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The concept of ‘missed nursing care’

Most issues of Journal of Advanced Nursing now include a concept analysis. I really hope that conceptualization is no longer regarded by any nurse as an airy fairy academic exercise but, on the contrary, as the crucial first step towards properly understanding an idea or phenomenon.

In this issue of JAN, there is a concept analysis paper (pp. 1509–1517) which, I think, is of real importance. It relates to the field of patient safety – the importance of which we all understand – and it exposes a key concept that, so far, has been missed: the concept of missed nursing care. This is not the same as a mistake, an error, which is where the patient safety agenda has focused to date. Kalisch et al.’s paper highlights that errors of omission are every bit as important as errors of commission for patient safety.

Not fulfilling a required aspect of a patient’s care is something that every nurse has done, whether knowingly or not, and probably more times than we would want to admit. Not all omissions will have harmful consequences, but some certainly will have an adverse effect on a patient’s condition or recovery. And, of course, not doing something – as distinct from doing something wrong – can result, at worst, in a patient’s death. Kalisch et al. bring the concept of ‘missed nursing care’ out into the open.

Why has ‘missed nursing care’ been an ‘undiscussable’ subject in nursing? Kalish et al. suggest that feelings of guilt, fear of reprisal or a sense powerless are some of the reasons. These were some of the beliefs of nurses in an earlier focus group study undertaken by Kalisch (2006). The concept of ‘missed nursing care’ emerged from that piece of research.

The step-by-step analytical process of the concept analysis is clearly described in this JAN paper. The resulting conceptualization of ‘missed nursing care’ is neatly summarized in an easy-to-understand model (Figure 1, p. 1512). The Missed Nursing Care Model provides the framework for a middle range explanatory theory of universal relevance. It provides a clear starting point for a new wave of research.

The field has not been entirely devoid of research. However, the focus has been on highly specific aspects of nursing care that have been omitted: for example, failure to turn bedfast patients or failure to provide patients with adequate information on discharge from hospital. Such studies, say Kalisch et al. (p. 1511), have not addressed the broader concept of missed nursing care.

It is easy to see how the Missed Nursing Care Model could enhance the design of research, perhaps especially in terms of investigating the factors that influence a nurse’s choice to complete, delay or omit items of patient care (p. 1513). The model identifies four groups of factors: namely, (1) norms of the team, (2) priority decision-making, (3) values, attitudes and beliefs and (4) habits.

‘Testing of the Missed Nursing Care Model has major implications’, say the authors, ‘for the generation of a new middle-range theory explaining missed care and how to counteract such errors of omission’ (p. 1515). They conclude with a powerful message: that ‘(t)he consequences of missed nursing care present threats to patient safety, and should be given consideration in state and national policy development globally’.

Right now, at the global level, the World Health Alliance for Patient Safety – operating under the auspices of the World Health Organization – has work underway towards an International Classification of Patient Safety (ICPS). Any classification system must start with agreement and definition of key concepts. A recently published paper (Runciman et al. 2009), freely available under open access, outlines the first stage of that conceptual work. Definitions and preferred terms have been agreed for 48 concepts. ‘Missed care’ is not among these concepts, but should it not now be added?

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