The impact of “missed nursing care” or “care not done” on adults in health care: A rapid review for the Consensus Development Project

Abstract Aim To identify outcomes of missed nursing care for adult patients. Design A five‐stage rapid review process was conducted as follows: refining the question, retrieving relevant studies, determining the studies to be included, organizing the data and synthesizing the results. Methods Papers published between 2010–2020 that focused on the UK, Europe, the USA and Oceania were searched for keywords in the title and abstract in major databases. The articles that identified the impact of missed nursing care on adults in health care were selected. Results Seventeen articles met the criteria. Major impacts of missed care in adult settings were increases in mortality, adverse events and failure to maintain. These same studies also identified a range of causative factors linked to ward environment, inadequate staffing levels and skills mix although are inconclusive. Solutions include continuing education, ward and work re‐design, and appropriate skill level.


| INTRODUC TI ON
There is considerable disquiet among citizens in the United Kingdom over the quality of patient care in the National Health Service (Francis, 2013). The University of Sheffield sought to engage citizens in a series of consensus development discussions in 2020 with the view of generating strategies for reform. The format of consensus development round tables draws on informed stakeholders and experts to explore a topic (Breart, 1990). The experts are tasked with providing stakeholders with a brief, evidence-based overview of the issue. This rapid review represents the data provided to those stakeholders considering "missed care for adult patients in acute care." A rapid review is a simplified systematic review that brings the evidence together in a timely manner but lacks the detailed rigour of systematic reviews. It takes a limited overview of the topic and may reduce the geographical spread and time periods covered and not employ the team-based procedures of systematic reviews. Its aim was to provide a quick and efficient overview on topics requiring immediate responses (Dobbins, 2017;Haby et al., 2016).
This rapid review explored the question; what is the impact of "missed nursing care" for adult patients? Four outcomes were identified in the research literature, with three addressed here: patient mortality (Schubert et al., 2012), adverse events (Brooks-Carthon et al., 2016;Liu et al., 2016;Patty et al., 2020) and failure to maintain (Bail & Grealish, 2016). The fourth factor, patient satisfaction is not addressed here. Factors contributing to missed care are also discussed, but only as reported in these papers. A range of current solutions are provided drawing on literature beyond the review.

| BACKG ROU N D
Missed care is defined by Kalisch (Kalisch et al., 2009, p. 1,510) as any "aspect of required patient care that is omitted (either in part or in whole) or delayed," while Schubert et al. (Schubert et al., 2012, p. 230) defined "implicit rationing of nursing care" as the "failure to deliver one or more types of needed nursing services." In reference to patient quality and safety theory, missed or rationed care is seen as an error of omission; something is missed, rather than an error of commission, something is incorrectly given (Kalisch, Landstrom, & Hinshaw, 2009, p. 3). The majority of studies examining missed care are those that ask nurses to estimate the number of times they missed a care task within the last shift or week. The results of these studies show considerable agreement in the list of nursing care tasks left undone (Kalisch, Landstrom, & Hinshaw, 2009). It is assumed that these omitted tasks are detrimental to the patient's health.
Most studies on missed care have been done in the acute hospital sector, in surgical and medical wards and intensive care units (ICU).
Nurses are less likely to miss those tasks ordered by doctors such as medication and treatment; hence, it is the caring tasks that tend to be left undone more often than treatment or technical tasks. Given these are basic nursing care tasks the question arises as to why this is problematic? One example suffices; poor mouth or oral care is important for preventing teeth loss, gingivitis, and periodontitis for patients who have long-term care such as those in Care Homes. Failure to maintain adequate mouth care can also be a factor implicated in hospital-acquired aspirational pneumonia or chest infections (Bail & Grealish, 2016).

| ME THOD AND DE S I G N
A search of keywords was performed using the following keywords (Nurs* AND ("failure to maintain" OR omitted OR "task undone") AND ("patient safety" OR "patient outcome*") AND (adult OR adults)) in the search fields of Title & Abstract in the database CINAHL (EBSCOhost) and then translated across to Medline (OVID), Emcare (OVID) and Scopus. The search was filtered by the publication years 01/01/2010 −24/01/2020 and limited to English language.
Following the comprehensive search, 242 citations were collated, uploaded into Endnote (Reference management program version X9.2) and duplicates were then removed leaving 184 citations to be appraised. (See PRISMA Figure 1). The search was conducted on 24 January 2020. An additional four papers were added that were not captured in the search but relevant (Ausserhofer et al., 2013;Ball et al., 2018;Brooks-Carthon et al., 2015;Lucero et al., 2010). These papers were identified from the reference list of retrieved papers. The paper was drafted by the first author and edited by the second author. The exclusion and inclusion criteria are presented in Table 1. It should be noted that while papers from South Africa, Central and South America, the Middle East and the Eastern Mediterranean Region have been excluded, studies on missed care have been conducted in these countries including Israel, Cyprus and Greece. Cyprus is one of the major leaders in this research domain (Papastavrou et al., 2016).

F I G U
The exclusion was linked to the original brief to focus on the United Kingdom, and the authors own geographical area of interest which includes South East Asia and China.
All articles were read, with 13 papers meeting the criteria and the remaining excluded. An additional search was completed in late 2020 to update the paper for publication. This was done given the proliferation of research in this area over the last four years. Sixty papers were identified with four meeting the criteria, with the first author performing the cull because of her expertise in the area. Of the total 17 studies accepted for this review, nine were cross-sectional designs, and three were retrospective studies of databases (Table 2) and five were narrative or systematic literature reviews (Table 3).
The majority of studies were surveys with nurses self-reporting care missed on a previous shift.

| E THI C S
Ethics approval for this study was not required as no individuals including patients were included. Funding was received from the University of Sheffield.

| RE SULTS
These are (i) mortality rates; (ii) adverse events; (iii) and failure to maintain.

| Mortality rates
Three papers demonstrated a statistical link between mortality outcomes and missed care Schubert et al., 2012;Tesoro et al., 2018) with two other studies finding no statistical links (Brooks-Carthon et al., 2016;Lucero et al., 2010). Three literature reviews reported on mortality rates, citing some of the papers listed above, but the authors came to varying conclusions; Recio-Saucedio et al. reported on the differences across studies, while Mandal and Ogletree concluded the evidence supported a link (Mandal et al., 2020;Ogletree et al., 2020;Recio-Saucedo et al., 2018). For example, Schubert et al. examined the association between explicit rationing and hospital mortality in medical, surgical and gynaecological wards demonstrating that patients treated at hospitals with the highest rates of missed care have a 51% increase in mortality (Schubert et al., 2012). These results were substantiated in a study by Ball et al. (2018) across 300 acute hospitals in nine European countries. As missed care increased, so too did case mix adjusted mortality rates within 30 days of admission . The less conclusive findings on patient mortality reported by Recio-Saucedo et al., identified four studies that explored the relationship between mortality and missed care (Ambrosi et al., 2016;Brooks-Carthon et al., 2016;Lucero et al., 2010;Schubert et al., 2012). The Ambrosi et al., paper is not included here as the missed care was recorded by relatives. Recio-Saucedo et al., conclude that only the study by Schubert et al., returned reliable results noting that once adjustments were made for patients, ward or hospital environmental factors the results were not statistically significant.

| Adverse events
Seven studies reported on adverse events, with five literature reviews repeating some of these results (Tables 2 and 3). Adverse events such as medication errors, urinary tract infections, patient  .

| Patient characteristics, missed care and adverse events
There is some suggestion in the research literature that patient characteristics make a difference to the number of care tasks that are missed and subsequent adverse events. This is tackled in two ways. Studies may adjust the findings based on the case mix, or characteristic of the patient, before making a definitive statement about the quality of the care provided given some patients are more vulnerable than others  in hospitals that did poorly on nurse-reported surveys on the work environment, although these hospitals were better staffed. While the authors admit that one of the underlying reasons for readmission may be the patient's lower SES which may impact on their access to specialist post-hospital care, including access to medications; the relationship between documentation and patient communication is seen as a key explanatory factor along with timely medication which had the strongest association with readmission rates per hospital. A more recent study conducted in California with patients with several comorbidities indicated that they were less likely to experience an adverse event. In this case the authors argued that nurses were less likely to miss care where they knew the patient was vulnerable (Patty et al., 2020).

| Failure to maintain leads to adverse events
The concept of "failure to maintain" coined by Bail (Bail & Grealish, 2016) traces the relationship between a sequence of missed care tasks, or mild neglect, and the onset of an adverse event for the frail elderly through a process known as cascade iatrogenesis. Failure to maintain is defined as "insufficient delivery of essential nursing care for an older person in hospital resulting in a complication, four of which are useful indicators for the quality of hospital performance particularly for patients with dementia" (Bail & Grealish, 2016, p. 153). In coining the term "failure to maintain," Bail is deliberately linking it to failure to rescue (death following a hospital-acquired adverse event). Ogletree et al., identified cognitive and functional decline, delirium and weight loss resulting from missed care (Ogletree et al., 2020) and Kalánková et al. (2020) in functional capacity.

| Adverse event/readmissions
Less research has been done within the care homes for older people. As Ogletree et al., noted in their systematic review, studies are inconsistent in reporting adverse events with some noting potential, but few providing direct evidence (Ogletree et al., 2020). Despite this caveat, Ogletree et al., define 14 outcomes as adverse events, although the study source is not identified. However, they do identify six papers that report a correlation between missed care and adverse events in aged care. Of the six papers they identified, two met the criteria for this rapid review. The other four papers included community-based patients making it difficult to distinguish residents in aged care homes (Nelson & Flynn, 2015;Recio-Saucedo et al., 2018). Nelson and Flynn (2015)

| D ISCUSS I ON: C AUS E S OF MISS ED C ARE
There is difficulty in establishing evidence to support claims that missed care leads directly to increased mortality, adverse events or failure to maintain given most studies are surveys that report on nurse's subjective observations. It is also difficult to establish the direct pathway between forgetting to assist a patient to ambulate and aspirational pneumonia, or any other adverse event.
Some studies reported here have also asked the respondents to rate the nursing working culture and to report on the nursepatient ratios at the time of doing the missed care survey (Liu et al., 2016Lucero et al., 2010). The work culture is invariably measured using the nurse work environment index, which asks nurses their views on staffing levels and resources, collegial relationships with doctors, their nurse manager's ability to lead and support the team and participation in hospital affairs. The nurse-patient ratio is measured by the number of nurses rostered on the shift against the number of patients (Schubert et al., 2012).
For example, Schubert's study on the association between explicit rationing of care and mortality rates used both approaches showing a correlation between the nursing environment, staffing levels, missed care and mortality rates, but this does not establish a direct causation, just a correlation. What is known is that good working environments lead to highly satisfied nurses who are less likely to miss care, resulting in better patient outcomes . Bail and Grealish (2016) cites increased patient throughput, acuity, comorbidity and disability along with the relentless healthcare systems and hospital focus on efficient length of stay, as factors that result in failure to maintain. She refers to this as the "disappearance of recovery time" (Bail & Grealish, 2016, p. 151 Few studies examine nurse characteristics, or report on any specific nurse qualities, other than to confirm that the population being surveyed mirrors that of the total nurse population (Schubert et al., 2012). Some papers note the number of nurses who have a university qualification Zhu et al., 2019), but there is no consistent findings on the relationship between nurse education or other characteristics and patient outcomes. A number of publications examine managerial leadership style but are not included in this review (Chapman et al., 2017;Srulovici & Drach-Zahavy, 2017).
Similarly, there are variations in nurse reporting of missed care based on experience and ethnicity, but not necessarily linked to specific patient outcomes (Blackman et al., 2015). In summary, the research on missed care remains inconclusive in terms of mortality, adverse events or failure to maintain but does suggest a correlation between patient outcomes and nursing omissions. The variety of papers identified in this rapid review also point to missed care being a global phenomena.

| CON CLUS I ON: P OLI C Y IMPLI C ATI ON S
The majority of studies identify resource and staffing shortfalls as the primary cause of missed care (Schubert et al., 2012). Research demonstrating the relationship between patient morbidity and mortality as a result of nurse staffing levels is now over twenty years in the making (Aiken et al., 2002). Despite this, the evidence on what nurse staffing levels should be remains elusive. As a consequence, policy has moved in two direction, particularly in the Anglo countries of the UK, USA, New Zealand, Australia and Canada. The first has been attempts to see missed care as a managerial or motivational issue and to address the problem through ward-based re-designs (for example, Lean production systems (Attwood-Charles & Babb, 2017), projects aimed at enhancing nurse compassion (O'Driscoll et al., 2017) or to go back to the fundamental of nursing care (Kitson et al., 2014)).

| Limitations and implications
There are two major methodological limitations in this rapid review. Rapid reviews are a limited approach to compiling the available evidence on a topic. They are performed quickly, may limit the parameters of the search and protocols employed and as a consequence risk missing important studies. For example, this rapid review omits a number of studies from countries that have produced significant work, for example Cyprus (Papastavrou et al., 2014) and focuses on Asia/Oceania. This reflects the first author's interest, and a desire to demonstrate the spread of the phenomena beyond Europe and the USA and to illustrate that no matter what healthcare systems are in place, nursing care is missed. Secondly, the copious research conducted on missed care, particularly over the last 4 years has raised a number of problematic issues (Vincelette et al., 2019). The first is the way the research data is gathered. The majority of studies ask for nurse's subjective observations of missed care, either during the last shift, or the last week (Kalisch et al., 2009), and all assume that the tasks are the sole responsibility of nurses. Little research has tested rates of missed care through ethnographic observations (Lake et al., 2016), or through recognized forms of documentation (Tesoro et al., 2018).
Alternative research approaches may provide a more reliable evidence base than nurses subjective records. Further, hospitals are staffed with more than nurses, yet little research has explored the impact other health professionals, such as the medical or allied health staff, may or may not have on rationed care.