Antecedents of unfinished nursing care: a systematic review of the literature

Abstract

Background

Unfinished Nursing Care (UNC) concept, that express the condition when nurses are forced to delay or omit required nursing care, has been largely investigated as tasks left undone, missed care, and implicit rationing of nursing care. However, no summary of the available evidence regarding UNC antecedents has been published. The aim of this study is to identify and summarise antecedents of UNC as documented in primary studies to date.

Methods

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, CINAHL, SCOPUS, and PROSPERO databases were searched for quantitative studies reporting the relationships between antecedents and UNC published after 2004 up to 21 January 2020. The reference lists of secondary studies have been scrutinised to identify additional studies. Two reviewers independently identified studies and evaluated them for their eligibility and disagreements were resolved by the research team. The quality appraisal was based on the Joanna Briggs Institute Critical Appraisal tools, according to the study designs. A data extraction grid was piloted and then used to extract data. The antecedents that emerged were thematically categorised with an inductive approach.

Results

Fifty-eight studies were included; among them, 54 were cross-sectional, three were cohort studies, and one was a quasi-experimental study. They were conducted mainly in the United States and in hospital settings. The UNC antecedents have been investigated to date at the (a) unit (e.g., workloads, non-nursing tasks), (b) nurse (e.g., age, gender), and (c) patient levels (clinical instability).

Conclusions

At the unit level, it is highly recommended to provide an adequate staff level, strategies to deal with unpredictable workloads, and to promote good practice environments to reduce or minimise UNC. By contrast, at the nurse and patient levels, there were no clear trends regarding modifiable factors that could decrease the occurrence of UNC. The map of antecedents that emerged can be used to design interventional studies aimed at changing research from merely descriptive to that which evaluates the effectiveness of interventions.

Background

Unfinished Nursing Care (UNC) is an overarching term encompassing several concepts [1] that express the condition when nurses are forced to delay or omit required nursing care [2]. The various concepts included in UNC have been largely conceptualised both theoretically [3, 4] and empirically by validating instruments measuring the occurrence of the phenomenon, namely the Tasks Left Undone Scale [5], the Basel Extent of Rationing of Nursing Care instrument [3], the MISSCARE Survey [6], and the Perceived Implicit Rationing of Nursing Care survey instrument [7]. Moreover, several studies have established outcomes associated with UNC both at the patient (e.g., falls, hospital-acquired infections, pressure ulcers) and at the nurse level (e.g., job satisfaction, intention to leave) [8, 9]. However, to inform decisions regarding which interventions should be implemented to minimise and/or reduce UNC [10], more studies about UNC antecedents have been recommended [11]. Above all, sound systematizations of the available evidence base on factors contributing to providing high quality nursing care or posing barriers in providing the care needed for sha** and optimizing nursing care are need. Despite the impetus reported in this research area [12], no summary of the available evidence about UNC antecedents has been produced to date: therefore, the primary intent of this study was to fill this gap.

Antecedents of unfinished nursing care

Within the overarching UNC term [1], there are three main concepts: Tasks Left Undone, Missed Nursing Care, and Implicit Rationing of Nursing Care. Tasks Left Undone was first conceptualised by Solchalski in 2004 [4], defined it as activities left unfinished during the last shift because nurses lacked the time to undertake them. In this context, nurse workloads and time constrains were both considered antecedents; however, specific factors triggering or hindering tasks left undone were not conceptualized [4].

A few years later, Kalisch [13] introduced the concept of Missed Nursing Care as every aspect of nursing care required by a patient that is partly or totally omitted or significantly delayed. In the first theoretical model, four elements at the nurse level were related to Missed Nursing Care: team norms, decision-making processes, internal values and beliefs, and habits [14]. In the same year, Kalisch and Williams [6] developed the MISSCARE survey to measure Missed Nursing Care. This instrument also includes a set of other reasons of missed care as perceived by nurses, namely deficiencies in communication, material resources, and labour resources. A few years later, Kalisch and ** the impact of patient and public involvement on health and social care research: a systematic review. Health Expect. 2014;17:637–50. https://doi.org/10.1111/j.1369-7625.2012.00795.x ." href="/article/10.1186/s12912-022-00890-6#ref-CR87" id="ref-link-section-d86321051e11102">87].

The study designs were largely cross-sectional in nature, with mainly convenience samples and a great variance in the participation rates, that all might have introduced biases in the evaluation of both antecedents and the UNC occurrence. In addition, antecedents and UNC occurrence have been largely measured at the same time point, thus assuming that the former has influenced the latter whereas control variables and/or confounding factors (e.g., the overtime, as paid or not) were not investigated. These issues have been reported also by Griffiths et al. [88] regarding the state of the art of the evidence about the nursing staffing and outcomes.

Longitudinal, pre- and post-study designs, or comparative studies are encouraged to increase the strength of evidence, by quantifying also the benefits of reducing/minimizing unfinished care and the costs, feasibility and long-term sustainability of implemented interventions. However, study designs should be considered in light of the complexity of the nursing care and the issue under study: UNC occurs in the real world of nursing across the world as a multifactorial phenomenon. Assessing precise antecedents might be difficult—moreover, designing interventional studies manipulating for example, the work environment, or the number of staff might be not feasible given the complexity of the turbulence of environments, and the challenges of the long-term implementation. Therefore, an in-depth discussion regarding the research issues in this field is required, analogously to that already developed in the context of nursing staffing and outcomes [88].

The antecedents of unfinished nursing care

Conceptual articles have highlighted that UNC is influenced by patient care demand, resource allocation, and relationship/communication issues [14] as well as by patient, organisational, nursing work environment, philosophy of care, and nurse variables [3]. In recent years, there has been a more comprehensive consideration of macro-, meso-, and micro-level factors by examining how upper-level management might affect clinical nurses and, consequently, UNC at the bedside [16]. However, according to the findings of this review, primary studies available to date appear to have investigated antecedents only at the unit, nurse, and patient levels. Therefore, despite a clear conceptualisation of the importance of the factors at the system level [16], empirical studies seem to have captured only a limited extent of factors with heterogeneous findings.

At the unit level, the staff adequacy as measured with different methods (e.g., workloads [40, 41, 44, 55, 68, 80] versus nurse-to-patient ratio [43, 51, 59, 65, 67, 69,70,71, 81, 82], using subjective or objective data) influences the occurrence of UNC. Moreover, other processes such as patients’ admissions and discharges or caring for patients with complex needs increase the occurrence of UNC, likely because they affect workloads in an unpredictable manner that requires a revision of staff dynamics and resource assignments [89]. On the other hand, performing non-nursing tasks [69, 80, 84] were documented to increase UNC as well as working overtime [11, 44, 57, 65]. Unfinished care might be triggered by the underuse of nurses, constrained to compensate for deficiencies in auxiliary resources thus leaving nursing care undone; conversely, unfinished care might be the consequence of the tiredness and reduced performance of nurses due to the amount of overtime work. A clear direction has not emerged regarding shifts (e.g., morning versus nights) and this might be due to the different patterns of both shifts (e.g., 12 h) and workloads established at the unit level. Specifically, those working morning shifts are required to deal with the high number of concentrated activities, while those working night shifts have few resources to meet care needs.

Within the unit level, the findings mainly reflect the structural variables [90] of the unit, with modifiable factors that might reduce or minimise UNC. These factors include adequate staff levels, preventing nurses from performing non-nursing tasks and working overtime, and implementing strategies to deal with the unpredictability of workloads for some shifts. The findings support the conceptualisation of Jones et al. [16] that factors affecting the occurrence of UNC can be considered in light of micro-economic theories as the efficient allocation of scarce resources to nursing care.

Several studies [8, 11, 29, 31, 38, 41, 44,45,46,47, 49, 52,53,54, 57, 59, 60, 62, 64, 66, 69, 71, 76, 77, 84] have concluded that a better work environment leads to a decrease in the UNC. Hence, promoting greater communication, better caring ethical climate, and respect among nurses and across health care professionals, all reduce or minimise the UNC. These factors, mainly reflecting the process variables of the unit [90], suggest that there is a need to invest in good practice environments for nurses, a strategy that can be developed by nurse managers but requires profound support from the entire system and education to work together effectively. Indeed, the findings that emerged regarding Magnet hospitals [48] and some hospitals/units (rural versus urban [11, 33], surgical versus medical [8, 47, 76]) can explain their capacity to minimise or reduce the UNC as work environments where nursing care is supported and valued.

Studies investigating the relationships between some individual characteristics of nurses (e.g., age, gender, and work experience) and the occurrence of UNC have mainly reported conflicting findings. Some authors also included variables that are not usually measured, such as the nurse’s personality and the country of origin [67, 73] and no trends in this dimension were detected. The interest in individual variables seems to be linked with the fact that the UNC has been investigated mainly as nurses’ perceptions; therefore, it is influenced by the profile of the nurse. However, apart from some antecedents (e.g., education), most of them appear to be unmodifiable, thus suggesting that they should be considered by nurse managers while, for example, they compose shifts that mix different nurse profiles (e.g., age, gender, education). Conceptually, authors have emphasised that nurses’ experience [36,37,38, 41, 43, 57, 66, 71, 73, 75, 77], education [11, 32, 91]. This reflection might also explain why nurses perceive more UNC [38, 43] compared with nurse’s aides suggesting that in studies investigating the unfinished care perceived, a stratification of the responders according to their educational level, is required. Additionally, some of the nurse variables that have been investigated seem to play a dual role as antecedents and as consequences of UNC. For example, decreased professional satisfaction levels [33, 35, 40, 54, 84, 85] might lead to increase the unfinished care but also might be a consequence of the UNC, as reported in conceptual models [

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].