Title Missed Nursing Care and Its Associated Factors: An Integrative Review

Background: Nursing care is a fundamental pillar of services provided to individuals in medical centers. Missed nursing care refers to care that nurses do not provide or fail to provide under certain circumstances. This review study aims to identify the factors contributing to the omission of nursing care from the perspective of nurses and propose solutions to prevent it. Objective: This review study addresses missed nursing care and the factors related to it. Method: In this comprehensive review study, the keyword "nursing care" was used to search the Farsi databases of Magiran and Civilica. Additionally, the MeSH section of the PubMed website was used to find keywords for searching international databases, including Wiley, Google Scholar, ScienceDirect, and PubMed . Results: In the primary keyword search, irrelevant articles and those without full text were removed from the initial 69 articles. Finally, 43 selected articles were approved. Among the 24 studies available in the findings section from 2014 to 2023, it was shown that neglecting nursing care has been a constant issue throughout history, exacerbated by the increase in the number of patients and the lack of personnel. This neglect endangers patient safety. The findings of the reviewed studies indicate that the largest share of neglected nursing care is attributed to factors related to material resources, human resources, and communication. Conclusion: The results of the data studies showed that nurses prioritize their missed clinical activities. High workload and lack of nursing personnel, as human factors, along with material and communication resources, play the biggest roles in increasing missed nursing care. These factors lead to the lack of necessary training for discharge, insufficient training related to the emotional support of patients, and inadequate monitoring of patients' vital signs.


Background
In recent years, the emergence of numerous problems in societies has resulted in psychological, financial, and occupational pressures on nurses.Consequently, nurses' work duties have been neglected, leading to a reduction in the quality of hospital services.Missed care encompasses various aspects of clinical, administrative, and emotional conditions with patients that have been delayed or left incomplete (1).According to information published by the Ministry of Health, approximately 13.5% of patients experience adverse situations during their hospitalization, some of which are related to nurses as a crucial part of the healthcare team.Estimates show that up to 44% of these incidents can be prevented (2).Missing nursing care (MNC) hinders the provision of comprehensive care at the required level for patients (3).The National Institute for Health and Care Excellence (NICE) considers missed care a "red flag" that serves as a serious warning regarding nursing shortages (4).
Several factors contribute to missed care, as identified in numerous studies.The findings indicate that severe mental disorders and clinical consequences significantly impact nurses' work duties (5).A 2015 study highlighted the influence of factors such as financial resources, human resources, and communication on missed nursing care (6).In a 2016 cross-sectional study by Zaharorud Dehghan, material resources accounted for an average of 82.2%, while human resources 2 Med Surg Nurs J. 2023; 12(3): e148232.
accounted for an average of 26.3% as the primary causes of missed nursing care (7).Winset et al. believed that staff shortages, emergency situations, and increased patient admissions and discharges contribute to the omission or forgetting of care (8).Additionally, teamwork and hospital characteristics are often overlooked factors in nursing care.In a 2009 statement, the World Health Organization emphasized the significance of patient-centeredness and its impact on nurses, particularly regarding payment conditions (9).Oserhofer et al. stated that care related to the mental dimension of patients tends to be more neglected than the physical dimension (10).Statistics reveal that Italy and the United States have the highest rates of missed nursing care (11).Sometimes, care is forgotten due to nurses' lack of knowledge and awareness of specific situations and patients' needs (12).In their thesis, Bragadottir highlighted essential examples of forgotten nursing care, such as oral and dental hygiene, patient feeding, and assistance with mobility and walking (9).Neglecting work in nursing services for patients is a key factor contributing to the increasing number of nurses leaving their jobs (13).Moreover, studies have identified some of the most significant complications in nursing, including falls from beds, pressure ulcers, hospitalacquired injuries, medication errors, and increased susceptibility to illness (13).One of the most important complications of missed nursing care includes falls from beds, which cause pressure ulcers, hospital infections, side effects from medication errors, and ultimately, an increased likelihood of prolonged patient hospitalization (14)(15)(16).
Additionally, the results of researchers' studies indicate the emergence of a global problem due to neglected nursing care (11), which necessitates an international platform to address this issue.Therefore, this research aims to compare the findings of previous studies regarding the factors and conditions that lead to nurses neglecting their duties toward each patient over the years... to... and to provide necessary solutions to reduce it.This study was conducted to determine the degree of neglect in nursing care and the related factors.For this purpose, the results of previous research studies can be utilized.

Objective
This review examines the results of 24 studies conducted on missed nursing care and its related factors.

Methods
This article is an integrative review study on the topic of missed nursing care and its contributing factors among nurses.It includes a summary of articles by other authors, extracting the results of previous research.The review encompasses articles published from 2014 to 2023.The steps of conducting an integrative review, based on Russell's model, are as follows: 1. Identifying the problem, objective, and research question.
2. Reviewing articles with similar titles and screening the most relevant ones.

5.
Interpreting and presenting the obtained results.

Revealing the Problem, Objective, and Research Question
Referring to the issues mentioned in the introduction and in line with the objective of understanding the factors causing neglected nursing care, two questions were formulated to address the goals of this study: 1. What are the barriers leading to missed nursing care?
2. When are nurses more likely to forget their duties?

Reviewing Articles with Similar Titles and Screening Their Relevance
International articles were obtained using English keywords and searching in the "MeSH" section of the NBC site.The search included terms such as "missed nursing care," "nurse's work environment," "nurse workload," and "misscare survey."Electronic databases including PubMed, ScienceDirect, Sci-Hub, Scopus, Google Scholar, and Wiley, as well as domestic databases such as Civilica and Magiran, were searched.The inclusion criteria for data entry were articles, dissertations, and books, while internal and non-English articles were excluded (Figure 1).

Data Evaluation
To screen and evaluate the materials, a research team was formed, including an assistant professor of nursing at Islamic Azad University, Najaf Abad branch, who was responsible for supervising the submitted materials and guiding the team.Additionally, the first author analyzed the texts and wrote the summaries.

Final Data Analysis
After a thorough examination of all the final materials and extraction of key sentences, the results from the articles and theses were compared and summarized in this review article.

Findings
During the initial stage of the search using the mentioned keywords, an article was identified but ultimately excluded due to a lack of response.Finally, a percentage of Farsi articles and a percentage of English articles were included to address the research questions and objectives of the article (Table 1).

The Extent of Forgetfulness in Nursing Care
Nursing care that has been forgotten can be delayed, partially completed, or completely neglected.Forgotten nursing care is also referred to as non-nursing care or unfulfilled nursing care (37).Precisely determining this forgotten nursing care has become a major challenge in the field of nursing.The calculation of forgotten nursing care in any environment varies according to hospital conditions and facilities.Studies have found that the amount of forgotten nursing care reported by nurses in different sectors ranges from 1.5% to 73%.In 2017, Lake showed that for each additional patient, the rates of missed nursing care increased by 53% for children's nurses and 73% for adult nurses (20).
Studies also show that the amount of missed care varies depending on the shift time and the number of patients.When the patient-to-nurse ratio increased from 6 to 10, nurses forgot 50% of the necessary nursing care.Ball et al. showed that when the number of nurses is nearly doubled, the rates of missed nursing care are reduced by 50% (18).Numerous studies have observed that missed care occurs consistently and is not dependent on the country, type of hospital, size, or location (1,31).

High Workload
Human factors are significant contributors to forgotten care among nurses, increasing both mental and physical pressure on them.When the patient load in a department is high, nurses may not have the opportunity to provide certain types of care due to the heavy workload, often caused by a shortage of nurses.Sometimes, these types of care are considered lower priority and are subsequently forgotten.Numerous studies have confirmed this finding and identified high workload and nurse shortage as influential factors contributing to the neglect of nursing care (6, 9, 17-24, 28, 30, 32-35).Med Surg Nurs J. 2023; 12(3): e148232.

Poor Communication and Lack of Coordination
The lack of cooperation and coordination among nurses and other members of the healthcare team affects effective communication.When team members collaborate and combine their roles and skills, individual performance improves, and errors and work overload are reduced.Several studies indicate that teamwork enhances job sensitivity among nurses, leading to a decrease in the occurrence of missed care.This includes the division of tasks among team members and the utilization of their experiences and assistance (9, 23, 29-31, 36, 38, 39).Promoting teamwork and equitable task allocation among nurses are significant factors in improving cooperation.According to Soltani et al. , their study demonstrated that teamwork enhances job satisfaction, and motivation, and reduces job pressure on nurses.Effective communication within the nursing work environment, whether with other healthcare team members or patients, is crucial for advancing therapeutic interventions and patient care.It is an essential element and can be divided into three categories: poor communication with healthcare team members, imbalanced work regulations, and lack of support from other healthcare team members, including inadequate patient handover from the previous shift.Effective communication with patients fosters trust and acceptance of the treatment process (6,21,22,29,34).On the other hand, ineffective communication with healthcare team members, imbalanced work arrangements, lack of support, and improper patient handover from the previous shift are considered causes of neglected nursing care (34).

Lack of Facilities and Equipment in the Department
The lack of adequate facilities in hospitals, such as insufficient bed capacity for admitting patients and creating disorganization, as well as a shortage of essential medical supplies and specific drugs, negatively impacts the quality of nurses' work and contributes to missed nursing care.Various studies have demonstrated that the scarcity of medications in hospital wards is one of the three significant factors contributing to an increase in neglected nursing care (6,17,19,21,22,34,39).Missed nursing care specifically relates to patient assessment, medication administration, and patient nutrition (19).

Personality Traits
Personality traits are another factor that can impact the occurrence of missed nursing care, as indicated by various studies (9,22,27,31).In a study examining conscientiousness, agreeableness, and openness, neuroticism was also identified as a personality trait influencing the likelihood of forgetting nursing care.Risk perception and accountability play a crucial role in the occurrence of missed care.Individuals with a more critical mindset tend to learn from their mistakes and strive to avoid repeating them in the future when they receive feedback or warnings.This characteristic is directly related to career and professional motivation, making individuals more inclined to engage in collaborative activities.Nurses who possess openness and positive moral characteristics are more motivated to fulfill their clinical responsibilities (27).

Lack of Time
Time has consistently been a significant factor influencing people's lives.Insufficient time increases the pace of work and may result in carelessness or the intentional or unintentional omission of tasks.In a study, the lack of time within the nursing work environment was identified as one of the most critical factors contributing to an increase in neglected nursing care, compromising the quality of service delivery and even posing a risk to patients' lives (35).Therefore, increasing the workforce and adequately distributing patient assignments among nurses can help ensure that each nurse has sufficient time to care for their patients effectively.

Job Burnout
Job burnout is indeed a common phenomenon attributed to the continuous stress experienced by nurses.It encompasses a range of emotional, attitudinal, behavioral, psycho-physical, and organizational signs and symptoms (40).Factors such as excessive workload, demanding tasks, shift work, psychological pressures, lack of social support, and poor collaboration with other healthcare team members have all been identified as contributors to burnout among nurses over the long term.In the reviewed studies, job burnout has been recognized as one of the factors associated with the occurrence of missed nursing care (24,25,32,40).

Length of Hospitalization
The length of hospitalization for patients has been identified as a factor that can contribute to the occurrence of missed nursing care.When a patient is hospitalized for an extended period, the attention of the healthcare team may shift more towards new patients, leading to decreased sensitivity toward the ongoing care of long-term patients.This phenomenon arises due to resource allocation priorities and the perception that new or special cases require more immediate attention (31,32).

Missed Nursing Care
Factors contributing to neglected nursing care can impact various aspects of patient care, including skin care, patient education about their disease, evaluation of medication effectiveness, patient re-evaluation, and oral and hygiene care (9).Studies have also examined the prevalence of neglected nursing care in areas such as skin care, emotional support, mouth care, patient education, patient evaluation, glucose monitoring, vital sign monitoring, and hand hygiene (29).Neglected nursing care has been identified in several key areas, including inadequate patient monitoring, reduced attention to patient skin care, insufficient patient and family education, neglect of oral and dental care, inadequate rotation of patient positions, lack of selfcare support, lack of affective support, poor vital sign monitoring, hospital-acquired infections, pressure ulcers, patient falls, and poor blood glucose level control (25,26,28,31,33).
Statistics on missed nursing care indicate that significant proportions of care are missed in areas such as patient discharge training (83.3%), emotional support for patients and their families (68.4%), patient education about their disease (62.8%), and vital sign monitoring (22.3%) during the time of patient discharge (30).

Discussion
In this review study, an attempt has been made to investigate neglected nursing care and related factors in hospital wards.Among the 24 studies included in the findings section, covering the years 2014 to 2023, many followed the PRISMA guidelines.Neglecting nursing care has been a constant issue throughout history, exacerbated by the increase in the number of patients and the lack of staff.This neglect endangers patient safety.The findings of the reviewed studies show that the largest share of neglected nursing care is attributed to factors related to material resources, human resources, and communication (6,9,(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)39).
Neglected care includes oral and dental care, skin care, patient and family education about the disease, and monitoring the patient's vital signs, such as blood pressure, temperature, pulse rate, and respiration.
Additionally, inadequate monitoring of glucose levels is a factor contributing to increased missed nursing care.Teamwork between nurses and other members of the healthcare team (9, 23, 29-31, 36, 38, 39)improves individual performance, job satisfaction, reduces job pressure, and enhances motivation.In the long run, it leads to stress reduction and increased focus on the services needed by patients.Poor communication between healthcare team members and lack of support from other staff can lead to a decrease in the quality of the treatment process and increased inefficiency (6,21,22,29,34).Insufficient facilities in hospital departments, such as inadequate bed capacity, lack of necessary medical equipment, and specific drugs, directly contribute to increased missed nursing care (6,17,21,22,24,39).Personality traits such as conscientiousness, agreeableness, openness, and neuroticism have also been identified as factors affecting the occurrence of neglected nursing care (9,22,27,31).Additionally, a lack of time for thorough patient examination (35) and burnout among nurses, caused by factors such as excessive workload, difficult tasks, shift work, and mental pressures, contribute to neglected care (24,25,32,40).The duration of hospitalization has also been identified as an effective factor in the incidence of neglected nursing care (31,32).Age, gender, level of education, and work experience of nurses were considered by the authors in all studies.The Misscare questionnaire, related to the amount of missed nursing care, was used by the majority of authors.In the screening of reviewed articles, it was found that out of 24 articles, 3 were published in Persian and the rest in English.Based on the findings of these studies, it is necessary to investigate the factors affecting neglected nursing care in the workplace and to take measures to minimize their impact on nurses' activities.Obstacles during the compilation included the lack of access to the full text of articles and the lack of translations into Persian or English.

Conclusions
The data studies showed that nurses should prioritize missed clinical activities, and governments are obliged to reduce the factors affecting nurses' service activities by making the necessary preparations.Investigations indicated that high workload and lack of nursing personnel, along with material and communication resources, play the biggest roles in increasing missed nursing care.This leads to a lack of necessary training for discharge and training related to emotional support.The involvement of patient companions and the examination of patients' vital signs Med Surg Nurs J. 2023; 12(3): e148232.lead to a decrease in the quality of nurses' services, especially among nurses with less experience, lower levels of education, and more working hours per week.Factors such as poor communication among nurses, lack of facilities, personality traits such as conscientiousness, agreeableness, openness, and neuroticism, lack of time, length of patient hospitalization, and job burnout were identified as contributors to missed nursing care.It seems that enhancing the level of nursing personnel is a key intervention that can significantly improve the quality of services.The results showed that insufficient nurses, the condition of the patient and the unavailability of drugs when needed are the factors that cause the loss of forgotten nursing care. (

Figure 1 .
Figure 1.Article selection method through prisma

Table 1 .
Factors Affecting Forgotten Nursing Care