Abstract
Missed nursing care has received relatively little attention in the nursing literature up to and including the first decade of this century. However, this is now changing and missed care has recently been recognized as an interesting and urgent matter by a number of nurse researchers. The first study recognizing this issue (‘care left undone’) was reported by Aiken et al., 1 and the first study examining the notion and reality of missed care was reported by Kalisch in 2006. 2 Several national and international research groups and networks, such as the RANCARE Consortium 3 and Missed Care Study Group, 4 are currently working with the concept and phenomenon of missed care. The need for such research is evident from the point of view of the connection with staffing and work conditions, patient safety and nurse-sensitive patient outcomes among other issues.
Missed care means any aspect of (nursing) care that is omitted or delayed, in part or in whole. 5 Kalisch and Xie 6 regarded missed care as an error, act of omission that leads to an adverse outcome or significant potential of such outcome. Thus, missed care can be seen as an outcome of activities and processes performed (or not performed), consciously or unconsciously, by professional nurses. Several synonyms or related terms for missed care have been used in the literature – terms such as ‘unmet care needs’ and ‘omitted care’. ‘Care left undone’, ‘delayed care’, ‘rationing of nursing care’, ‘covert rationing of nursing care’ or ‘implicit rationing of nursing care’ 7 have been used especially in the context of limited resources to describe the activity of professional nurses. For example, Schubert et al. 8 defined rationing in nursing in terms of ‘the withholding or failure to carry out necessary nursing tasks due to inadequate time, staffing level and skill mix’. Furthermore, many studies have shown that low Registered Nurse staffing levels is associated with reports of missed nursing care in hospitals. 4 Research results also show that missed care is a common issue in nursing contexts, especially in acute care hospitals, where the topic has been studied most. Furthermore, reviews and many studies have revealed that the patterns of unfinished care were consistent with the subordination of patient education, comfort care and emotional support activities to those related to physiologic needs and organizational audits. 7,9
From the ethics point of view, missed care as an outcome, and the processes leading to such an outcome, warrants closer examination. Decision-making and prioritization happens daily in nursing when nurses take care of many patients at the same time and, for example, the urgency of needs is different. There is need for close examination of this kind of decision-making and of the ethical elements inherent in such decision-making. Nurses may be either ethically aware or ‘ethically blind’ in such situations. Ethical elements and aspects are the most problematic when they are hidden. 10 Although ethical awareness may lead to ethical problems and conflict, the situation becomes worse if the ethical dimension of such, normally covert, decision-making is not recognized. This may lead to significant injustices, discrimination, ethically unacceptable distributions of nursing time and ultimately negligent nursing.
Earlier in this editorial, it was mentioned that nurses’ prioritization strategies leave patients vulnerable to unmet educational, emotional and psychological needs. 7,9 Many studies have revealed quite similar results about these areas (educational, emotional and psychological) where nurses are unable (or unwilling for whatever reason) to respond to the necessary, assessed needs for patients, resulting in missed care. From, professional nursing rhetoric, literature and historical nursing texts, meeting such patient care needs have been cherished in nursing and considered being a part of the core of nursing care (comfort care, psycho-social support, patient education and so forth). However, as we routinely audit and measure and record certain elements of nursing care perhaps we have been dazzled by these very measurement tools into mistakenly believing this is all that nursing is – that is, nursing is completely defined and described by what our tools measure. Have we given too little attention to the possibility that we are moving to a new, much less holistic, hollowed out conceptualization and model of nursing care? Due to the effects of austerity, staff shortages and lack of real accountability for clinical nursing practice have we moved, unconsciously or otherwise, to see nursing care through a narrow, reductionist lens? Is our focus largely mechanically, task-oriented and driven by rigid protocols for delivering physical care?
Scholars and researchers are responsible for developing models for understanding nursing and nursing care and for providing critical scientific bases for new perspectives for analysing this demanding topic. We suggest patients as recipients of nursing care, and members of the general public (as potential patients) also urgently need to be involved in this discussion and analysis of nursing care and what is required of nurses in our 21st century health services.
Philosophically, it is very difficult to study something that is missing – that is, ‘missed care’. One possibility is to consider the ethical bases for resource allocation, prioritization and where necessary rationing decisions in the daily activities of nursing care – that is, the allocation, prioritization and rationing of nursing time and skill. We argue that this is an urgent and necessary public, national and international discussion that is required in order that members of our general public may become more aware of the genuine resource constraints on available nursing time – and therefore on available nursing care – but also to try to come to some general consensus of what a fair, just and acceptable distribution of the available nursing time and nursing care looks like for particular patients and patient groups. This is a far too important matter to be left to the un-evidenced resource allocation decisions of inadequately informed health service managers, or to the vagaries and biases of the individual nurse at the bed side, reacting to the loudest voice or to the individual practitioner’s conception of the ‘deserving’ patient.