Missed Care from the Patient’s Perspective – A Scoping Review

Introduction

Literature related to missed care has increased over the last decade,¹ providing evidence of its prevalence and the threat it poses.^2,3 The primary cause of missed care seem to be limited nursing resources.⁴ Missed care is an international problem as most nurses report at least one task left undone in a shift, based on an international review.³ However, little is known about patients’ views on this timely topic. Patients’ perspective in this review is viewed as patients’ personal perception about missed care as well as patients’ perception of their care environment where care is missed based on nurses’ reports. Missed care has been associated with decreased nurse-reported care quality, job satisfaction and patient satisfaction, as well as increased adverse events, turnover and intent to leave.³ Furthermore, an association has been found between missed care and nursing work environment and patient safety culture.⁵ Predictors of missed care include nurse’s shift type, resource allocation, health professional communication and workload intensity, and predictability.⁶ Therefore, the worldwide prediction of a nurse shortage underlines the importance to understand the phenomenon.⁷

The terminology referring to missed care varies in literature, as some studies view missed care as an implicit rationing of nursing care, referring to nurses’ bedside decision-making, leading to failure to carry out all needed nursing interventions because of inadequate resources.⁸ In addition, the terms care left undone,^9,10 nursing task left undone,¹¹ task incompletion^12, and unmet nursing care needs¹³ have been used. The first report on this topic was from the International Hospital Outcomes Research (IHORC), using the term nursing care left undone.⁹ The term missed care was first used in 2006 by Kalisch in her identification of nine elements of regularly missed nursing care and the reasons for them.¹⁴

Missed care occurs when any aspect of required patient care is omitted (in part or whole) or delayed,¹⁵ including all aspects of clinical, emotional and administrative nursing care.³ There are some conceptualization of missed care¹⁶ including the Missed Nursing Care Model, which is a middle-range theory developed by Kalisch (2009).¹⁵ This model identifies external antecedents for missed care, such as resources and communication and relationships among staff, that have an effect on the nursing process. If nurses lack resources, they must prioritize how to best use the resources available. This decision-making interacts with the internal processes of nurses (including staff norms, the prioritization of the care, personal values and behavior). All these factors contribute to missed care, which has adverse outcomes for patients. The model identifies organizational characteristics as factors that facilitate or constrain nurses’ practice.¹⁵ Another conceptual model, Implicit Rationing developed by Schubert (2007), is mainly used with cost reduction and the allocation of inadequate resources. This model also recognizes nurses as decision-makers, as they must prioritize, and acknowledges both individual and organizational factors contributing to rationing of nursing care. The number of omitted nursing activities measures the extent of the rationing and is an important indicator of the quality of care.⁸ The conceptual framework of The Task Undone was originally described by Lucero et al (2009) using the Process of Care and Outcome model. In this model, the necessary care activities that are left undone reflect the quality of provided nursing care as they have negative outcomes for patients.¹⁷

Missed care is associated with patient safety culture,⁵ which has been examined in different theoretical frameworks. Groves et al¹⁸ recommend structuration theory of safety culture, which is a middle-range theory that is widely used to examine different organizational topics. It views safety culture as a system that involves individual actions as well as organizational structures. Nurses share values regarding patient safety and enact them in their practice. Organizational structures, such as resources and rules, both enable and constrain nurses’ action to keep patients safe.¹⁸ This model could also be adapted to examine missed care. However, there is currently a lack of a theoretical framework and common terminology to describe missed care as it remains unclear whether an understanding exists about how it occurs or whether the causation and response to missed care are similar across different health-care environments; development of a theoretical framework to describe and understand missed care is thus highly needed.¹⁹

Missed care is an ethical issue challenging nurses’ professional and moral values, consequently leading to imbalance between patients’ needs and available and/or scarce resources. Therefore, nurses need to prioritize their work, and missed care is an outcome of this prioritization process.²⁰ Missed care is an error of omission, meaning failure to do the right thing, which potentially leads to adverse outcomes to patients, impacting the quality of care negatively. Higher missed care has been associated with a greater risk of patient falls, while missed ambulation can cause pressure ulcers, pneumonia, delayed wound healing, and increased pain and suffering.²¹ Thus, missed care has been associated with lower patient safety.^22,23

The research emphasis of this topic has mainly been on nurses’ perspective^3,10 Thus, the aim of this scoping review is to analyze the patients’ perspective to missed care as it has not received adequate research interest. Today, patients are recognized as partners in health care and experts on their situation, working alongside professionals, with their own rights as well as responsibilities.²⁴ This view is associated with the empowerment philosophy to health, which aims to increase patient autonomy and freedom of choice, encouraging patients to oversee their own health values, needs and goals.²⁵ Therefore, patients should be involved in the discussion about the requirements of nursing care and the prioritization process where nurses are unable to respond to patients’ needs.²⁰ This paper adds to the existing literature by examining how patients’ perceptions on missed care have been examined, how patients are able to identify missed care, what care has been mostly identified as missing by patients, and how patients experience the received care when nurses report missed care. In this review, the term missed care expresses patients’ perception that something is missing, delayed or not done during their health-care treatment. The goal of the analysis is to deepen our understanding of the concept of missed care and to provide a basis for further studies in the field.

Materials and Methods

This scoping review was conducted using the five-stage approach by Arksey and O’Malley (2006).²⁶ In the next paragraph, the five stages of analysis are described in more detail.

Stage 1: Identifying the Research Question

The following research questions were identified to guide the scoping review:

1. How have patients’ perceptions of missed care been studied?
2. What instruments were used to measure patients’ perceptions on missed care?
3. What were the main findings of the studies?
4. What are the implications and suggestions for further research in the studies?

Stage 2: Identifying Relevant Studies

Six electronic databases (PubMed, CINAHL, PsycINFO, Web of Science, ProQuest/Scholarly Journals and Philosophers Index) were searched in April 2019 using the terms omitted care, unfinished care, care undone, care unfinished, missed care, care left undone, task undone and implicit rationing. No time limitation was used in the search. The search phrases, chosen in collaboration with the university library information specialist, followed the guidelines of each database. In addition to the systematic database search, a manual search of the reference lists of the included articles as well as scanning through Google Scholar and Academic Search Premier databases was conducted; however, no new articles were identified. In total, the search produced 2145 hits (Figure 1).

Stage 3: Study Selection

Study selection started by determining the inclusion criteria for the articles.²⁶ After the search was conducted, two research approaches in studies of missed nursing care from the patient perspective were identified. The first approach used validated instruments for measurement of missed nursing care from the patient perspective. The second used validated instruments to measure missed nursing care from the nurse’s perspective, linking it to patient data. In these studies, mostly patient satisfaction was measured. These studies have proven that patient satisfaction is linked to missed nursing care from the nurses’ perspective.²⁷ Therefore, it is important to include these studies in this review because they give us important answers of patients’ perspective of their care in an environment where nurses report missed care. Hence, articles were eligible for inclusion if they: 1. Examined missed care in the nursing context; 2. Had patients as participants to provide full or partial data, so that at least some data were collected from patients (patient-reported missed care or patients’ perceptions on nurse-reported missed care); and 3. Were empirical study reports in English. Studies conducted solely from the nurses’ perspective were excluded. Records were first screened by title and afterwards by abstract, leading to exclusion of 1994 articles. Full-text articles (n=18) were finally read among those that were selected based on abstract. Finally, 13 articles were included in the analysis (Table 1).

Figure 1 Flowchart on the article selection process.

Table 1 Articles Included in the Analysis

Stage 4: Charting the Data

The data chart (Table 1) included the following topics: Authors, Publication year, Country, Purpose, Methods and Sample, Instruments, Main Results, Validity/Reliability, and Implications for Further Research. These variables were central in answering the research questions.

Stage 5: Collating, Summarizing and Reporting the Results

Stage five included descriptive numerical summary analysis as well as thematic analysis. Descriptive numerical summary included basic numerical analysis of the extent and nature of the included studies.^26,28 Thematic analysis in scoping review resembles qualitative data analysis; researchers may thus consider using qualitative content analytical techniques. Therefore, the data were analyzed with content analysis, where it was organized thematically and presented according to the research questions.²⁸ Themes were not preconceived but emerged inductively from the included articles,²⁹ as scoping review does not seek to synthesize evidence on a particular topic, but rather, to describe the account of available research.^26,28 The PRISMA-Sco checklist for scoping review was used to guide the reporting of the results.³⁰

Results

Studies Involving Patients’ Perceptions About Missed Care

Description of Studies and Methods Used

The included studies (n=13), published between 2008 and 2018, were from the USA (n=5), Switzerland (n=3), South Korea (n=1), Cyprus (n=1), Mexico (n=1), and the UK (n=1), and one combined data from eight countries (n=1, Table 1).

The data included one qualitative study using phenomenological approach with data collected using in-depth, semi-structured interviews of 38 patients.³¹ Other studies (n=12) were quantitative in nature. Five studies inquired about missed nursing care directly from the patients. Sample sizes in these varied between 160 and 1555.^32–36 Seven studies collected data about patients’ satisfaction with care and compared it to missed care data collected from nurses. The sample size in these varied between 352 and 66,348 patients^27,37–42 Quantitative studies (n=12) were descriptive cross-sectional studies using structured questionnaires and statistical analysis.

All participants were adults and the studies were conducted in different clinical hospital settings: medical (n=11), surgical (n=11), rehabilitation unit (n=2), mixed unit (n=1), intensive care unit (n=1), gynecological unit (n=2), and maternity care (n=1).

Instruments Used to Measure Patients’ Perceptions on Missed Care

In the included studies, three different instruments were used to examine patients’ perceptions on missed care: the MISSCARE Survey – Patient,^32–34 MISSCARE Survey,³⁵ and Hospital Consumer Assessment of Health Providers and Systems survey (also known as the HCAHPS^®).³⁶

The MISSCARE Survey – Patient, developed by Kalisch (2014), was used in three studies.^32–34 In these studies, patients were asked to identify whether nursing care was provided during their hospitalization. This instrument contains three sections: 1. Demographic characteristics and health status (including patient age, sex, race, education, marital status, hospitalized days, health status, diagnosis, and disease history), 2. Elements of nursing care, and 3. Adverse events. The section of elements of nursing care contains 13 items and uses 5-point Likert-type scales for measurement of communication and basic care (1 = never, 2 = rarely, 3 = sometimes, 4 = usually, and 5 = always) and for measurement of timeliness (from 1 to 30 mins). The mean of all 13 items is used as a total score for the scale, and the potential range of scores is 1 to 5.^32–34

The MISSCARE survey, originally developed to measure missed nursing care and the reasons for it from nurses’ perspective, was used to measure patients’ perspective of missed care in one study.³⁵ It contains two parts. Part A consists of 24 listed elements of nursing care. Nurses are asked to indicate how frequently each nursing care element was missed in their unit by all staff, including themselves, using the scale “rarely”, “occasionally”, “frequently”, “always”, or non-applicable. Part B consists of 17 reasons listed for missed care. Nurses are asked to rate each item using the scale “significant factor”, “moderate factor”, “minor factor”, or “not a reason for unmet nursing care”. In addition, demographic/background data contain characteristics of the respondent’s gender, years of working experience, highest nursing degree, current employment status and unit.³⁵

One study used the HCAHPS survey,³⁶ which was originally developed for measuring patients’ perceptions of their hospital experience⁴¹ and includes 32 items consisting of nine-key domains pertaining to patient care. The survey has items that ask whether and at what frequency patients experienced a critical aspect of hospital care, rather than whether they were satisfied with their care. The survey also includes four screener items directing patients to relevant questions, five items to adjust for the mix of patients across hospitals, and two items supporting Congressionally-mandated reports.³⁶

The Main Findings of the Studies

Missed Care Reported by Patients

Patients can recognize and report several aspects of missed care.³¹ MISSCARE Survey – Patient divides missed care into three domains: missed basic care, missed communication, and timeliness. In studies using this questionnaire,^32–34 patients (n=210-729) reported mostly missed basic care (mean 2.29–3.57, SD 1.06–1.23), followed by missed communication (mean 1.69–2.02, SD 0.71–0.83) and timeliness (mean 1.29–1.52, SD 0.54–0.64).^32–34

MISSCARE Survey – Patient views missed care as unperformed nursing activities. To begin with missed basic care, mouth care (missed 32.1–50.3% of the time), ambulation (missed 20.3–41.3% of the time), lifting to a chair (missed 38.8% of time), bathing (missed 26.9% of time), assistance with hand washing (missed 29.4% of time) and support for chancing position (missed 17% of time) were recognized as missed.³² Moreover, activities categorized as missed communication included nurses providing necessary information to patients and families (missed 11.9–27% of the time), discussing the treatment plan with patients (missed 26.5% of time), considering patient’s opinions (missed 20.4% of time), patient knowing who their assigned nurse was (missed 11.2% of time), and listening to patient (missed 7.8% of time).³² Finally, activities related to timeliness were listed, including timely help to the bathroom (missed 10.1–10.9% of the time), fulfilling call light requests (missed 10.3–16.4% of time) and responding to beeping monitors (missed 8.8% of time) as well as call lights (missed 8.6% of time).³²

In the study using MISSCARE Survey,³⁵ patients (n=160) also mostly reported missed basic care, followed by missed individual needs, which included activities such as emotional support for the patient or family (reported as missing by 43.7% of patients), visits for assessments by other professional such as physician or nutritionist (reported as missing by 26.2% of patients), and evaluating the effectiveness of drugs (reported as missing by 16.7% of patients), as well as patient education during hospitalization (reported as missing by 36% of patients) and discharge plan (reported as missing by 73.7% of patients).³⁵ Furthermore, one-third (38%) of the patients (n=1125) reported at least one nursing activity from the HCAHPS survey as missed during their hospital stay.³⁶

Factors Associated with Missed Care

Several patient-related and staff-related factors were associated with missed care. Among patient-related factors, patients with poorer health status and patients with mental health problems reported more missed care,^32,36 as did patients who experienced adverse events during hospitalization compared to those who did not; a significant positive association was thus found between patient-reported missed care and patient-reported skin breakdown, medication error, new infection, intravenous infusion (IV) running dry and IV leaking.³² Dabney & Kalisch (2015) found patients’ older age to be a predictor of missed timeliness,³³ as opposed to Orique et al (2107).³⁶ Similarly, Kalisch et al (2014) found that patients with lower education level reported more missed care,³² whereas Orique et al (2017) found no significant association between patient’s education level and missed care.³⁶ Patient’s gender did not predict missed care.^32,36

Staff-related factors contributing to missed care perceived by patients (n=160) included lack of staff (18.1%), staff with insufficient experience (13.8%), lack of teamwork (7.5%), lack of staff communication between shifts and the attitude of staff members (5%).³⁵

Patient-reported missed care was also associated with nurse staffing levels. The total number of productive hours worked by registered nurses, total number of productive hours worked by all nursing staff members, and the proportion of registered nurses in the total number of nursing staff members had a significant negative correlation with missed patient reported timeliness as opposed to patient-reported missed basic care or communication.³³ However, in another study³⁴ the actual patient-to-nurse ratio was not significantly associated with patient-reported missed care while patients’ perceptions of staffing adequacy had a significant positive association with patient-reported missed communication and patient-reported missed basic care. Nurse-perceived staffing adequacy had a significant inverse relationship with patient-reported missed communication but no significant relationship with patient-reported missed basic care.³⁴

Patients’ Satisfaction

Missed care was also connected with the outcomes of care, the outcome mostly being patient satisfaction. In the studies reviewed, patient-reported satisfaction with the nurses’ care showed a significant negative association with nurse-reported missed care.^27,37–41 Even low levels of nurse-reported missed care associated significantly with low patient satisfaction.⁴⁰ Furthermore, a significant negative association was found between nurse-reported missed care and patients rating their care as excellent,³⁷ as well as between nurse-reported missed care and patient-reported patient-centered care.⁴²

Implications and Suggestions for Further Research in the Studies

In most of the studies, the authors reported suggestions for further studies. There is variation in this as well. Suggestions for future research referring to patients’ perspective of missed care are limited. Authors agree that data should be collected from both nursing staff and patients, which would permit comparison of the reports of missed nursing care.³³ Future research is also needed to explore the effect of engaging patients and families more extensively in their nursing care,³² and to study the expectations of patients regarding professional hospital care.³⁹

Discussion

Patients’ perspective in missed care literature is very limited, as studies were only included in the review if they had patients providing missed care data or examined patients’ perceptions of nurse-reported missed care and yet, in the search with no time limit, only 13 studies, published 2008–2018, were identified. The selected studies included mostly data about patients’ satisfaction compared to nurse-reported missed care whereas direct information on patients’ perceptions on missed care is extremely scarce: only six studies included these data.

Research on this field has mainly focused on the amount and nature of missed care as tasks experienced by patients and the factors associated with it whereas no causal conclusions can be made about these relationships. In the reviewed studies, patients mostly reported missed basic care, followed by missed communication and missed timeliness.^32–34 The studies are from several countries and the results on the amount of missed care experienced by patients are similar, potentially indicating an international problem. The estimation of a shortage of two million nurses by 2030⁷ suggests an increasing amount of missed care requiring attention since patient-reported missed care is associated with patient-reported adverse events during hospitalization.³²

Some patient- and nurse-related background factors were associated with missed care. However, the results about patients’ education level and age as predictors of missed care were conflicting,^32,36 as were the results about an association between staffing level and missed care, highlighting the need for further research. The determination of staffing level varies between studies, making it more difficult to combine these results. Cho et al (2017) used patient-to-nurse ratio (the average number of patients at midnight over the past 7 days divided by the average number of nurses per shift) to determine staffing level, and this was not significantly associated with patient-reported missed care,³⁴ whereas Dabney & Kalisch (2015) used three variables to measure nurse staffing: RNHPPD (the total number of productive hours worked by RNs in a designated inpatient unit during a specific calendar month, divided by the total number of patient days for the corresponding unit and month), NHPPD (total number of productive hours worked by all nursing staff members in an inpatient unit during a designated calendar month, divided by the total number of patient-days for the corresponding unit and month), and RN SKILL MIX (the proportion of RNs in the total number of nursing staff members). These variables were not associated with patient-reported communication and basic care, as opposed to missed timeliness,³³ which runs counter to previous studies that highlight the association between lower staff levels and increased amount of missed care.^1,21 Nurse-reported missed care was significantly associated with patients’ satisfaction with care, potentially indicating the mediating effects of missed care on the relationship between nurse staffing and patients’ experiences.³⁴

Patient-perceived staffing adequacy was, however, significantly associated with patient-reported missed care, and lack of staff was named as the primary factor contributing to missed care perceived by patients, which raises the questions of how patients recognize missed care and how patients perceive staffing adequacy. Patients may not be able to separate nurses from other health-care professionals or they may not recognize care needs with the same scope as professionals; in addition, each patient also has their individual expectations for nursing care. Among the studies reviewed, different questionnaires were used to measure missed care perceived by patients. The questionnaires included different numbers of listed nursing care tasks, and patients were asked whether or not this task was performed during their hospitalization. This, however, does not say what is important to patients or what nursing care they and their family members value the most; further research would thus be useful to examine how patients identify missed care, what activities they consider that nurses perform, and how they define care that is completed in correspondence with their views on their care needs.

These results support the conceptual models developed to understand missed care, as there were organization-related factors, such as resources and lack of teamwork, identified as contributors to missed care perceived by patients. Moreover, missed care was associated with adverse events and lower patient satisfaction, thus resulting in negative patient outcomes, which could be an indicator of care quality. In these conceptual models, nurses are decision-makers who, in situations that require prioritization, make a choice about what activities to perform and what to leave out. In addition to conceptual models, these results could also be viewed through the framework of structuration theory.^15,17 In this framework, nurses would be acknowledged as agents who, based on their education and experience, have knowledge about the necessary nursing activities they should provide, and are able to reflect upon how they carry out these activities. Nurses as agents must also make choices on whether or not to perform a specific task. Nurses carry out their work intentionally, based on their knowledge and the expected outcomes of these activities to patients or themselves. In addition to personal choices, nurses practice their work in a specific social environment and structural system which, for example, provides the resources available.¹⁸ Based on these results, basic care was mostly missed; this would indicate that nurses mostly decide that the expected outcome of missed basic care would not be as severe as that of some other nursing activities. However, based on these articles reviewed, no conclusions can be drawn about nurses’ decision process.

The imbalance between patients’ care needs and the resources available forces nurses to prioritize between patients and different nursing tasks, making it an ethical challenge.²⁰ Prioritization has consequences for nurses as well as patients as it may cause nurses to experience moral distress as well as feelings of frustration and powerlessness. The consequences for patients include missed care, dissatisfaction and loss of trust,⁴³ as the prioritization process leaves patients vulnerable to unmet care needs.³ However, the ethical perspective on missed care was not adduced in the reviewed articles, and further research is needed on this topic.

This study has strengths and limitations. The strengths include that the search was comprehensive, using six databases, and conducted in collaboration with an information specialist. In addition, the PRISMA-ScR checklist for scoping reviews was used to guide the reporting of the results.³⁰ The limitation is that only English-language articles were included in the review, and it is therefore possible that relevant articles in languages other than English were left out. However, the studies in the selected articles were conducted internationally in different countries and cultures. The term “patient perspective” was left out of the search phrases because of possible difficulties of including all the terms describing it, as a result of which something relevant might be left out. Even without this, it was possible to go through all the found articles by title.

Further research is needed to form a clear definition of missed care and to state what the definition includes, as it is challenging to examine something that does not exist. In addition, further research is needed to gain a deeper understanding of missed care as perceived by patients and the factors influencing it, including different organizational structures, as the literature on this topic is limited and the existing results were partly conflicting. Based on this review, it is not possible to identify a specific nursing context that encloses missed care, which is why future research is needed within a variety of patient groups and health-care contexts, as so far, all the participants have been adult patients in clinical hospital setting. Missed care has been investigated in aged care from the nurses’ perspective, and one study showed that additional unplanned care⁴⁴ was most frequently missed, whereas basic care was mostly missed among the medical patients in the studies reviewed. As populations age in many parts of the world, prioritization might also increase in older people care in the future.⁴⁵ Furthermore, in the future it would be useful to examine how patients identify missed care and to explore the ethical perspective on missed care, as it was not addressed in the articles reviewed.

Conclusion

Research about missed care from patients’ perspective is scarce, although anticipated to be an extremely common phenomenon. Patients mostly report missed basic care, followed by missed communication and timeliness. The included articles pointed out that researchers can investigate patient’s perspective of missed nursing care using validated instruments; however, we suggest also asking patients’ views more broadly. In addition, patients’ perception on some of the missing nursing tasks and areas had strong correspondence with previously studied nurses’ perception. However, since identification of missed care is not simple, it presents, and will continue to present, a great challenge for researchers, clinicians and patients.