Missed or rationed nursing care: Where to now for the nurse manager?

The year 2020, to date, has been unusual in its focus, intended and unintended, on what nurses ‘do’. First, the World Health Organisation (WHO) designated 2020 as the Year of the Nurse to coincide with the 200th anniversary of the birth of Florence Nightingale and in recognition of the contribution to health care of the nursing profession. This global initiative has been invaluable in showcasing nurses and nursing. More recently, the publication of the State of the world's nursing 2020: investing in education, jobs and leadership (WHO 2020) drew attention to current concerns for the profession and challenged governments to invest in nurse education, expand the workforce and strengthen leadership with nurse voices in health policy decisions as an essential factor. Furthermore, a global pandemic has ensured that nurses and what nurses ‘do’ have been headline news in countries across the world over recent months. It is ironic therefore that within the profession, the work that nurses do not ‘do’, or cannot ‘do’, is the focus of many researchers. This special issue focuses on missed or rationed nursing care and on related concepts such as care left undone. Necessary patient care that is either omitted or left incomplete by nurses is included within these descriptors. The phenomenon of missed care has been researched and discussed for 20 years within the profession, leading us to consider what might be an appropriate next step. An EU Cost Action project entitled Rationing- Missed Nursing care: An international and multidimensional problem (RANCARE CA 15,208, 2016–2020) brought together researchers from 33 countries to facilitate discussions and move this research forward. Many of the papers in this special edition have been submitted by RANCARE researchers, demonstrating the success of the action. The relevance of nurses and nursing care in the context of patient safety has been widely studied, and the concept of missed nursing care is clearly established within the patient safety arena. The Institute of Medicine (Kohn, Corrigan, & Donaldson, 2000) first highlighted the contribution of nurses and nursing in a patient safety context. Following this, the International Hospital Outcome Study (IHOS) underlined the relevance of nurse staffing, skill and grade mix, and the quality of the nurse work environment as predictors of positive patient and nurse outcomes (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken, Clarke, Sloane, & Sochalski, 2001; Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). For the first time in the IHOS, ‘nursing care left undone in the last shift’ was measured. This provided evidence of something we always suspected—nurses across health systems left necessary nursing care undone at the end of their shift due to lack of time. In the Swiss part of the IHOS study, implicit rationing of nursing care was studied using the Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Schubert, Glass, Clarke, Schaffert-Witvliet, and De Geest (2007) defined implicit rationing of nursing care as the withholding of, or failure to carry out, necessary nursing measures for patients due to inadequate time, staffing levels and/or skill mix. This refers less broadly to nursing care, but rather refers to care judged necessary by participating nurses to reach the desired outcomes, to protect patients from negative events and to prevent outcomes such as falls or pressure sores. Almost at the same time, Kalisch, Landstrom, and Hinshaw (2009a) introduced the concept of missed nursing care as an error of omission, which could be measured using the MISSCARE instrument. Missed care was defined as any aspect of required patient care that is omitted (either in part or whole) or delayed. The results of these three seminal projects, and subsequent studies using these instruments, indicate that across countries where the concepts have been studied in the acute care setting, fundamental nursing care is frequently missed. Fundamental care includes ambulation of patients, turning and positioning of patients, mouth care, documentation, nursing care planning, emotional or psychological support; and in the community care setting, preventive care (e.g., health promotion, re-assessments). Between 55% and 98% of nurses admit to leaving patient care undone (Jones, Hamilton, & Murry, 2015) due to lack of resources. Nursing care that is less frequently rationed or missed includes medical-oriented tasks or treatments, and patient monitoring. In several studies, higher levels of rationing or missed nursing care were significantly linked with higher rates of adverse events such as falls, medication errors and inpatient mortality, and lower perceived quality of care and patient satisfaction with nursing care (Schubert et al., 2008, Kalisch, Tschannen, & Lee, 2012, Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014, Ball et al., 2017 and Kalisch, Xie, & Dabney, 2014). There are also indications that higher levels of missed and rationed nursing are linked with higher levels of nurse job dissatisfaction and intention to leave (Kalisch, Doumit, Lee, & Zein, 2013, Smith, Rogowski, & Lake, 2019, and Cho, Lee, You, Song, & Hong, 2020). In order to better understand the underlying mechanisms and contributing factors, the predictors of rationed or missed nursing care have been evaluated in several studies. Frequent predictors identified were the quality of the nurse work environment, teamwork, communication, resource adequacy (staffing and skill mix), workload, patient care needs, safety climate and culture, ethical climate and nurse job satisfaction (Kalisch et al., 2009a, Schubert et al., 2013, Blackman et al., 2018, Cho, Kim, Yeon, You, & Lee, 2015, Griffiths et al., 2018, Palese et al., 2015, Bragadottir, Kalisch, & Tryggvadottir, 2017, and Friese, Kalisch, & Lee, 2013). Interestingly, as evidenced in a scoping review contained in this issue, to date the nurse manager role has been largely absent in the literature on missed or rationed care (McCauley, Kirwan, Riklikiene, & Hinno 2020). This seems an obvious oversight, which fails to take into account the important role of the nurse manager in relation to planning patient care delivery. Many of the articles included make recommendations for nurse managers on how to address missed or rationed care within their units and therefore will help to inform their practice. Articles submitted to this special issue clearly demonstrate that missed and rationed nursing care is a very real issue for nurses across the globe. Researchers from Europe, Asia, Australia, the Middle East, South America, the USA and Canada have contributed to this growing body of knowledge. In keeping with previous patterns of research, many studies reported here were carried out in acute settings, but others looked, in many cases for the first time, at missed or rationed nursing care in other settings across countries. These included residential or long-term care facilities, labour wards, neonatal and paediatric settings, intensive care units, primary care units, community settings and health promotion units. This broadening of the research area and the findings of these studies confirm that care is rationed or missed in all settings with consequences for patients and nurses. In several studies reported here, the associations between system factors, such as nurse staffing and skill mix, and missed nursing care or its influencing factors, mostly combined with the frequencies or levels of missed nursing care were investigated. The results confirm the known system and organisational factors and predictors of missed nursing care such as the adequacy of staffing and skill mix, the leadership skills of the nurse managers, and the quality of the nurse work environment. These are known modifiable factors on which nurse managers have some influence, although we must caution that in some systems, nurse manager influence over staffing levels is limited. In a number of studies, the association between missed nursing care and patient and nurse outcomes, and quality of care was studied. The results confirm the known associations between missed nursing care and patient safety, such as the number of adverse events, falls with injuries, medication errors and unexpected death. In one of these studies, a significant link between the levels of missed nursing care and nurse job enjoyment and intention to leave is shown. The results also contribute to the small body of knowledge so far, which looks at the well-being and the emotional status of the nurse in the context of missed care. Nurse managers must pay attention to staff well-being and support them in their work. From all these studies, we gain some new insight because the results underline the relevance of these factors across the world, in many differently organised health care systems. A smaller group of studies focus on interventions or strategies, to reduce or to manage the levels of missed nursing care. Interventions or strategies that were evaluated in this context were as follows: modifications of the nurse work environment, efficient communication between the interprofessional team, integration of the patient as an important member of the care team, implementation of a primary nursing care model and enhanced compassion competence in nursing staff. The results indicate that with these interventions, the levels of missed nursing care can be reduced. Another small group of studies focuses on missed nursing care decision-making processes, specifically on the need to make priorities in nursing visible to prevent missed nursing care event, and to ensure a fair allocation of limited resources. The results underline that it is necessary to get a better understanding of the decision-making processes around missed nursing care, and to clarify the fundamental need for nursing care and what this implies for patient care in different organisational settings. The nurse manager role in setting standards around decision-making and prioritization cannot be overestimated. In three studies, the psychometric properties of translated established instruments for measuring missed or rationed care were evaluated. The results confirmed that these instruments are valid and reliable and therefore can be used for measuring these concepts in different countries. Interestingly, one of these looked at the translated version of an instrument developed to measure missed nursing care in infection prevention and control, which is the first attempt at developing a more focused tool beyond the generic approach to missed nursing care (Henderson, Willis, Roderick, Bail, & Brideson, 2019). This advances our thinking around missed or rationed care and suggests that generic instruments for measuring the concepts may not capture the intricacies of specialist nursing practice. Perhaps there is a need for adaptation of instruments for specialist areas such as intensive care, renal dialysis, community nursing settings or mental health facilities in order to capture specific elements of care missed or rationed within those areas. The implications for nurse managers of the studies included this issue are clear. Missed or rationed nursing care is ubiquitous across health systems and across care settings. Ongoing measurement of missed or rationed care events would seem necessary with a view to understanding the problem in context. There are known modifiable factors, which can enhance patient care and reduce levels of missed or rationed care. These include staffing and skill mix levels, the environment in which nurses practice, nurse leadership and visibility. Other interventions have been suggested in this issue, which may further help reduce levels. By creating an atmosphere of transparency around missed or rationed care, nurse managers can ensure better outcomes for both patients and nurses. But crucially, they have a responsibility to acknowledge the problem, and to make explicit, both within their units and within their organisations, what it is that nurses ‘do’ and indeed what they cannot ‘do’, due to lack of time or resources. By making explicit the frequency of these missed or rationed care events, and the subsequent impact on patients and staff, nurse managers can draw attention to the factors known to contribute to these phenomena, both within organisations and at policy level.

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