Missed nursing care and complexity theory: a conceptual paper

Introduction

Missed nursing care (MNC), also called nursing care left undone and omitted care, is a global healthcare issue (Bragadóttir and Kalisch, 2018; Caldwell-Wright, 2019; Mandal and Seethalakshmi, 2019). It not only compromises patient safety (Albsoul et al., 2019), and leads to patients’ dissatisfaction with the quality of healthcare (Recio-Saucedo et al., 2018), but also negatively impacts on nurses’ satisfaction with their jobs (Hegney et al., 2019; Zeleníková et al., 2019) and imposes a substantial financial burden on the healthcare system (Kalisch, 2016; Kalisch et al., 2009a; Sasso et al., 2017). The issue of MNC has been presented in the literature using several different definitions and descriptions (Jones et al., 2015), suggesting that the conceptualisation of MNC is not yet fully established. An oft-cited definition is supplied by Kalisch et al. (2009a) who state that MNC refers to ‘any aspect of required patient care that is omitted (either in part or in whole) or delayed’ (p. 1510). Nonetheless, such descriptions often relate MNC to the elements of nursing care totally or partially omitted by nurses in their shifts (Ausserhofer et al., 2014), as well as prioritizing and decision making about which nursing care to provide, and which nursing care to postpone or leave (Blackman et al., 2018).

MNC is a widespread and serious healthcare problem resulting in reduced quality healthcare (Bragadóttir et al., 2017; Mandal and Seethalakshmi, 2019). Caldwell-Wright (2019) asserted that MNC is a ‘pandemic issue’. A systematic review of the literature found that 55–98% of nurses leave one or more aspects of patient care unperformed during their shifts (Jones et al., 2015). In that context, MNC has been recognised as a frequent subject for candid investigation (Caldwell-Wright, 2019; Piscotty and Kalisch, 2014) accompanied with increased international interests in finding solutions to the problem of MNC (Zeleníková et al., 2019).

The international body of evidence into MNC is rapidly evolving. The extant literature in this area chiefly focuses on the aspects of nursing care that are frequently missed, and on the factors that influence the occurrence of MNC. Previous research clearly articulates that nurses often do not address emotional or psychosocial (compassionate) requirements of patients (Ausserhofer et al., 2014; Bagnasco et al., 2019; Vinckx et al., 2018). However, nurses report that they do attend to patients’ medical (physiological) needs (Al-Kandari and Thomas, 2009; Ball et al., 2016; Bekker et al., 2015; Hernández-Cruz et al., 2017; Kalisch, 2006; Marven, 2016; Scott et al., 2013; Williams et al., 2009; Zander et al., 2014). In short, nurses adopt a ‘curative’ approach in prioritising of patient healthcare (Mandal and Seethalakshmi, 2019). It has also been acknowledged that MNC occurs as a result of a composite of complex factors (Kalfoss, 2017; Laranjeira, 2015; Phelan et al., 2018; Willis et al., 2014), whereby the number of nursing staff represents only a single aspect of this pervasive conundrum (Feo and Kitson, 2016). In addition, communication breakdown between nurses and doctors has been identified in the literature as one of the causes of MNC (Albsoul et al., 2019).

Conspicuously, the prevailing paradigm of the present science in MNC is reductionist. Reductionist approaches to MNC research are based on the premise that a system, which refers to any interacting group of components, is best comprehended and fixed by stripping the system back to its main components and addressing every component individually (Kernick, 2002; Widmer et al., 2018). The dominance of reductionism indicates that quantitative methods, particularly cross-sectional surveys, are principally used by investigators in this subject matter. Management recommendations under the existing paradigm tend to focus primarily on modification of the structural components in the practice environment to manage MNC (Duffy et al., 2018). That is to say, the simple ‘find and fix’ management model dominates the current management practices in healthcare organisations (Braithwaite et al., 2015).

The reductionist approach in examining MNC represents a form of tunnel vision (Verschuren, 2001). In fact, healthcare problems frequently occur due to interactive and multidimensional system influences and they hardly can be reduced to a single contributing factor (Baghbanian and Torkfar, 2012). The reductionist approach risks not identifying overarching system influences and thus can lead to inappropriate management strategies to prevent or reduce MNC. For example, one study identified that teamwork resulted in a small, non-significant decrease in the missed care levels (Marguet and Ogaz, 2019). Another study identified that increasing nursing time has no effect on reducing missed care (McNair et al., 2016). In fact, such conventional management models based on a reductionist approach view institutions as machines that consist of several elements each of which can be fixed individually to promote organisational performance as a whole (Tuffin, 2016). However, available evidence suggests that healthcare system issues would not be resolved by applying reductionism approaches (Stengers, 2004). Applying a reductionist approach in complex systems is almost futile as it does not take into account the unpredictability evident in complex systems (Westhorp, 2012). Indeed, emerging claims suggest that MNC is better understood as a ‘wicked problem’ (Jones et al., 2019). Wicked problems are complex, intractable problems that are difficult to define (Buller, 2017) and show resistance to linear approaches to problem solving (Periyakoil, 2007). Given the unpredictability in the healthcare system that may result in MNC, using methodologies that consider the complexity and context such as realist evaluation, is important to investigate, identify for whom and in what circumstances particular interventions work in managing these problems (Hewitt et al., 2012).

As a consequence, Jones et al. (2019) argued that ‘structuration theory’ is of significance in the conceptualisation of MNC. Structuration theory acknowledges the interaction between structure and process (Dopson et al., 2008). However, structuration theory has been widely criticised for considering the structures as simulated elements, that present merely in the interaction between agents, meaning inability of the theory to reveal the association between agency and structure in an appropriate manner (O’Boyle, 2013). According to The Institute of Medicine’s (IOM) landmark work, Crossing the Quality Chasm, healthcare practitioners are essential contributors to transformation in the healthcare provision system (Committee on Quality of Health Care in America, 2001). It is imperative to recognise that healthcare practitioners, including nursing staff, do not simply apply theoretical scientific research determinedly to the healthcare context surrounding them. Instead, they collectively co-operate in discussion and engaging with others in their everyday operating practice (Dopson et al., 2008).

Complex healthcare issues require complex responses (Ashby, 1991). From a complexity thinking perspective, utilising traditional reductionist approaches in dealing with healthcare system issues can lead to inadvertent consequences (Martin and Sturmberg, 2009). Braithwaite (2018) argues that change in healthcare requires a learning environment that applies a complexity standpoint. Foreseeing and performing within this constant change is expected from practitioners in the complex system (Crowell, 2011).

Research into implementation of interventions to nurture quality healthcare proposed that complexity is one the key challenges that influence the success of recommended interventions for complex healthcare issues (Reed et al., 2018b). Therefore, it can be argued that one of the possible reasons for failures of the proposed interventions for MNC management is the failure to address and capture the complexities of the healthcare system where the MNC problem occurs. It has been claimed that to find effective solutions to MNC, the complexity of the healthcare environment in which it takes place should be carefully considered (Bar-Yam, 2006; Chaffee and McNeill, 2007; Kannampallil et al., 2011).

It has been acknowledged that understanding complexity is a crucial element for improving quality healthcare and promoting patient safety (Bar-Yam, 2006). By definition, complexity is an explanatory concept aimed at describing change and operations in social systems (Baghbanian and Torkfar, 2012). Healthcare systems are immersed with complexity and risk as a result of patient acuity, increased prevalence of co-morbidities and increased utilisation of technology (Simmons, 2010). As such, the progressive change in the healthcare system and its accompanied uncertainty, which occurs due to a complex healthcare system, linear thinking, and organisational leadership expectations, were found to directly influence nursing practice (Orde, 2016). For example, it has been suggested that misuse of technologies in the complex healthcare environment results in frequent delivery of dehumanised patient care by nursing staff, which represents a form of MNC. This indicates that nursing procedures tend to be reduced to a simplistic biomedical model of care (Riegel and Crossetti, 2017). Evidently, nursing care cannot be considered in reductionist terms, rather it is a complex practice that involves interactions, contemplations and self-information (Cruz et al., 2017; Notarnicola et al., 2017). In other words, nursing procedures comprise interactions among human beings, along with dynamic, non-linear and emerging processes. (Chaffee and McNeill, 2007).

We propose that the application of complexity theory (CT) can give new insights into the MNC phenomenon and its management in acute-care settings. Davidson and Ray (1991) indicate that utilisation of the complexity paradigm facilitates comprehension of complex nursing events. Additionally, Ralph and Viljoen (2018) state that ‘issues such as missed care require an acknowledgement of this complexity by continuing to search for and communicate effective, stakeholder-informed solutions in environments where quality improvement processes are embedded, iterative, recursive and ongoing’ (p. 4). Further, CT acts as a framework to aid nurses to improve healthcare processes (Kiviliene and Blazeviciene, 2019). Dealing with complex issues such as MNC requires distinctive problem solving methods (Hodiamont et al., 2019) tailored for localised circumstances (Kiviliene and Blazeviciene, 2019).

Against this background, this paper aims to develop a conceptual understanding that goes beyond the limitations of the existing paradigms for better understanding of MNC phenomena. We propose a way of thinking about MNC phenomena based on the fundamentals of CT. We further suggest management practices to address the complex factors influencing MNC are very different from those prescribed by the conventional reductionist approach. This theoretical paper could help healthcare researchers to design research that better suits and promotes a better understanding of MNC phenomena in the complex healthcare environment. It also offers a perspective that informs improved patient care.

In the following sections, we first introduce CT. Then, we present the conceptual understanding of MNC developed using a CT lens. Following, we discuss implications for practice, policy and future research.

What is CT?

CT emerged to examine systems and to compensate for the restrictions of the reductionist (scientific) way of thinking (Brainard and Hunter, 2015; Mitchell, 2009; Plsek and Greenhalgh, 2001). It has been applied in the last few decades as a conceptual framework in areas such as healthcare management, nursing (Paley and Eva, 2011) and evidence-based practice (Kent and McCormack, 2010). CT views organisations as complex adaptive systems (CASs) (Anish and Gupta, 2010), which demonstrate sensitivity to historical occurrences and patterns (Reed et al. 2018a). In other words, previous behaviours impact on the current behaviour (Kernick, 2006).

CASs include several agents (staff), structuring and restructuring based on non-linear interactions and positive and negative feedback (Cilliers, 2002). Non-linearity in the CAS means that minor efforts to change the system can result in large effects, while major efforts may result in little or no change to the system (McDaniel, 2007), which can be called the ‘butterfly effect’ (Kernick, 2006). In essence, cause and effect in the complex system are hard to follow (Brainard and Hunter, 2015). Hence, identifying interventions to tackle complex healthcare issues such as MNC, might be troublesome, as the system reacts to the changes in unanticipated ways according to the context (Caffrey et al., 2016).

A CAS, is capable of modification and learning from its previous experiences (Touati et al., 2019). It reacts to the local environment and local knowledge within which it operates (Chaffee and McNeill, 2007). In this conjecture, CAS is characterised by distributed control, and outcomes thus occur due to self-organisation rather than being controlled by a centralised body (Zimmerman et al., 1998).

Self-organisation is designated as the process by which the components of the system collaborate within the system and over time (Bailey et al., 2012). Ashmos et al (2002) posit that effective management initiatives would be based on management practices that modify how people relate to one another rather than depending on top down authoritative directives. Top-down initiatives in the CAS can result in unforeseen consequences by enhancing latent feedback loops within the cause and effect network (Van Beurden et al., 2011). From this perspective, the quality of relations between agents of the system may be more significant in enhancing the performance of the system than the quality of the agents of the system themselves (McDaniel, 2007; Pype et al., 2017). In other words, supporting the practice environment is essential in allowing nurses to tackle the complex nursing situations and make changes within the system, and thus improve processes and outcomes in the CAS. This support involves harnessing relationships and reinforcing capacities and skills of individuals who comprise the system (Best et al., 2012).

As the healthcare environment is infused with uncertainties, unpredictable events based on relationships are superimposed in care processes (Cruz et al., 2017). The healthcare organisation can be classified as a CAS (Begun, Zimmerman, and Dooley, 2003; Chaffee and McNeill, 2007; McDaniel and Driebe, 2001), and viewing healthcare as a complex rather than a linear system allows many innate features in the system to be capitalised to impact on its dynamic behaviour, and direct the system on a more promising track (Lipsitz, 2012), thereby reducing MNC incidents.

Complexity inspired conceptual understanding for MNC

Based on our view of healthcare organisation as a CAS, we propose that CT can be advantageous in describing the events related to MNC in acute-care settings. We reconceptualised MNC as a CAS. We then applied CT concepts to evaluate the findings from the MNC literature, which helped in the identification of strategies that would be effective in tackling this healthcare issue. CAS approaches help to investigate the unpredictable aspects of healthcare institutions, therefore allowing for the success of interventions which promote patient healthcare results (Bucknall and Hitch, 2018).

MNC is affected by a group of complex factors. Thus, it has been viewed that comprehension, describing and handling of the MNC issue is better attained using CAS thinking rather than focusing on one factor and overlooking many interconnected and interdependent system elements that may potentially affect a clear understanding of MNC. Possibly, there might be latent faults in the system (e.g. challenges with retrieving information from patient health records) that have a considerable impact on the occurrence of MNC and these faults cannot be recognised and acted on if we depreciate our thinking about such complex issues using a traditional reductionist approach. What has arisen from the growing corpus of evidence on CT is that the core concepts of CT relevant to MNC are adaptation and self-organisation, non-linear interactions and history.

Implications for practice, policy and future research

The intention of this paper was to develop a conceptual understanding for MNC using CAS approaches. Indeed, CT literature identified that handling complexity in healthcare can be performed through conversation, relationships and culture (Provost et al., 2015). As such, healthcare managers adopting complexity paradigms are responsible in helping employees adapt to uncertainty and to contain unpredictable events (McDaniel and Driebe, 2001). Their key responsibilities involve sensemaking, learning and improvisation rather than command, control and planning (McDaniel, 2007). From this perspective, inserting nursing reflective practice into nursing actions might be an effective initiative in reducing MNC in acute-care environments, and therefore improving the quality of nursing care.

In its widest concept, reflective practice can be defined as the process of making sense of events, conditions and activities in the working environment (Oluwatoyin, 2015: 33). In other words, it is the process of self-assessment of everyday practice in order to place new intuitions into practice, allowing healthcare providers to engage in a continuous learning process (Coombs and Ersser, 2004). As MNC may result from communication breakdown between nurses and physicians, it can be suggested that sensemaking may also be effective in tackling MNC by improving communication between physicians and nurses through establishing consensus about clinical problems (Manojlovich, 2013).

It has been claimed that a lack of critical reflection in healthcare professionals is one of the potential reasons for erosion of care (de Vries and Timmins, 2016). On the other hand, Ling and Yu (2019) allude that practising critical reflection allows for establishing time for patients. It permits reorganising the order of nursing work in future practice, increases the efficiency of the nurses and thus increases the time available for emotional care provision, hence reducing MNC incidents. So, to ensure holistic care provision, nurses must establish collaborative learning environments, and pedagogic strategies that include mindfulness, reflection and refinement of emotional experiences (Mazzotta, 2016). These strategies play a role in enhancing nursing resilience and improving conflict management skills. Therefore, reducing MNC. Moreover, educating nurses and providing continuous mentorship programmes will provide them with the opportunity to address practice gaps, as well as engaging in meaningful connections with patients (Mazzotta, 2016). Offering continuous education opportunities for nurses assists the individual nurses in dealing with complex nursing care circumstances in a positive manner and thus strengthens and inspires them (Kentischer et al., 2018).

Methodologies that take into account the CAS approach are commonplace in healthcare research, including nursing. However, the extant literature on MNC is lacking in such an approach. Therefore, future research directions could be oriented towards convergence of research methods to investigate MNC and its context at environmental complexity level (Kernick, 2006). This is important, because a challenge inherent in the present research paradigm for developing policies in healthcare services, is that these decisions are characteristically formulated as detached from the complex context of healthcare delivery (Kuziemsky, 2016). Stated another way, policy makers principally rely on policy formulation on work as imagined rather than work as done at the frontline (Braithwaite et al., 2015). Better understanding is needed with respect to how complex factors leading to MNC intervene in the complex healthcare system. Failure of policy makers to do so can ensue in ‘policy resistance’ (Atun, 2012; Sterman, 2006). Policy makers need to acknowledge the dynamic, adaptive and unpredictable nature of the healthcare system while developing policies to resolve complex issues, such as MNC. In doing so, leverage areas within the system can be identified, hence promoting system performance (Lebcir, 2006).

Viewing healthcare institutions as CAS necessitates a group of research means that facilitates an examination and investigation of dynamic, non-linear and adaptive events in the healthcare system (Bar-Yam, 2016; Khan et al., 2018). Because the work of nursing is non-linear (Potter et al., 2005), the conventional scientific inquiry based on certainty and linear causality can’t portray the complex context within which nurses provide patient care. This must be augmented by the study of how we can best deal with uncertainty and unpredictability. To achieve this, we need context specific research designs that contemplate dynamic interactions. Mixed-methods case studies can act as a context-dependent approach, including ethnographic research (Cohn et al., 2013; Flyvbjerg, 2006). These methods are needed to investigate and better explain why MNC occurs, and to try to isolate key system predictors of MNC that lead to reductions in MNC. An understanding of the complex interaction of factors helps managers and practitioners to identify the factors and the way in which they interact, and thus to design strategies that may better reduce the adverse impacts of their interaction.

Therefore, implementation scientists can be directed to concentrate on these predictors to improve healthcare outcomes. Utilisation of CAS as a theoretical framework may be useful in establishing of appropriate interventions. It also reflects a greater emphasis on healthcare professionals as agents in the healthcare system and therefore comprising a relevant factor in the process of inquiry by contributing to the healthcare results (Hodiamont et al., 2019).

Conclusion

This paper provides a conceptual framework and a comprehensive understanding for the MNC phenomenon using CT. The text discloses that MNC can be conceptualised using CT concepts into three broad areas: adaptation and self-organisation, non-linear interactions and history. The science of complexity allows various perceptions on the same phenomenon, enabling co-operation among professionals with their diverse perspectives (Notarnicola et al., 2017). We suggest that this conceptualisation is of importance for nursing practice and further research in this field.

This paper was motivated by the perceptions of the researchers that an holistic understanding of the MNC phenomenon, and thus identification of potential solutions to manage it, are still largely constrained by the theoretical approaches and methods used by investigators in this field.

To date, there is little contemporary research which has addressed the complexity of the MNC issue. This paper suggests that management practice for MNC is not as simple as it is thought. Conventional ways of thinking propose simple cause and effect relationships. It also endorses reducing a situation to its parts and investigating factors in separation (McDaniel and Driebe, 2001). Based in this reading, we argue that adopting the conventional mode of thinking in investigating and managing MNC may be misleading. This does not mean rejection of previous establishments, but to complement them depending on a complexity standpoint (Begun, 2008; Braithwaite et al., 2015). All in all, there is a pressing need to acknowledge the interactions among system elements. Future research should consider these interactions as well as the non-linearity among factors that may influence the occurrence of MNC in the complex healthcare environment.

Key points for policy, practice and/or research

Missed Nursing Care (MNC) may be considered a ‘wicked’ problem.