Unfinished Nursing Care: State of the Science Review

Purpose:
The science on unfinished nursing care has not been formally evaluated. Given the international prevalence of this problem and associated outcomes, a critical evaluation of this phenomenon is warranted. The purpose of this project is to evaluate the state of the science for unfinished care.

Background/Significance:
Quality problems associated with underuse of healthcare services are more common than those of overuse and misuse combined. Unfinished nursing care is a distinct form of underuse that has been reported under a variety of terms to include missed care and implicitly rationed care. The purposes of this project were to: compare definitions and frameworks; compare approaches to instrumentation; describe prevalence and patterns; identify antecedents and outcomes; and describe mitigating interventions.

Methods:
The state of the science review was based on a Boolean literature search in CINAHL and MEDLINE using the terms implicit ration*; miss* care; task* undone; and unfinish* care. The search was limited to English articles in peer reviewed journals; no date restrictions were imposed. Articles were included if they contained the following information on unfinished care in the hospital setting: conceptual definitions/concept analyses, original qualitative or quantitative research related to the experience, prevalence, patterns, correlates, and/or predictors of unfinished nursing care; or development and/or psychometric evaluation of instruments. Fifty-four articles met inclusion criteria.

Results:
Quantitative studies involved cross-sectional surveys (14 variations identified) in 22 primary samples; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Most nursing personnel (55-98%) reported leaving 1 or more tasks undone. Patterns of unfinished care were consistent with the subordination of teaching and emotional support to activities related to physiologic needs and compliance audits. Predictors included team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is associated with negative effects on: perceived quality of care, patient satisfaction; adverse events; turnover; job satisfaction; and intent to leave.

Conclusions and Implications for Practice:
Unfinished care is a significant problem; prioritization strategies leave patients vulnerable to unmet educational and emotional needs. However, the science is limited by common method/source bias, a lack of transparency in secondary analyses, and inconsistency in the format of prevalence reports.