What underlying priority criteria influence which nursing activities get left unfinished? Findings from a national mixed methods study

doi:10.21203/rs.3.rs-5238101/v1

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Research Article

What underlying priority criteria influence which nursing activities get left unfinished? Findings from a national mixed methods study

https://doi.org/10.21203/rs.3.rs-5238101/v1

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Background: Priority setting is the act of classifying immediate actions versus what can be delayed until a later time; thus, some activities get left unfinished. Although several factors that increase or minimize the occurrence of unfinished nursing care (UNC) have been documented, the reasons why nurses decide to provide one intervention instead of another are still under-investigated. Expanding the knowledge regarding priority criteria adopted by nurses may help nurse managers provide support to clinical nurses and address and develop their competencies to set priorities, with the ultimate intent to minimize UNC episodes.

Methods: A mixed methods sequential explanatory design according to the Good Reporting of A Mixed Methods Study was conducted. The quantitative phase consisted of a national survey of 15 hospitals, 110 units, and 1,977 nurses invited to fill in the Unfinished Nursing Care Survey (from 1 ‘never unfinished’ to 5 ‘always unfinished’). A subsequent qualitative phase involved focus groups with nurses identified from hospitals with high, medium, and low UNC occurrence, which were revealed in the quantitative phase. A joint technique displayed where qualitative findings were used to explain which UNC patterns were adopted.

Results: A total of 1,400 nurses (70.8%) reported UNC ranging from 1.92 out of 5 (SD = 0.31) to 2.48 (SD = 0.32). Four priority criteria emerged: (1) “addressing biomedical needs”; (2) “physician expectations come first”; (3) “signing for/audited activities”; and (4) “it depends; there are absolute and relative priorities”. Data integration showed a thematic association that confirmed prioritization criteria underlying the pattern of UNC coherent with the elements of care mostly withheld in daily practice by nurses.

Conclusions: Overall, two priority criteria were based on biomedical patient needs and physician-centric workflow expectations: one pertained to organizational expectations and rules, and only one pertained to nursing as a discipline. Nurse managers are in the best position to foster organizational excellence not only by addressing the underlying causes of time scarcity and UNC, but also by creating supportive work environments that empower nurses to prioritize activities linked with the scope of their discipline.

priority setting

unfinished nursing care

missed nursing care

decision-making

mixed methods

Three main terms that represent three different approaches [1] have been used to examine the experiences of clinical nurses who face the challenges of providing all the care needed by patients, which means some tasks get omitted or delayed, including task undone (TU) [2], implicit rationing (IR) [3, 4], and missed care (MC) [5, 6]. The phenomenon of unfinished nursing care (UNC) has been investigated for the last 20 years, with increasing attention over the last 10, mainly per its occurrence and less for its underlying reasons [7]. According to the MC theoretical model [5], omissions or delays in care may occur at any stage of the nursing process and may be influenced by both external and internal factors.

The way nurses carry out the nursing process depends on factors within the care environment that facilitate or inhibit the practice of nursing, such as demands for patient care, resource allocation, and professional relationships. However, the choice of nurses to complete, delay, or omit activities of care is additionally influenced by internal processes like team norms, decision-making habits, and values, attitudes, and beliefs that nurses perceive about their roles and responsibilities [5]. Although several factors which increase or minimize the occurrence of UNC have been documented, the reasons why nurses decide to provide one intervention instead of another are still under-investigated [8, 9]. Expanding the knowledge in this area may help nurse managers provide support to clinical nurses and address and develop their competencies to set priorities through supervision, education, and critical analysis of daily practice, with the ultimate intent to minimize UNC episodes.

There exists a sequential nature in nursing actions, and sequence matters in terms of maximizing the benefits for patients. Hendry and Walker defined priority setting as the process of classification of problems and concerns into those requiring immediate actions and responses versus those that can be delayed, using knowledge of urgency and/or importance to establish a preferential order for nursing actions [10]. When resources are scarce (e.g., low staffing levels, poor skill mix, reduced time, poor practice environments), the priority setting process changes: The act of establishing a preferential sequence for care activities includes the act of withholding care activities. Although the original intent of prioritization decisions may be to sequence care, an unintentional consequence of these decisions can be care left undone [8].

Nurses must synthesize large amounts of information daily and think through complex and often emergent clinical situations to make critical decisions about patient care, including the delegation of some aspects of care to other registered nurses (RNs) and unlicensed personnel [11]. The nature of nursing care is to deal with uncertainty, and decision-making is particularly challenging because nursing work is characterized by unpredictability: Critical thinking and decision-making are complicated by the fact that nurses care for multiple patients within environments that are fast-paced and change on a minute-by-minute basis [9, 12, 13]. The combination of a rise in care demand caused by the pandemic [14] and a nursing workforce shortage [15] has increased the work intensification occurring in healthcare settings.

The issue of a health workforce shortage, especially nurses, has been widely debated [16, 17] and exacerbated by the global financial crisis followed by the current COVID-19 pandemic [18]. Economic downturns have impacted all sectors of the economy, including healthcare; therefore, nurses, being the largest professional group in the healthcare sector, have been strongly affected by budget-balancing attempts [19]. The gap in the optimal level of nursing workforce was described in a recent publication on the future of the Italian National Health System, reporting a deficit of nurses ranging from 200,000 to 300,000 professionals, if compared with other European standards [20]. To ensure patients’ needs, it is necessary to combine the revision of staff levels and care models with the creation of an enabling environment where nurses have skills to establish priorities.

As a consequence, deepening the knowledge available regarding how nurses decide priorities is important: On one hand, it is inevitable, given the progressive shortage of nurses and its dramatic increase [21]; conversely, its impact on the quality of care and patient outcomes is undeniable. Prioritizing assessed care needs and dealing with conflicting expectations or urgency of needs, also including that of patients, may increase the risk of adverse patient outcomes, threatening patient safety and challenging nurses’ professional and moral values [13]. Available conceptual models suggest that multiple factors influence this prioritization [5]; however, only quantitative evidence pertaining to how nurses prioritize care in response to time scarcity has been provided to date [1], while studies concerning the underlying criteria or factors influencing such decisions have been produced to a limited extent [22]. Understanding nurses’ prioritization processes should help in the development of strategies to guide them, especially when no alternative exists, to prioritize necessary care in a way that minimizes negative impacts on patients [23]. Above all, this may support nurse leaders at the unit level to effectively allocate resources, manage staff workloads, and ensure that critical nursing activities are completed, ultimately improving patient outcomes and overall care quality.

The aim of this study was to explore the priority criteria adopted by nurses in daily practice that influence reported patterns of UNC.

4.1 Study design

To date, the applied methodologies in the UNC research field have relied on quantitative or qualitative approaches to answer separate research questions (e.g., amount of UNC; prioritization processes) by using a single research paradigm [9, 24]. Moreover, quantitative approaches have predominated, suggesting we lack a full understanding of the complexity of the phenomenon under study. Therefore, to overcome the limitations of the methodologies in this field, with the purpose of initiating a different course of research more closely aligned to the complexity of the UNC phenomenon by also incorporating the flexibility allowed by the qualitative exploration, a sequential explanatory mixed-methods study design [25] was implemented. For the aim of this study design, both a cross-sectional survey and a qualitative descriptive study [26] were conducted.

Regarding the sequence, priority, and project’s integration [25], this study was based on the following characteristics:

Sequence: A quantitative method was applied first to measure the occurrence of UNC, followed by a qualitative method aimed at understanding the criteria that nurses use to set priorities in daily practice.
Priority: The qualitative method assumed a dominant status in terms of weight (quan, QUAL) [25].
Integration: As a sequential explanatory design, data collected in the consecutive phases were connected through an intermediate step where the findings of the first quantitative phase informed the data collection of the second phase [27].

Methods and findings will be reported here according to the Good Reporting of A Mixed Methods Study [28], as summarized in Supplementary Table 1.

4.2 Phase 1 – Quantitative

4.2.1 Settings and participants

Fifteen Italian hospitals, geographically spread from north to south, were invited to participate by the Italian Nurse Directors’ Association. All voluntarily accepted to participate: three in the north, eight in the centre, and the remaining two in the south. Among them, seven were teaching hospitals. All medical-surgical units (110) were included in this study: RNs with clinical responsibilities, with more than 3 months of experience, and working full- or part-time with job contracts exceeding 50%, were invited to participate in our initial survey. Therefore, RNs not involved in direct patient care, as well as nursing students and newly hired nurses with < 3 months of experience, were excluded.

4.2.2 Data collection instrument and process

UNC occurrence was measured with the Unfinished Nursing Care Survey (UNCS) [29] composed of Part A (elements of UNC) and Part B (reasons for UNC) with 21 and 18 items, respectively. Specifically, for the purposes of this study, only Part A was used where participants were asked to rank each item using a 5-point Likert scale, from 1 ‘never unfinished’ to 5 ‘always unfinished’. The UNCS has shown high acceptability (> 90%); regarding the Mokken scale, Part A has shown strong scalability (Loevinger H coefficient = .52), thus suggesting a hierarchical structure among the items. Moreover, Part A has shown high reliability (Rho = .96) using the Rho coefficient, as expected in Mokken analysis [30].

All eligible RNs working in the 110 units were invited to complete an anonymous self-administered survey.

A total of 1,977 paper-and-pencil questionnaires were distributed by the contact person identified in each hospital and accompanied by a letter explaining the aims of the study and its procedures. For each question, RNs were asked to indicate the response that best described their clinical practice in the last 7 working days. Based on the pilot test, the estimated time for completion of the survey was 25–30 minutes. Completed questionnaires were dropped within 3 weeks into a closed box placed in the units; the contact person in each hospital provided reminders (two during the study period); the return of completed surveys was considered informed consent.

4.2.3 Data analysis

Descriptive statistics (frequencies, percentages; means, standard deviations [SDs]; or median and interquartile ranges) were used to describe the main characteristics of participants. Subsequently, the average and SDs of the overall UNCS scores at the hospital level and for each item were calculated. Statistical data analyses were performed with SPSS 24.00 software (Chicago, IL, USA).

4.3 Phase 2 – Qualitative

4.3.1 Settings and participants

According to the UNC framework [31], the occurrence of the phenomenon is linked to the efficient allocation of resources in a context of resource scarcity, whereas other elements, such as political, cultural, and ideological factors, may increase or hinder its occurrence. Therefore, settings and participants for the qualitative phase were identified according to the quantitative findings [25]. The overall UNCS score was used to identify hospitals with a high, medium, or low occurrence of UNC: Among the 15 hospitals, four were identified as high, seven as medium, and four as experiencing a low UNC prevalence. In each, a purposeful sample [32] of RNs was recruited with the collaboration of the nurse manager of each hospital. The eligible RNs where those who participated in the UNCS and were willing to participate. Six to 10 nurses from each hospital were expected to be involved [33].

4.3.2 Data collection

Three focus groups [34] were conducted. A written consent form was collected, and participants were informed that their confidentiality could only be protected if all individuals agreed to keep confidential the information shared within the group.

A semi-structured interview (Table 1) based on relevant literature [8, 35] was used. The first question was aimed at introducing the data and focusing participants’ attention; the second question focused on the prioritization process and on prompting the discussion; finally, follow-up questions were needed to elicit participants’ perception of the phenomenon, and a few questions investigated participants’ demographic and professional profile to ensure anonymity.

The principal investigator led the data collection with the support of an observer who did not intervene in the discussion and took notes of non-verbal communication among participants. Focus groups were conducted in a quiet environment that facilitated interactions among participants without any interruptions. Each group lasted, on average, 90 minutes; they were audio-recorded and then transcribed verbatim. To ensure dependability, quotes were extracted from each focus group and numbered progressively (i.e., FG1, FG2, FG3).

Table 1

Interview guide for conducting focus groups
Introductory phase: 1. This focus group relates to the data collected regarding unfinished nursing care. I will offer some overall findings [show the overall data, not specific to the units]. 2. Can you describe the overall context where UNC occurs in your unit? What are the main reasons, criteria, underlying factors (hereafter ‘criteria’) that trigger you to postpone or omit some nursing care intervention in your daily practice?
The core questions: 3. By deepening each specific decision to postpone or not some interventions, what are the elements of care that you consider more important to deliver than others? Please explain, and give some examples.
4. When you know you can’t get everything done, how do you decide what to do? How do you set priorities? Please provide some examples.
The ending questions: 5. Are there other criteria that affect your decision in prioritizing some elements of care in favour of others?
Note. UNC, unfinished nursing care.

4.3.3 Data analysis

Qualitative content analysis [36] was performed to understand the manifest nursing actions and latent content of the data by two researchers independently (EB, TJ), then supervised by a third researcher (AP). In the coding process, the words used by participants were kept preserving the original meanings, and the researchers did not use the frameworks available in the field [10] to ensure the flexibility needed to examine the phenomenon in its natural state.

Specifically, the following analytical steps were undertaken: (a) The transcriptions were read and re-read carefully by the researchers, and a first level of analysis was conducted by selecting those units of meaning; (b) then, each unit statement was initially coded independently and then via consensus among the researchers; finally, (c) the codes were categorized into themes and subthemes (also in this case, initially in an independent manner and then by common agreement), and a full description of themes and subthemes was also created through team discussion. Both quotations from the transcripts and the sources of the quotations are reported in the findings to support theme and subtheme credibility, indicating the focus group source (e.g., FG2).

To confirm the researchers’ interpretation, member checking [37] was accomplished by having three of the RNs initially involved in the focus groups meet again as a group; they were asked to review the codes and check if the findings represented the way they set priorities during their shifts. Specifically, one theme was identified – the context of daily care – and the second – the core theme that modulated the priorities in such a context.

4.3 Phase 3 – Qualitative and quantitative data integration

To draw out new insights beyond the information gained from the quantitative and qualitative results, an integration process was performed [38] that used the ‘explaining’ joint technique, where qualitative findings are used to explain the data collected in the quantitative phase [39]. UNC occurrence results and the themes which emerged from the focus groups were merged and integrated through a joint display: The qualitative data were combined and integrated with the quantitative data collected according (a) to the examples provided for each subtheme by the focus groups and their consistency with the 20 interventions included in the UNCS tool [29]. Initially, the columns regarding the occurrence of UNC with the mean score for each care intervention (sorted from most to least unfinished), as measured during the quantitative phase, were prepared by the researchers (see authors). Then, in the first round, the subthemes were analysed and connected to each intervention (e.g., the subtheme “addressing biomedical needs” was displayed nearby the care activity “record vital signs as planned") according to (a) the examples provided by the participants in the focus group and (b) their logical connection with the interventions (e.g., the subtheme “signing for/audited activities” was linked to the care activity “perform bedside glucose monitoring as prescribed”). In a second round, the weight of each subtheme (as influencing the priority to perform each intervention) was ranked by two researchers independently (EB, TJ) as high, moderate, or low. Therefore, for each intervention, the roles of specific priority criteria (i.e., the subthemes revealed in the qualitative phase) that influenced or not the priorities were established. Finally, a third round was performed. It included reaching common agreement and integrating the results in a joint display. To confirm the researchers’ interpretations, member checking [37] was performed with three of the RNs initially involved in the focus groups again as a group; the nurses were asked to review the codes and validate the findings.

4.4 Ethical issues

This research project was approved by the Ethics Committee of Ferrara University Hospital (number register 26, date: 16/02/2017). In both phases, namely, qualitative and quantitative, participation was voluntary, and no rewards were offered. Moreover, on a preliminarily fashion, all eligible were informed regarding the study aims and procedure and the following inclusion was started after having obtained the written informed consent by each. Data was collected and managed in accordance with the Declaration of Helsinki.

5.1 Phase 1 – Quantitative

Fifteen hospitals equipped with a range of 120–1,398 beds were involved. A total of 110 units, from two to 14 in each hospital, participated. Of the 1,977 RNs invited to participate, 1,400 (70.8%; 56–88.5% at the hospital level) returned the questionnaire. The respondents were mostly female (1,096; 78.3%) aged 35 to 54 years (857; 61.2%); some were university educated (777; 55.5%), and some had a nursing diploma (478; 41.3%). They were working in medical (616; 44%), surgical (610; 43.5%), or mixed units (66; 4.8%). Most participants reported more than 10 years of nursing experience (878; 62.7%), followed by those working for 2–10 years (477; 34%) and in their current unit (596; 42.7%). The average reported nurse-to-patient ratio was 1:14.44 (SD = 7.29). For additional data, see Supplementary Table 2.

At the overall level, the UNCS scores ranged from 1.92 (SD = 0.31) to 2.48 (SD = 0.32) across hospitals (Table 2). Furthermore, at the overall level, the most frequent UNC activities included mouth care (2.67 out of 5, often unfinished; 95% CI: 2.60–2.73), spending time with patients and their caregivers (2.54; 95% CI: 2.47–2.60), and supervising delegated activities (2.54; 95% CI: 2.48–2.60). The least frequent UNC activities included bedside glucose monitoring (1.60; 95% CI: 1.53–1.66), recording vital signs (1.61; 95% CI: 1.55–1.68), and completing a clinical handover (1.75; 95% CI: 1.68–1.81).

Table 2

Hospital profiles, participant nurses, and UNCS overall scores
Hospitals	Size	Units involved	RN participants	UNCS overall	SD
Hospitals	Beds	Number	Number (response rate %)	Scores^§
Hospital A	537	6	50 (84.0)	2.485	0.320
Hospital B	925	14	250 (56.0)	2.475	0.226
Hospital C	461	5	106 (78.3)	2.400	0.298
Hospital D	662	8	130 (66.9)	2.187	0.362
Hospital E	747	12	190 (64.7)	2.172	0.453
Hospital F	573	7	152 (71.7)	2.156	0.343
Hospital G	658	4	96 (85.4)	2.069	0.351
Hospital H	150	3	71 (57.7)	2.066	0.355
Hospital I	1,398	6	130 (69.2)	2.047	0.437
Hospital J	482	12	166 (77.1)	2.013	0.359
Hospital K	199	3	70 (65.7)	2.002	0.393
Hospital L	560	10	187 (70.1)	1.999	0.290
Hospital M	721	12	251 (75.7)	1.996	0.369
Hospital N	120	2	41 (75.6)	1.957	0.352
Hospital O	292	5	87 (88.5)	1.923	0.309
Note. Letters ‘A’ through ‘O’ represent anonymized names of the hospitals involved.

§ from 1 ‘never’ to 5 ‘always’ unfinished.

The data were analysed to categorize UNC occurrence as high, medium, or low, according to the overall scores as expressed in quartiles of UNC (quartile 3 [Q3] = high occurrence from 2.17 to above; Q2 = medium occurrence from 2.06 to 2.16; Q3 = low occurrence from 1 to 2.05, IQR = 0.179). These data were discussed with Nursing Services; three nurses, one per each level of occurrence, agreed to participate in the following qualitative phase.

5.2 Phase 2 – Qualitative

Twenty-seven RNs participated in the focus groups. They were all female, mostly educated at the bachelor’s level (20; 74.1%), and the remaining at the diploma level (7; 25.9%). They reported an average RN experience of 14.3 (SD = 9.1) years. At the time of the survey, they were working in medical-geriatric (19; 70.4%) or in surgical (8; 29.6%) units, either as a generalist or specialist. The average professional experience in the unit was 11.6 (SD = 9.1) years.

The criteria that informed priorities were summarized into one main theme, named “the rules of engagement”, reflecting the formal and informal criteria that the RNs used to guide priority decisions. Four subthemes emerged: (1) “addressing biomedical needs”; (2) “physician expectations come first”; (3) “signing for/audited activities – feeling obliged to do what we have to sign for”; and (4) “it depends; there are absolute and relative priorities, and human dignity counts”.

Regarding the first subtheme (“addressing biomedical needs”), the participants agreed about “medication first” or “first of all medications, unless there is something urgent”. RNs stated they had to give priority to the interventions driven by severity of illness or emergency. The urgency of the health problem and the medical treatment plan had the stronger impact on their clinical judgment, addressing the priorities given.

Medications first (FG1).

If then there is any urgency whatever, what you are doing comes second (FG2).

In addition, “physician expectations come first”, given that RNs’ roles and priorities were placed within a biomedical model where physicians were seen as the main decision-makers, addressing the priorities of the nurses. In this context, what doctors said or expected became a priority, even if it was not related to life-threatening situations:

Even the physicians influence the setting of priorities. If they give us things to do, they obviously become priorities (FG1).

Sometimes you don't sit patients in chairs. It is planned, but if there is no time, you can omit it because it's not an important thing that doctors care about (FG2).

In my opinion, this is something typical of my hospital, I mean, the idea that we must have reverence towards physicians (FG3).

As medical tasks must be done first, elements of care dealing with the relational, social, and emotional needs of the patients were described as dispensable add-ons, causing the nursing care provided to focus on a curative approach. Time and resource constraints further worsened the situation: RNs reported they faced difficulties in fulfilling their professional role and balancing the needs of individual patients, demands from the organization, and their personal values:

What I see is that, necessarily, the time we have is mostly dedicated to the priorities set by medical aspects managed by physicians (FG2).

All the nursing care aspects – therefore our own specific scope of practice that refers to the management of the nursing process through the care planning – is left out because of the workload and the lack of time (FG3).

Furthermore, interviewed RNs described the prioritization process as influenced by the likelihood that a missed activity would be noticed by others. In fact, according to the subtheme “signing for/audited activities – feeling obliged to do what we have to sign for”, participants often set priorities to complete the visible tasks first and the non-visible elements of nursing care dealing with relational needs at a later time. Also, among the visible tasks, priority was given to activities that were mandatory by law and could not be omitted or delayed to a subsequent shift, as the RNs had to sign after providing them (e.g., medications, device replacements):

The important thing is to give the pills, and then we must also sign off; we are "obliged" to have this priority … because the pill has to be signed for, the bed sheet replacement must not be signed off on anywhere (FG2).

The word exchange can't be signed (...). In my opinion, we put into the background care that should be given to the person (FG3).

Participants reported that the way they set priorities was also influenced by how nurse managers expected them to behave in terms of time management and compliance with routine schedules, which included dealing with bureaucracy (e.g., answering the phone, organizing patient transports to diagnostic procedures). These aspects, sometimes described by participants as “non-nursing tasks”, influenced the prioritizing process, creating an internal conflict between the RNs’ values and their perceptions of their role. RNs reported being ethically challenged by the prioritization of administrative tasks over those promoting emotional support and preserving human dignity:

We give priority to things that, in reality, in my opinion, do not take such priority (FG3).

However, according to some participants, “it depends. There are absolute and relative priorities and human dignity”, and deciding priorities was not a simple task, and there were no absolute priorities described. There were aspects unique to patients and situations, as those required to preserve the dignity of the person cared for. To establish priorities in the best way possible, the RNs had to combine a standard system of establishing priorities with an overview of each individual patient situation, like navigating a hierarchy within a hierarchy. Setting priorities was seen not only as involving a rigid list of problems, but as including a dynamic inventory that should take account of the patient as a whole person:

So, the priorities are very relative ... I mean, it depends (FG1).

The right priority depends on the patient and on the moment (FG2).

For example, managing incontinence and providing personal hygiene can become a priority because of its connection with human dignity and the prevention of skin ulcers or healthcare related infections:

We care for totally dependent and elderly [people], many with incontinence. I cannot leave them dirty, I mean, personally, I cannot do it (FG1).

If that patient has called me for 2 hours, I cannot leave him dirty because I know the next colleague will go there 2 hours after her arrival; then, he will remain dirty for 4 hours ... there's ulcer risk and … oh ... human decency! (FG1).

Sometimes patients say, "I'm dirty. I do not want to use non-invasive ventilation [NIV] if I'm dirty". If they are confused or becoming unconscious, I force them to use the respiratory support because it's a treatment. I understand them – old people who are dirty ... otherwise, if a patient has done the NIV all night long and his respiratory parameters are not too bad, I give priority to hygiene care. I can understand him, poor man (FG2).

5.3 Integration of the quantitative and qualitative results

After integration of the data, a thematic association allows one to explain the underlying criteria concerning priorities. As reported in the joint display (Table 3), those activities more likely to satisfy some criteria for prioritization were less frequently unfinished. For example, bedside glucose monitoring and recording vital signs were not left undone because they represented biomedical needs, and they were both influenced by audit effect and physician expectations.

In contrast, care activities less likely to satisfy the reported criteria for prioritization were left undone the most (e.g., mouth care; spending time with patients). When the subtheme “it depends” was considered, the thematic association between the prioritization process and the withheld nursing activities changed in pattern. In this context, RNs balanced a standard system of establishing priorities with the desire to protect patient dignity. This mechanism highlighted a hierarchy within the hierarchy: Providing personal hygiene and managing incontinence was one of the least frequent UNC activities, even if it was not affected by audit effect or physician expectations.

Table 3

Integration of the quantitative and qualitative results
Overall mean score§	95% CI	Interventions as measured with the UNCS tool (Bassi et al., 2020)	Rules of engagement
Overall mean score§	95% CI		Biomedical needs	Physicians’ expectations	Signed for/audited activities	“Depends” (human Dignity)
2.67	2.60–2.73	Provide mouth care to patients who need it	Moderate	Low	Low	Moderate
2.54	2.47–2.60	Spend time with patients and their caregivers	Low	Low	Low	High
2.54	2.48–2.60	Supervise the tasks assigned to the nurse aides	Low	Low	Low	Low
2.47	2.41–2.53	Communicate with patients and caregivers	Low	Low	Low	High
2.45	2.39–2.51	Involve patients and caregivers in discharge planning	Low	Low	Low	Moderate
2.42	2.35–2.48	Ensure patients' comfort (microclimate, patient positioning)	Moderate	Low	Low	Moderate
2.37	2.31–2.44	Teach patients and caregivers how to self-care at home	Moderate	Low	Low	Moderate
2.31	2.24–2.37	Assess the effectiveness of the care provided (e.g., reviewing if nursing care needs have been met)	Moderate	Low	Low	Moderate
2.10	2.04–2.16	Prevent negative outcomes for patients at risk (e.g., falls, pressure ulcers, malnutrition)	High	Moderate	Moderate	Moderate
2.16	2.09–2.22	Properly document the interventions provided and the revision of the care plan	Moderate	Moderate	High	Low
2.13	2.07–2.20	Respond promptly to patients' calls (within 5 minutes)	High	Moderate	Moderate	Moderate
2.02	1.96–2.08	Perform physical assessment (e.g., skin integrity, invasive device insertion site)	Moderate	Moderate	Moderate	Low
1.94	1.88–2.01	Prevent healthcare associated infections, adopting good clinical practice (e.g., hand hygiene between patients, closed urinary drainage system)	High	Moderate	Moderate	Low
1.94	1.88–2.01	Check pressure ulcers and change dressing according to protocols	Moderate	Moderate	High	Moderate
1.91	1.84–1.97	Monitor pain as planned	High	High	High	High
1.88	1.81–1.94	Monitor administered drug effects	High	High	High	Low
1.85	1.79–1.91	Administer PRN medications within 15 minutes of the patient's request	High	High	High	Low
1.78	1.71–1.85	Provide personal hygiene to patients who need it	Moderate	Low	High	High
1.75	1.68–1.81	Perform clinical handover to adequately inform the next shift nursing team about patients' conditions	High	Moderate	High	Low
1.61	1.55–1.68	Record vital signs as planned	High	High	High	Low
1.60	1.53–1.66	Perform bedside glucose monitoring as prescribed	High	High	High	Low
Note. Abbreviations: CI, confidence interval; UNC, unfinished nursing care; UNCS, the Unfinished Nursing Care Survey; PRN, pro re nata (from Latin, ‘as needed’).

§ from 1 ‘never’ to 5 ‘always’ unfinished.

The aim of this study was to explain the underlying criteria used by RNs when they establish priorities that affect UNC. Past studies had used qualitative or qualitative methods and provided evidence that produced no agreed frameworks capable of assisting nurses in making decisions about priorities of care in all situations [10]. The knowledge is limited, and very few attempted to use data drawn from a national survey combined with qualitative data [40, 41], which was our aim. Moreover, updating the evidence available may inform nurse managers regarding the strategies that can be best used to help clinic nurses make decisions on appropriate criteria, and to address their education and supervision with the ultimate goal to minimize UNC occurrence.

First, our quantitative findings had some variation in UNC occurrence across the same National Health Service, suggesting that continuing to investigate the occurrence, also as a source of benchmark data, would be valuable. Only by comparing similar units and hospitals with respect to their performance is it possible to improve strategies to minimize missed care and, ultimately, to improve quality of care [42]. In this context, nurse managers may play an important role, given they are often faced with major determinants of UNC like human resource shortages, communication issues within teams, and priority setting skills [43]. However, overall, our quantitative findings are in line with the international data documented to date [44].

Second, our qualitative findings suggested four different underlying criteria: two based on biomedical patient needs and physician-centric workflow expectations, one related to organizational expectations and rules, and only one connected with nursing as a discipline. Similarly to previous literature [40, 41], activities related to biomedical needs took initial priority, and this could affect the time devoted to emotional support or basic care. The prioritization of physiologic needs above emotional and psychological needs is consistent with Maslow's universal hierarchy of human needs, often taught during undergraduate education: Therefore, it is reasonable that nurses applied what they were taught. Although this may be considered a plausible and logical pattern, caution has been suggested in using Maslow's framework during nursing because it fails to recognize the individuality of each person and could be inappropriate for professionals who espouse a philosophy in which each person is valued as an individual [10].

The prioritization process was also influenced by physicians’ hierarchical role and expectations: This suggested a still-present hierarchy, even if nurses are considered as independent entities in establishing priorities. Previous authors [41, 45] reported similar findings, suggesting that nurses play a guarantor role in several medical prescriptions and therefore they prioritize related activities; on the other hand, this may suggest deficits in nurses’ perceived confidence to be independent professionals [46]. Therefore, promoting independence to effectively execute autonomous time-use decisions in accordance with established schedules, policies, and, as in this case, physician-centric workflow expectations is suggested [47].

Another prioritization criterion emerged in relation to the audit effect, concerning those care activities routinely audited, formally or informally, by employers, regulatory staff, or other members of care teams versus unaudited care activities that are scheduled as first [8]. Our nurses claimed to feel a sort of obligation to prioritize what they had to sign for, like administering medications or replacing devices. The timely completion of these activities “in the spotlight” was subject to audits or questions by peers, doctors, or hospital administration. This audit effect has also been reported in previous research [12, 23, 45, 48], describing a higher prevalence of UNC in areas where the impact was not likely to be immediately noticed by others, like during emotional support or patient education. The nurses also described their daily prioritizing experience at bedsides as including concurrent actions where what had to be done first “depends on the patient and the situation”. Their daily struggles in finding a balance between a standard system of priority setting and the evaluation of each individual patient situation, for example in the management of incontinence and the provision of personal hygiene, emerged. Regarding scarcity of time, basic care was often left undone, but not incontinence management because of its connection to human dignity and the prevention of skin ulcers or healthcare-related infections. Our focus group participants emphasized the difference in terms of priorities between routine hygiene (refreshing) and interventional/therapeutic hygiene (care for faecal/urinary incontinence) as reported in the literature [49]. Routine hygiene could be delayed or unfinished; conversely, incontinence management was a priority that competed with medical treatments in the hierarchy of what could not be left undone. Similarly to what emerged from previous studies [13], the nurses attempted to prioritize nursing care with the aim of meeting all the needs of their patients in a holistic and comprehensive manner. The participants felt forced to choose between different but equally important patient needs like cure (the first two criteria), safety (audit/signatures), and dignity. Although the nurses often gave priority to medical treatments or tests, their efforts to find the time to ensure activities related to the patients’ individual needs and reflected their attempts to fulfil their professional/ethical role and to feel less morally distressed. However, education or emotional support – even if strongly connected with patient dignity – was among the most frequent UNC. This was probably due to the fact that the time needed for some activities (e.g., patient hygiene) could be more accurately estimated than that needed for emotional support [23]. When nurses enter a patient room and start talking, offering patients emotional support, they cannot estimate how long it will take as accurately as, for example, when administering drugs or changing wound dressings. Activities like communication and education cannot be provided in an abbreviated or fast form necessarily: They indeed require an active involvement of the patients and cannot be done without giving the patients time to express their feelings or to understand what they are hearing.

In line with the underlying criteria revealed in this study, the most frequently unfinished elements of care, measured with the UNCS, were basic care (mouth care, patient positioning), emotional support, patient education, and care supervision. In contrast, activities in the following categories were among the least frequently unfinished: medication administration, tests, vital signs and pain monitoring, patient hygiene, and clinical handover. Many of these findings cohere with the prior evidence about task completion during time scarcity [1, 13, 41, 50]. Moderating the external expectations (medical, organizational) and giving the right emphasis to those priorities directly linked with the nursing discipline require a strong professional identity, support, courage, as well as knowledge and experience [10, 51, 52, 53]. Nurses’ educational and experiential factors may directly or indirectly affect how they prioritize their tasks, together with the availability of time and other resources (e.g., staffing levels); moreover, the philosophy of their organization, which might be shaped by nurse managers, can make a significant difference.

6.1 Study limitations

This study had several limitations. First, our quantitative data collection per UNC occurrence was performed with a retrospective survey based upon nurses’ self-reports. All the tools now available include an inventory of nursing activities in which nurse respondents are required to rate the perceived frequency of each activity left undone; a transition towards objective measures of the phenomenon would be preferable [22], however. Moreover, our qualitative data were used to explain the priority process after a national survey. Although this seems to be unique in the landscape of UNC research [22], the time that elapsed from the quantitative data collection to the focus groups may have changed some patterns in the decision-making process and thus affected the findings. Furthermore, our qualitative phase involved three hospitals and related RNs, according to the occurrence of UNC; however, future research should consider collecting data simultaneously and in all settings to gain insights into the different patterns of priorities that may be influenced by local culture. Finally, the integration of data was performed by researchers (see authors), and no member checking was performed by involving, for example, focus group participants.

The nurses set priorities according to four criteria (1): “addressing biomedical needs”; (2) “physician expectations come first”; (3) “signing for/audited activities”; and (4) “it depends; there are absolute and relative priorities”. Overall, two criteria were based on biomedical needs and physician-centric workflow expectations, one on the organization expectations and rules, and only one on nursing as a discipline. The revealed prioritization criteria left patients particularly vulnerable to unmet emotional and educational needs and may have exposed nurses to moral distress related to the distance between their ideals regarding nursing care and their daily practices.

The nurses’ decisions were influenced by the necessity to meet expectations of dominant group members (physicians, organizational leaders) rather than individual patient needs. To provide individualized care, dominant group expectations should be balanced with individual autonomy, and nurses should improve their skills in negotiating their time for caring.

Overall, our findings underscore the critical role of effective leadership in fostering organizational excellence, not only by addressing the underlying causes of time scarcity and UNC, but also by creating supportive work environments that empower nurses to prioritize activities linked with the scope of their discipline. Future research is also needed to assess the effectiveness of different strategies aimed at making decisions based on priorities capable of enhancing the quality of patient experiences within nursing care.

Focus Group

Implicit Rationing

Missed Care

Quartile

Registered Nurse

Standard Deviation

Task Undone

UNC

Unfinished Nursing Care

Ethics approval and consent to participate

This research project was approved by the Ethics Committee of Ferrara University Hospital (26/16/02/2017).

Consent for publication

Not applicable.

Clinical trial number

not applicable

Consent to Participate declaration in the manuscript:

Every human participant has provided his/her written consent to participate.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors declare that they have no funding.

Authors' contributions

EB, AP and DT conceived and designed the study. EB and DT coordinated the data collection. EB, TJ and AP analyzed the data. EB, SC, ADM and AP drafted the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgements

The authors thank the nurse directors of the participating hospitals and all the nurses who participated in the focus groups for their contribution to this research.

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No competing interests reported.

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What underlying priority criteria influence which nursing activities get left unfinished? Findings from a national mixed methods study

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Abstract

1. INTRODUCTION

2. BACKGROUND

3. AIM

4. METHODS

4.1 Study design

4.2 Phase 1 – Quantitative

4.2.1 Settings and participants

4.2.2 Data collection instrument and process

4.2.3 Data analysis

4.3 Phase 2 – Qualitative

4.3.1 Settings and participants

4.3.2 Data collection

4.3.3 Data analysis

4.3 Phase 3 – Qualitative and quantitative data integration

4.4 Ethical issues

5. RESULTS

5.1 Phase 1 – Quantitative

5.2 Phase 2 – Qualitative

5.3 Integration of the quantitative and qualitative results

6. DISCUSSION

6.1 Study limitations

7. CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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