing care was quite usual in U.S. hospitals. In that study, nearly three-fourths of nurses reported at least one miss care during their last shift. This measure has been found to be greatly higher in developing countries, such a way that all nurses reported the incidence of miss care in some hospitals (13). In a study conducted by Matin et al, on the reporting of nursing errors in Iran between 2000 and 2017, It was found that the prevalence of nursing errors in different regions of Iran is different and is between 17 and 88%, which is an average of 53% of the total number of nursing errors.
Overall, this concept is highly important and is associated with nurses' performances and patients' outcomesThus, it requires a comprehensive and acceptable theoretical de nition, so that professional health team members will be able to measure the experimental features of the concept in order assess its impacts on quality, patient safety, and nurses' work environment. Although miss nursing care occurs frequently, it has not been de ned comprehensively and has not been recognized as an important phenomenon in nursing. Thus, the reasons why this concept has been less taken into consideration have to be explored. In order to investigate the concept, it should be determined what missed care refers to and how it is differentiated from the related concepts (5) also miss care is a context bond concept and should be examined with a focus on the context and context surrounding the concept. Concept analysis is a major technique in development of nursing knowledge (14). Some researchers also believe that concept analysis is of particular importance in development of nursing knowledge and theories (15). Indeed, many nursing theories have been created based on such concepts. Therefore, concept analysis has been supported as an important approach in development of nursing knowledge. Miss nursing care is a phenomenon that is frequently reported in nursing services, but it has been described using various terms with no precise boundaries such as implicitly rationed care, nursing care left undone, unmet patient needs, un nished nursing care, and delayed nursing care. Additionally, it has been assumed that miss nursing care might be directly associated with nurse and patient outcomes (16).Hence, increased recognition of this phenomenon can increase the understanding of its relationship with patient care quality (17). The present study aims to answer the following questions: What is miss care? Why does it occur? How do nurses experience miss care? What are its consequences for patients and nurses? In this context, various approaches have been employed by researchers for development of the concept. Concept analysis has been considered to be a strategy for development of the concept as well as its basic elements with the aim of determining its nature and function.

Aims and objectives
The present study aims to analyze the concept of miss care based on literature review and experimental observations so as to make the concept applicable in clinical environments in Iran's healthcare system.
The ndings can enhance healthcare specialists' perception of the characteristcs, de nitions, features, causes, and outcomes of miss care.

Hybrid method
The hybrid model helps clarify, identify, analyze, and modify concepts in the primary stages of development of a theory. This model is mostly utilized in nursing (18). The hybrid model is a combination of deductive and inductive approaches and aims at identi cation of the basic properties of a concept and clarify presentation of the concept based on the participants' experiences of observations and interviews (19). In other words, such components as previous studies, eld work, and their combination can help clarify the concept. This model is composed of three stages, namely theoretical phase, eld work phase (semi-structured interviews with nurses), and nal analytical phase (integration of the results of the two previous stages). The theoretical phase helps progress and deeply analyze the concept in the following stages. The eld work phase is performed simultaneously with the rst phase. In this step, qualitative data collection helps emphasize the experimental component of the process so as to empower the primary concept. Finally, the last stage aims at integrating the results of theoretical analysis and those obtained from experimental observations and reporting the nal ndings (20). In this way, the concept is clari ed and novel concepts, which are sometimes completely different from the primary ones, will be revealed (19).

Theoretical phase
In this stage, search was conducted in reliable databases, including Science Direct, Google Scholar, Scopus, Prequest, and Pubmed. A search was conducted using the Mesh terms keywords: "implicitly","Nursing Care","Delay". Review of the related articles was done in a 20-year period from 2004 to 2018. Totally, 182 English and articles were found 29 of which met the inclusion criteria of the research( Figure 1). The inclusion criteria were existence of keywords in the article, relatedness to the concept, availability of the full text, and not being repeated. This stage aimed at rede nition of the concept and presentation of a working de nition to be used in the eld work phase.

Field work phase interview
This phase aimed at empowerment of the concept formed in the previous phase using experimental observations. Since this clinical concept has no boundaries for healthcare service providers, particularly nurses, the eld work phase was begun with clinical data collection in a hospital a liated to Shiraz University of Medical Sciences. In the hybrid model, the thoroughness of interviews is more important than the number of interviews and often 3-6 interviews are deemed su cient (19). To ensure the accuracy of data, the interviews were continued until data saturation, i.e., the data became repetitive.
After gaining a relatively comprehensive viewpoint towards miss care in the theoretical phase, the participants were selected based on purposeful sampling from the experienced individuals who provided nursing care in various wards. The participants were selected from the various wards (Intensive Care Unit [ICU] and the internal, surgery wards) of university hospitals in the city of shiraz, Iran. In this way, six clinical nurses were selected with the mean age of 33 years (ranging from 28 to 39 years). Five out of the six nurses were single and female and had B.Sc. degrees. The interviews lasted for 20-30 minutes. The contents of the interviews were digitally recorded and used as the main data of the research. Data collection was conducted between 3 October 2018-5 November 2018.
The procedures were explained in detail,including the fact that interviews would be audio-recorded. After obtaining oral and written consent, face-to-face interviews were conducted with the participants. To protect the privacy of the participants, numerical codes were used instead of their names and any identifying information was removed from the transcripts. We tried to hold the interviews in a private room in the wards where the nurses worked, which is the natural environment for the phenomenon in question. All written reports were kept in a safe place and made available only to the researchers working on the project.
The interviews were performed individually using open-ended and semi-structured questions. These questions were designed while reviewing the literature. The rst question was "Based on your experiences, what kind of cares do you provide for patients during a work shift". The following questions dealt with miss care and included "At the time of patient care, what aspects of nursing care have you neglected or delayed?", "How did you experience it?", "What are the barriers against the provision of complete patient care?", and "What are the consequences for patients and nurses?". After listening to the interviews, the all data were transcribed and the data were analysied using a conventional qualitative content analysis approach and explored codes were classi ed into categories. It should be noted that the participants were reassured about their freedom to take part in the interviews and the research. Con dentiality of the participants' information was observed, as well. Furthermore, trustworthiness of the research were ascertained via the researcher's prolonged engagement with the participants, better understanding of the environment, and review of the data by the second researcher(peer check) and result and research process checked with research team(expert check).

Final phase
This phase involved integration of the two previous stages and explored characteristics in the theoretical and led work phases. Afterwards, the characteristics were compared, and an comprehensive de nition of the concept was provided.

Ethical considerations
This study was approved by the Ethics Committee of University of Social Welfare and Rehabilitation Sciences(uswr).Tehran,Iran. all methods were performed in accordance with the relevant guidelines and regulations. All the participants were informed of the aim of the study and a written consent was obtained from each of them. Participation in the study was entirely voluntary and the participants could withdraw at any stage of the study. Con dentiality of the data was also taken into consideration and the results were published anonymously.

Review of literature: Theoretical phase
Miss nursing care was rst identi ed by Kalisch (2006) in a qualitative investigation (21). That study was conducted using ve 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 uids 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, ine cient delegation of authority, habits, and denial) (7).
Since missed nursing care a key measure for patient safety, a clear de nition 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 identi ed as an important nursing phenomenon.

Characteristics and de nition of missed nursing care
Miss nursing care has been referred to as restricted nursing care, nursing care left undone, unmet patient needs, un nished 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 de ned as any dimension of patient care neglected or considerably delayed by nursing staff due to frequent demands and insu cient resources (22). It has also been de ned as an element of nursing care that has not been performed completely rather than a nursing care carried out incorrectly (23). Another study de ned 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 de ned 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 de ned 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) de ned un nished 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 de nitions for miss nursing care. Moreover, most studies had explored the reasons for miss care, speci c 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 scienti cally 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) Un nished nursing care: Un nished 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 ful lled (33). This may include evaluation of patients, development of care plans, and provision of nursing cares required for patient care (35). Overall, un nished 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 de ned 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 ful lled 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 classi ed 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 quali ed individual reduces miss care and affects the care outcomes (38).
1-B) Available nancial resources for helping the performance of the patients' required measures: This refers to nancial 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 rst-line managers' support, su cient 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 in uential in miss nursing care (39). Overall, nurses' decisions for ful llment 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 ve 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 scienti c 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 di culty 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 classi ed 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 ful ll 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 exibility 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 de nition: Based on the literature review, features, antecedents, and outcomes, the following working de nition 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. 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 wordby-word for several times. At rst, 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 eld 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 identi ed in the theoretical phase were observed and explored in the eld work phase.
A.Organizational restrictors: Based on the participants' experiences, organizational restrictors, such as high workload, insu cient time, lack of on-arrival training, weak managerial support, inappropriate nurseto-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 identi ed in the eld 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 eld 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 di culty 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 eld work phase and consisted of undesirable incidents and patient dissatisfaction( Table 2). 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.

Lack of family participationin care
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 rst 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.

Sensory-motor dysfunction
Adverse events

Patient Outcomes
We tell the visitor that you have to wash the baby in warm water in order to doesn , t get annal scher , wound and Constipation, because of low immunity, it can cause infection.

Skin infection
Oral care is most important for oncology patients, especially for children

Mouth fungus
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.

Lack of communication Patient dissatisfaction
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 nal analytical phase
In this phase, the results of eld work and theoretical phases were compared and integrated in order to produce a de nition 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 de nition of the concept. The new information could be employed for con rmation or revision of the hidden theoretical ideas in the operational de nition. 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 ndings. Further details have been presented in Table 3.

The nal de nition 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 eld work phases were integrated. Accordingly, the concept of miss care obtained in the theoretical analysis was rede ned based on the insight gained through experimental observations. Analysis of the data obtained through the literature review and eld work revealed four features for the concept of miss care as follows: unmanaged care, and silent care, healthcare error, negligence (Table 3). All subcategories related to the theoretical and eld work phases were also integrated in the nal analysis. Comparison of the antecedents of miss care in the theoretical and eld work phases indicated that the antecedents mentioned in the texts were more focused on nancial 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 eld 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 eld work phase.

Discussion
The present study aimed to clarify the concept of miss care via the concept analysis method using the hybrid approach. The results demonstrated novel perspectives regarding the concept of miss care.
Accordingly, miss care can be regarded as a leading index in investigation of the function of organizational quality programs so as to promote the quality of nursing services and improve patients' conditions.Review of the literature indicated that the concept of miss care is an act of omission (7,8,33). which occurs as a result of nursing staff's non-adherence to the standard elements of nursing care. World Health Organization (WHO) has de ned error as not completing a planned action or application of an incorrect plan (49). In the eld of patient safety, two types of errors have been mentioned as follows: acts of commission (e.g., marking the wrong eye for surgery) and acts of omission (e.g., not moving the patient). Miss nursing care is a form of acts of omission. These errors are easily neglected in comparison to those occurred due to carelessness and may lead to undesirable outcomes among patients, including dissatisfaction, sideeffects, mortality, and re-hospitalization (7).
In the eld work phase in the present study, miss care was de ned as unmanaged care and silent care. Some features obtained in the eld work phase were supported by the literature, as well. For instance, DehghanNiri disclosed that silent care resulted from systemic and managerial obstacles, which caused nurses to neglect cares and consider priorities in care provision. The results also showed that these priorities were determined based on the system's expectations, physicians' orders, and nurses' roles in the system (39). Another study indicated that miss care as a care process could be placed in the structureprocess-outcomes framework. Accordingly, organizational structure could affect the care process, revealing the mutual relationship between service providers and patients all through the care provision process. Then, this process could impact the care outcomes. In case this process is not managed well, it may result in the incidence of miss care (50). Hence, by providing care on the basis of nursing process, nurses can create a precise structure for nursing care provision and reduction of miss care (5). Yet, nurses' attempts alone are not su cient and healthcare organizations have to provide the ground for patient care provision by creating motivation, provision of a supportive environment, and provision of nancial and human resources (50).
The present study ndings indicated that miss nursing care could affect safety, satisfaction, and length of hospital stay among patients and motivation, job satisfaction, absence, and request for ward change among nurses. In the same vein, Kalisch stated that the nurses' supportive capabilities for completion of patient cares could improve their care experiences and satisfaction (17). In another research, Kalisch reported that the nurses who experienced lower miss cares were more satis ed with their occupation (45).
Yet, provision of high-quality care services needs some prerequisites. In case these prerequisites are not provided, miss nursing care may occur in the care environment (5). In this context, organizational and process restrictors were among the themes found in the present investigation. In this regard, some studies (5,10). have revealed the lack of personnel as the main reason for miss care. For instance, inappropriate substitution of nurses at the time of absence or shift leave increased workload.
Furthermore, organizational policies including employment of non-quali ed personnel (such as nursing students) and execution of obligatory overtime in consecutive shifts due to failure or delay in service provision could lead to miss care (10).Moreover, availability of nancial resources including medications and required instruments and equipment could affect the nurses' capability for care provision (5). Miss nursing care is not only a clinical process, but it is also an ethical decisionmaking process. Therefore, researchers investigated missed nursing care from the ethical viewpoint. They came to the conclusion that in addition to its negative consequences for patients (e.g., falling out of bed and pressure ulcer), miss nursing care could lead to role con icts and ethical dilemmas among nurses (51).
Indeed, Srulovici et al. disclosed that nurses' responsibility played a far more important role in miss care compared to workload. Responsibility is a basic value associated with an individual's personal and professional identities, which has its roots in one's nurture, social and economic status, cultural background, professional socialization, and professional experiences (52). Nurses' responsibility can increase job motivation and guide them to decrease miss nursing care by the ethical standards obtained through individual and professional promotion irrespective of lack of resources (51).

Conclusion
It seems that the result of this study somewhat assisted in clearing the concept of missed nursing care.
By identifying the facilitating and preventive factors, and the concept of miss care, nursing managers and instructors will be able to design and run their management and educational activities based on scienti c ndings which could provide the necessary conditions for learning and proper implementation of nursing interventions.

RELEVANCE TO CLINICAL PRACTICE
Miss care affects nurses' performances and patients' outcomes as well as the whole system's managerial policies. Thus, nursing managers are faced with the problems associated with miss care directly or indirectly. By identi cation of the background factors of miss care, managers will be able to take measures for empowerment of human and nancial resources and elimination of incompatibilities between the staff and workload. In this way, patients are continuously provided with the required cares, eventually preventing miss care and its impacts on care outcomes. Overall, clari cation of the concept of miss care for nurses and provision of essential nursing services based on patient needs can reduce healthcare expenditures and increase motivation among nurses. Future studies are recommended to compare this concept to similar ones so as to identify clinical distinctions. Additionally, a questionnaire with appropriate psychometric properties is suggested to be designed in order to evaluate miss nu Declarations Figure 1 Search strategy

Supplementary Files
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