Introduction

Missed nursing care corresponds to any care component that is omitted (totally or partially), or significantly postponed. This phenomenon can contribute to lengthened hospitalization periods, an increased number of falls and an increased prevalence of pressure ulcers/infections. It can also hinder effective pain management and result in medication errors, among other negative effects (^{Kalisch et al., 2009}).

Quality of care, patient safety, and patient satisfaction are highly related to the nursing care provided. Therefore, it is important to evaluate the correlation between missed nursing care and the previously mentioned indicators of healthcare quality (^{Ahansaz et al., 2024}).

Frequently, there is a need/choice to prioritize some forms of care over others, sometimes on a minute-by-minute basis. However, there is still no scientific foundation for this practice, which is essential for conducting further research. Aspects associated with the patient’s psychosocial needs, care planning, and ambulation appear to be often postponed/omitted, while other components (e.g., care related to the administration of therapeutic substances) are usually prioritized (^{Wakefield, 2014}).

In general, the critically ill patient is admitted to a hospital through its emergency department. Afterward, he/she may or may not be admitted to the hospital’s intensive care unit (^{Mboya et al., 2023}). Concerning emergency departments, if their size/human resources are inadequate, missed nursing care can take place, namely associated with high patient numbers, lack of physical space, and insufficient nurse-to-patient ratios (^{Duhalde et al., 2023}). As regards intensive care units, since they accommodate highly complex tasks, they are particularly susceptible to the occurrence of nursing care omissions (^{Nobahar et al., 2023}).

Nurses who provide care to critically ill patients or to patients whose condition may become acute are expected to do so effectively while ensuring care quality and safety (^{Wakefield, 2014}). They have a direct influence on the quality of the provided care, since their role entails a close proximity to the care recipient. Therefore, it is crucial that they are able to identify care omissions and the respective potential causes, in order to establish precautionary measures (^{Bispo et al., 2023}).

Given the reality portrayed above, it is essential to determine which nursing care omissions are common in emergency departments and intensive care units. Furthermore, it is important to ascertain the causes and effects of omissions, as well as possible mitigation strategies.

1. Methods

Firstly, we analyzed the state of the art regarding missed nursing care common to emergency departments and intensive care units, which revealed the absence of recent scientific evidence on this particular field of knowledge.

At that stage, we recognized an opportunity to map the existing scientific evidence related to the abovementioned phenomenon in a precise and summarized manner. Therefore, we decided to conduct this scoping review as a starting point for the production of knowledge on the subject under study, devising the following research question: “What is the current knowledge on missed nursing care common to emergency and intensive care settings?”

In addition, we considered four sub-themes, represented by the following questions:

Thus, the present work’s development addresses the issue of nursing care omissions shared by emergency departments and intensive care units, being based on PRISMA guidelines. After choosing the research questions, we defined several inclusion and exclusion criteria. Next, we selected the relevant articles, applying the aforementioned criteria. Lastly, we analyzed and discussed the results that were obtained.

To perform the bibliographic search, we followed the PCC mnemonic (“Population,” “Concept,” and “Context”), which, following the same order, refers to “adult patient,” “missed nursing care,” and “intensive care and emergency department.” We employed a Boolean search method, using diverse terminology (free/natural terms, MeSH terms, and CINAHL subject headings) that reflected the established concept and context. To expand the search results, we did not use any terminology associated with the target population. Instead, we subsequently applied a filter within the different databases to select works involving adult patients.

To address the concept, we applied the terminology shown below:

The search was carried out between February 25 and March 26, 2024, within several databases: Scopus, Medline, PubMed, CINAHL, MedicLatina, and RCAAP.

As regards inclusion criteria, we considered articles freely available in full text, which corresponded to quantitative/qualitative/mixed studies, systematic literature reviews, or gray literature, and were written in Portuguese, English, or Spanish. With respect to publication date, no time limit was applied. In terms of content, we only included works that addressed the following topics:

The database search produced a total of 5923 works, of which 1827 were duplicates. The Rayyan platform was used to perform title and abstract reading of the remaining 4096 articles. During this stage, 22 works were selected to be read in full. However, one of them was subsequently excluded due to the unavailability of its full text.

The full-text version of each article was subjected to a “blind reading” carried out by two reviewers. In case of disagreement, two additional reviewers were consulted. Moreover, we sought to conduct an in-depth analysis to consolidate the employed search expressions. At this point, one article was excluded because it focused on medical errors. In contrast, six articles were excluded because they addressed missed nursing care in contexts other than emergency departments and intensive care units. Hence, the final sample consisted of 14 works. The entire selection process described above is shown in Figure 1.

Figure 1 Flowchart of the articles’ selection process (PRISMA Diagram 

2. Results

The obtained results are presented in Table 1, being organized according to title, author(s), year of publication, type of study, location(s), context, and findings.

As can be observed, the 14 articles included in this review depict qualitative studies, conducted between 2016 and 2024. These works analyze data obtained in different locations (four studies gathered data from the Americas, two from Oceania, eight from Asia, two from Europe and one from Africa).

Of the 14 included articles, two focus specifically on missed nursing care in emergency departments, eleven concentrate on missed nursing care in intensive care units, and one addresses both contexts.

Most of the included studies exhibit a level of evidence IVb, which reflects the research’s qualitative nature (^{JBI Levels of Evidence and Grades of Recommendation Working Party, 2020}).

Among the included works, nursing care omissions related to the previously identified context are identified in nine articles. Similarly, the associated causes are described in nine articles, while the associated effects are described in only three articles. Possible mitigation strategies are addressed in 10 articles.

To provide an answer to the research question, “What is the current knowledge on missed nursing care common to emergency and intensive care settings?” it is necessary to individually look at the previously mentioned subthemes.

When it comes to nursing care omissions common to both settings, we were able to identify eight care components mainly related to direct patient care, leading us to provide an answer to the first subtheme.

Regarding the causes of missed nursing care, we found four common topics mainly related to the volume of work, providing an answer to the second subtheme.

Due to the lack of evidence related to the common effects of missed nursing care, we were unable to provide an answer to the third subtheme.

Concerning mitigation strategies, scarce evidence was found, which did not allow us to answer unequivocally to the respective subtheme.

3. Discussion

Due to various causal factors, multiple components of nursing care are often significantly delayed or even not executed at all. Such omissions, in themselves, can affect the provided care’s quality and safety (^{Nantsupawat et al., 2022}).

The 14 works included in this review not only identify the main care omissions that occur in emergency departments and intensive care units but also explore their causes and effects while suggesting strategies to minimize their incidence. Nonetheless, the studies in question refer to a variety of services, provide a wide range of data, and appear to be unrelated until they are viewed in the light of the research questions, seeking a hidden connection. Hence, despite the studies’ distinct approaches/findings, we were able to discover common points that allowed answering some of the aforesaid questions.

The omission of nursing care within the studied contexts affects several care components, such as feeding the patient while the food is still warm (^{Higgs et al., 2020}), establishing a positive nurse-patient relationship (characterized by emotional support, interest, and compassion) (^{Duhalde et al., 2023}), and ensuring adequate planning, as well as patient/family education, for discharge (Silva et al., 2020). As regards missed nursing care common to emergency departments and intensive care units, we identified various affected elements, namely:

Moreover, by analyzing the obtained results, we were able to recognize numerous causal factors that contributed to the omission of nursing care, being mostly related to management issues (regarding care procedures and human/material resources), miscommunication between teams/professionals, and an unfavorable work environment (^{Al-Mnaizel & Al-Zaru, 2023}; ^{Duhalde et al., 2023}; ^{Liu et al., 2019}; Silva et al., 2020).

As to the causes of missed nursing care common to intensive care and emergency departments, we identified the following aspects:

It is important to acknowledge how emergency department reality has changed, specifically when it comes to the increase in the length of stay (^{Amritzer et al., 2024}) and how well-equipped the departments are to handle the constantly shifting nurse-to-patient ratio.

With respect to consequences, we were able to discover several negative effects of nursing care omissions in emergency departments, such as the deterioration of the patient’s condition, the development of pressure ulcers, treatment-related errors, and triage errors (^{Duhalde et al., 2023}). On the other hand, in intensive care units, missed nursing care increased the number of adverse events and resulted in worse perceptions regarding care quality and safety (Vincelette et al., 2023). Furthermore, it raised the incidence of healthcare-associated infections and ventilator-associated pneumonia (^{Alanazi et al., 2023}).

In this category, it was not possible to establish common points between the two environments since we found scarce evidence on the consequences of nursing care omissions in such settings. Nonetheless, we can identify various negative outcomes that could easily occur in both types of settings while seeking to adopt preventive strategies. For instance, hospitalization in emergency departments can be associated with the development of pressure ulcers due to prolonged positioning on hard surfaces, stretchers, etc. (^{Santamaria et al., 2019}). This phenomenon could also be observed in intensive care units since patient mobilization is one of the care components recognized as deficient in that particular context (Vincelette et al., 2023).

Having identified the nursing care omissions common to the studied environments, as well as their possible causes, it was equally important to identify the shared mitigation strategies in order to hinder the occurrence of adverse events.

Concerning emergency departments, the available literature mentions several mitigation strategies, namely teamwork, effective team leadership, implementing regulations, creating a balance between salary and workload, adequate planning and task distribution, direct monitoring of individually assigned tasks, and leading by example (^{Ghezeljeh et al., 2021}). In this sense, the advantages of employing experienced nurses were also mentioned since such professionals have the ability to detect more nursing care omissions (^{Higgs et al., 2020}; ^{Mohammadi et al., 2023}).

Likewise, as regards intensive care units, the included studies describe numerous mitigation strategies, often highlighting the importance of a good work environment (^{Al-Mnaizel & Al-Zaru, 2023}; ^{Hendy et al., 2024}; ^{Liu et al., 2016}; Vincelette et al., 2023). In these circumstances, the presence of more nurses can ensure suitable volumes of professionals, as well as adequate nurse-to-patient ratios, thus contributing to the minimization of missed nursing care (which, in turn, increases job satisfaction while reducing the incidence of healthcare-associated infections) (^{Alanazi et al., 2023}; Al-Mnaizel & Al-Zaru, 2023; Liu et al., 2016; Silva et al., 2020).

Enhancing job satisfaction is one of the key measures applied in intensive care units, as well as offering the possibility of career progression, acknowledging the team’s dedication and hard work, guaranteeing immediate medication availability, planning for unexpected increases in the number of patients/sudden worsening of the patient’s health status, and implementing effective communication strategies (^{Al-Mnaizel & Al-Zaru, 2023}). The significance of strong professional ties, together with continuous training on ethical values and nursing care, is also recognized (^{Hendy et al., 2024}).

In the abovementioned setting, there are other relevant aspects that mitigate missed nursing care, such as teamwork, moral sensitivity (including respecting the patient’s independence, knowing how to communicate with the patient, dealing with ethical problems/conflicts, and applying moral principles during decision-making processes, while showing honesty, benevolence, and ample professional knowledge); and the existence of older elements within the team (^{Nobahar et al., 2023}).

After analyzing the obtained evidence on mitigation strategies for missed nursing care, only teamwork and experienced/older team elements seem to be common in the studied environments. Thus, we were not able to answer unequivocally to the respective research question.

Conclusion

Missed nursing care is often used as an indicator of the quality of care provided. This study allowed us to map the available scientific evidence on missed nursing care common to the emergency department and intensive care unit, providing answers to some of the previously established research questions and revealing the main nursing care omissions common to both settings, as well as their causes. Nonetheless, it presents limitations, namely related to the scarce available evidence, as substantial shared effects/mitigation strategies were not detected. Accordingly, there is a clear need for further research on missed nursing care in the abovementioned context.

In this sense, it is crucial to develop additional studies on nursing care omissions, their causes, their effects, and possible mitigation strategies in emergency departments and intensive care units. The need to produce more scientific knowledge is particularly noticeable in the case of emergency departments since only three of the 14 included studies addressed this setting. Regarding the effects of missed nursing care in this setting, it is striking how scarce the evidence is, leading us to believe that the knowledge about mitigation strategies could also be improved if more evidence in primary studies were to be produced. One of the aspects that may affect missed nursing care in emergency departments is the high influx of patients as well as their increased length of stay in this department; both variables have not been acknowledged in the previously found evidence.

Moreover, besides examining each context individually, shared aspects should also be investigated, as both settings receive critically ill patients who require highly complex care.

They equally involve teamwork when treating a critically ill patient, and in several studies, this concept is identified as having an impact on the mitigation of missed nursing care. When it comes to job satisfaction, it is mentioned as having a high impact on intensive care units, and even though this concept is not directly approached in emergency departments, the balance between salary and workload, adequate planning, and task distribution, amongst other topics, all contribute to improving professional satisfaction. Considering this fact, developing future research surrounding the creation of strategies to improve professional satisfaction and optimization of teamwork and its relation to missed nursing care would pose as a valuable approach to this topic.

As previously mentioned, patients are often transferred from emergency departments to intensive care units, which leads us to believe that an interesting approach would be to improve the transfer procedures as well as the teamwork between both settings, thus mitigating missed nursing care by reducing the loss of patient-related information.

When dealing with critically ill patients in diverse contexts, the scarcity of scientific evidence on missed nursing care significantly hampers care management, also hindering the implementation of quality/safety-promoting strategies. Hence, this specific field of knowledge is of utmost importance for an effective, high-quality, and safe nursing practice.

Author’s contribution

Conceptualization, F.J., M.C., T.S.A. and P.P.S.; data curation, F.J. and M.C.; formal analysis, F.J., M.C., T.S.A. and P.P.S.; investigation, F.J., M.C., T.S.A. and P.P.S.; methodology, F.J., M.C., T.S.A. and P.P.S.; project administration, F.J. and M.C.; resources, F.J., M.C., T.S.A. and P.P.S.; software, F.J. and M.C.; supervision, T.S.A. and P.P.S.; validation, T.S.A. and P.P.S.; visualization, F.J. and M.C.; writing-original draft, F.J. and M.C.; writing-review and editing, F.J., M.C., T.S.A. and P.P.S.

Conflicts of interest

The authors declare no conflict of interest.