The nurse’s experience of decision‐making processes in missed nursing care: A qualitative study

Abstract

Aims To explore nurses’ perspectives regarding the decision‐making processes that lead to missed nursing care and to identify the personal and contextual attributes involved in these processes. Design A qualitative study was undertaken between April – October 2018. Methods A total of 28 registered nurses working in different wards in hospital settings participated in nine focus groups with semi‐structured interviews. An interview guide encouraged nurses to share perceptions of missed care and the personal and contextual attributes shaping their decision‐making. Results Content analysis revealed three themes related to nurses’ decision‐making processes for whether to omit or delay care. First, nurses emphasized the role of nurses’ agency, suggesting explicit or implicit rationing of care, regardless of scarce resources. Second, nurses distinguished between two modes of thinking that they labelled “automated thinking,” activated in routine situations and “effortful thinking,” initiated in more novel situations. Finally, nurses identified situational factors triggering fluctuations in their awareness such as task type, difficult patients and the presence of relatives and the head nurse. Conclusions Nurses are aware of the processes guiding a decision to omit or delay care. They pointed to patient, nurse and ward conditions that serve as cues in their decision whether to miss care. Identifying these cues supports Hammond's cognitive continuum theory of decision‐making and may serve in the development of training programmes for nurses aimed at limiting the phenomenon. Impact The study addressed missed nursing care through a decision‐making lens. The findings pointed to nurses’ agency as shaping decisions about whether to miss care and identified the personal and contextual cues that guide nurses’ decisions. These findings call for organizational training programmes encouraging nurses to identify barriers and facilitators of missed nursing care and how to overcome them.

Causes of Missed Nursing Care During COVID-19 Pandemic: A Qualitative Study in Iran

“…Also, another study conducted in Iran in 2018 mentioned that delays in accessing prescribed medications during one shift lead to prescribing medications in the next shift ( 18 ). Abdelhadi et al also admitted that nurses delayed care they thought was urgent ( 38 ).…”

Fast thinking: How unconscious bias and binary language contribute to rationing of care to older persons

“…It is well understood that within hospital environments, nurses often face short staffing and pressure to be efficient as result of cost containment (Cho et al, 2018;Griffiths et al, 2019Griffiths et al, , 2021Suhonen et al, 2018). Hospital contexts are ever changing, chaotic, fast paced, with complex challenges (Abdelhadi et al, 2020;Bjork & Hamilton, 2011;Krishnam, 2018;Muntean, 2012;Thompson et al, 2013). Thus, it would follow that to survive shift by shift, nurses must rely heavily on fast thinking, with little time provided to engage in slow, critically reflective thinking.…”

“…Care rationing is doing good enough to get through the shift with a workload perceived as unwieldy. Abdelhadi et al (2020) identified three themes influencing missed nursing care: the role of the nurses' agency in explicit/implicit rationing; automated thinking in routine situations with effort thinking reserved for more novel situation; and situational triggers, such as difficult tasks, patients perceived as difficult or, the presence of others such as patient family or an authority figure such as a head nurse. This parallels Kahneman's (2011) explanation of how fast thinking is used predominantly in routine situations and slow critical thinking is reserved for new or challenging situations.…”

“…Thompson et al (2013) cautions that nurses can become over confident in decisions they make based on what they believe to be intuitively correct. Scholars agree that the clinical context for front‐line hospital nurses are noisy, full of complexity and interruptions, ever changing, with time pressures and demands from others sources such as concerned families or managers (Abdelhadi et al, 2020; Bjork & Hamilton, 2011; Krishnam, 2018; Muntean, 2012; Thompson et al, 2013). We assert that decision‐making in this kind of environment can lead to overreliance on intuitive fast thinking, with little opportunity for more intentional, critically reflective and effortful slow thinking.…”

Commentary: Missed nursing care and complexity theory: a conceptual paper

“…Indeed Kalisch et al.’s (2009) own widely cited concept analysis of MNC indicates that the antecedents to MNC involve workforce, resources, communication and teamwork, which are then coupled with elements of the nursing process and the internal perceptions and values of the nurse. More recent work echoes this complexity, whether they are exploring prevalence and predictors of MNC (Jones et al., 2015) or qualitative work examining the contribution of nurses’ decision-making processes to MNC (Abdelhadi et al., 2020) or the role of effective leadership and supportive relationships being central to the influence of nurse managers on MNC (McCauley et al., 2020).…”