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Missed and rationed care: What do we know? – Review of qualitative studies

Dominika Kalánková*, Daniela Bartoníčková**, Katarína Žiaková*, Radka Kurucová*
* Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Department of Nursing
** Charles University in Prague, 2nd Faculty of Medicine, Department of Nursing


KALÁNKOVÁ, D. –  BARTONÍČKOVÁ, D. – ŽIAKOVÁ, K. – KURUCOVÁ, R. Missed and rationed care: What do we know? – Review of qualitative studies. In Ošetrovateľstvo: teória, výskum, vzdelávanie [online], 2020, vol. 10, no. 1, pp. 18-23. Available on:

Aim: To review qualitative studies that examine missed and rationed care.

Background: The qualitative research of missed and rationed care is limited but offers us a perspective on this multidimensional problem.

Methods: The research was conducted between March 2018 and December 2019 using three scientific databases PubMed, Scopus, and Web of Science. We examined 22 full-text qualitative studies using the CASP tool resulting in 16 eligible studies for further analysis. A thematic analysis was used.

Results: Five themes were identified in our review - elements of care regularly missed or rationed, main reasons and consequences of missed and rationed care, barriers to report the phenomena and strategies on how to prevent its occurrence. Studies reflected the insight of nursing students, nurse managers, patients and nurses.

Conclusion: According to the findings of this review, more focus should be placed on the implications for nursing students, nurse managers and patients, but also for nurses to gain a deeper understanding of the phenomenon of missed and rationed care.

Key words: literature review; qualitative research; missed care; rationed care; nurse


Nowadays, increased attention is given to the phenomenon of missed and rationed care in the context of research conducted in the field of nursing. Furthermore, in the last decade, the number of publications concerning the conceptualization of the phenomenon has increased. More focus is also concentrated on the impact of the phenomena on nurses providing continuous nursing care as well as on the health status of patients (Jones, Hamilton, Murry, 2015, p. 1122). To investigate the concepts of missed and rationed care from different perspectives, it is possible to apply qualitative research. However, while these concepts have different definitions, authors conducting the qualitative research may use these terms interchangeably. According to Kalisch and colleagues (2009, p. 1510), missed nursing care is a delay in or omission of nursing care activities. On the contrary, according to Schubert and colleagues (2007, p. 417), rationed care is the withholding of or failure to carry out nursing care activities due to insufficient resources. Not only in the non-English literature, these concepts are frequently replaced but rationed care is the process of decision-making of nurses in the context of the prioritization of nursing care resulting in an outcome – missed nursing care (Jones, Hamilton, Murry, 2015, p. 1122). Resulting from both problems, the most frequently missed and rationed nursing care activities are those that nurses are competent to initiate based on their knowledge and skills – the independent ones, such as hygiene care, patient education or turning. Different perspectives may reveal activities regularly missed or rationed, but also reasons for its omission and the moral and ethical aspects. One of the perspectives is the point of view of nursing students, who have already been introduced to clinical practice and have been in contact with patients. Students are direct providers of nursing care, and in some way influence the prevalence of missed care and/or are the agent of rationed care at specific workplaces (Bagnasco et al., 2017, p. 1). A valuable perspective is also the point of view of registered nurses who are often afraid to express their opinions regarding the issues of the phenomenon through quantitative methods, therefore, methods like focus groups or interviews are frequently used (Scott et al., 2018, p. 2–4). The third perspective from which one may get a better understanding of the phenomenon of missed care and rationed care is the point of view of nurse managers who need to find a solution to the causes of the occurrence of the phenomenon and implement strategies to eliminate the phenomenon (Willis et al., 2017, p. 3107). On the other hand, the phenomenon of missed care and rationed care does not concern only the providers of nursing care. Most significantly, it affects the patients themselves, and it was proved that their views are essential to understanding the phenomenon (Kalisch, Xie, Dabney, 2014, p. 415). In addition to various perspectives from the phenomenon can be viewed, the qualitative research into the subject offers us a more in-depth look into the ethical and moral aspects of missed care and rationed care (Scott et al., 2018, p. 1–2). Because of this, we focused our study on the summarization of qualitative research regarding the phenomenon relating it to the exploration of common themes from previous studies to understand the phenomenon better.


To review and synthesize qualitative research in order to examine missed and rationed care. The research question was stated as follows: What has been known about missed and rationed care from different perspectives in qualitative studies?


The paper has a character of the literature review of qualitative studies. The search was performed between March 2018 and December 2019 in three scientific databases PubMed, Scopus, and Web of Science because of its availability at Comenius University in Bratislava, where the study was conducted. The same key terms were used to search in the above-mentioned databases: missed care, rationed care, qualitative research, nurse, patient, student, manager. The selection was limited by the following search criteria: language (English), empirical studies, publishing year (2000–2019), which was stated based on the increasing number of publications during the last two decades. According to the predefined key terms, 138 studies were found following their titles and abstracts, in selected databases as follows: PubMed 28, Scopus 49, and Web of Science 61. After removing duplicates, 105 studies were further analyzed. The inclusion criteria used was: a) qualitative studies regarding missed care, b) qualitative studies regarding rationed care, c) peer-reviewed articles. The exclusion criteria were: a) reviews, commentaries, story-tellings, b) mixed-method studies, c) not focus on nursing. The search was conducted following the PRISMA recommendation (Fig. 1). After applying the inclusion and exclusion criteria, we got 22 studies which were read as full-texts. To assess the suitability of the retrieved studies and to obtain the most relevant resources, a quality appraisal tool was used – Critical Appraisal Skills Programme (CASP) for quality assessment of qualitative studies (CASP, 2018) and applied by two independent reviewers. The main criterion for including a study for review was the score received between 8 to 10 positive answers to the ten possible answers available. Reviewers stated this criterion based on the inclusion of only high-quality papers regarding its methodology. The rest of the papers were excluded because of inappropriate methods of data collection which did not reflect the research questions or because of unclear data analysis. Overall, 16 studies were included in the qualitative analysis. The data analysis was conducted using an inductive thematic analysis described by Braun and Clarke (2006, p. 16–23), which is divided into 6 steps – familiarization with the data, generating initial codes, searching, reviewing defining themes, and writing up.

Figure 1 Flow diagram – recommendation PRISMA


The most studies (n = 16) included in our review used the concept of missed care whilst one study explicitly focused on
rationed care (Table 1). Most of these studies aimed to describe the phenomenon in the specific context (e.g., Dehghan-Nayeri et al., 2018; Wolf et al., 2017) or to provide the data for the development of specific measuring tools (e.g. Kalisch´s MISSCARE Survey). Some of studies aimed to provide theoretical explanations for the occurrence of missed or rationed care
(e.g., Henderson et al., 2016; Willis et al., 2016). Based on the thematic analysis of included studies, five themes emerged:
elements of care activities regularly missed or rationed, leading causes of missed or rationed care, its consequences and
barriers to report these phenomena and strategies on how to prevent missed or rationed care.

Tab. 1 Overview of studies included in the review
Author, year Aim Sample (n) Data collection Data analysis CASP
Kalisch, 2006 To identify missed care activities and its reasons. n = 107 RNs*, 15 licenced practical nurses, 51 NAs** Focus groups Grounded theory 9
Bittner, Gravlin, 2009 To explore the delegation of nursing care by RNs. n =27 RNs Focus groups Content analysis 9
Kalisch, Gosselin, Choi, 2012 To explore missed care and its reasons in different care units. n = 60-120 RNs Focus groups Grounded theory 8
Kalisch, McLaughlin, Dabney, 2012 To identify elements of missed care and its extension. n = 38 patients Semi-structured interviews Thematic analysis 10
Winter, Neville, 2012 To explore the concept of missed care within a New Zealand context. n = 5 RNs Semi-structured interviews Inductive analysis 8
Papastavrou, Andreou, Vryonides, 2014 To investigate the perceptions of RNs about prioritizations, omissions and rationing of nursing care. n = 23 RNs Focus groups Inductive analysis 10
Dehghan-Nayeri, Ghaffari, Shali, 2015 To explore nurses’ experiences of missed care and factors affecting it. n = 23 RNs Face-to-face interviews, phone interviews, focus groups Content analysis 10
Coker et al., 2016 To explore how RNs provide bedtime oral hygiene care and what factors influence their ability to provide oral care. n = 25 RNs Observation, conversations, interviews, analysis of the documents, tools, equipment Thematic analysis 9
Henderson et al., 2016 To explore the impact of rationing of staffing and other resources upon delivery of care. n = 21 RNs Semi-structured interviews Thematic analysis 10
Moore et al., 2016 To describe RNs perceptions of dynamic patient events impact on workflow and patient care. Not specified Focus groups Thematic analysis 8
Rooddehghan, Yekta, Nasrabadi, 2016 To investigate aspects of rationing of nursing care in Iran. n = 18 RNs In-depth unstructured face-to-face interviews Content analysis 9
Willis et al., 2016 To suggest the strategies on how to prevent missed care. n = 15 RNs Interviews Thematic analysis 9
Kalfoss, 2017 To explore nursing students´ perceptions of missed care in Norway. n = 31 nursing students Focus groups Content analysis 9
Wolf et al., 2017 To investigate RNs perceptions of factors involved in safe staffing levels. n = 26 RNs Focus groups Inductive analysis 9
Dehghan-Nayer et al., 2018 To identify factors affecting missed care in oncology units from the perspective of nurse managers. n = 20 nurse managers Interviews (face-to-face, telephonic) Content analysis 9
Gibbon, Crane, 2018 To explore the impact of missed care on the professional socialisation of nursing students. n = 18 nursing students Focus groups Thematic analysis 9

Legend: * registered nurses; ** – nursing assistants

Activities regularly missed or rationed

The first qualitative study exploring missed care was conducted by Kalisch (2006). She identified the elements of care regularly missed, including patient ambulation, turning, feeding, hygiene care, patient teaching and/or emotional support. The evidence is consistent with the study of Gravlin and Bittner (2009) who added skin and mouth care which was reiterated by Winters and Neville (2012) reporting patient surveillance is one of the most missed care activities. Dehghan-Nayeri, Ghaffari and Shali (2015) found that Iranian nurses most omitted communication with patients. Likewise, discharge planning was found to be omitted by nurses (e.g., Gibbon, Crane, 2018; Kalisch, Gosselin, Choi, 2012). Moreover, one study specifically focused on performing oral care to patients and Coker and colleagues (2017) found that specific activities such as assessing the outcomes of oral hygiene care or assessing of oral health in general which are usually observed utilizing the standard tools are often missed. According to Papastavrou, Andreou and Vryonides (2014), the most rationed care activities were the independent ones, such as hygiene care, especially mouth care, nutrition care and regular monitoring of vital signs. In another study by Willis and colleagues (2016), it is stated that nurses were not toileting patients appropriately as well as they were omitting standard rounds within care units. Another nursing care activity being rationed by nurses was reported in the study of Henderson and colleagues (2016) and described as delays in cleaning and preparing rooms for patients leading to complications in admitting patients to wards. Besides, several authors confirmed the least frequently missed care activities are the dependent ones, such as monitoring the vital signs (Kalisch, Gosselin, Choi, 2012), application of the intravenous therapy and administration of medication (Dehghan-Nayeri, Ghaffari, Shali, 2015).

Reasons for missed or rationed care

According to several authors (e.g., Dehghan-Nayeri et al., 2018; Kalfoss, 2017), the leading cause of missed or rationed care are labour constraints which result in time constraints (e.g., Moore et al., 2016) or work intensification (Willis et al., 2016) but also in performing non-nursing duties (e.g., Deghan-Nayeri et al., 2018). Another reason for missed care is differing prioritisations of care (Gibbon, Crane, 2018; Coker et al., 2017), working only according to minimal standards instead of providing good or excellent care (Papastavrou, Andreou, Vryonides, 2014), ineffective or poor teamwork (e.g., Kalisch, McLaughlin, Dabney, 2012), an ineffective delegation of nursing tasks and poor coordination of care (e.g., Kalfoss, 2017), and lack of communication (e.g., Winters, Neville, 2012). Other reasons included time-consuming rounding or not appropriate rounding (Willis et al., 2016), but also increasing needs and demands of patients (e.g., Papastavrou, Andreou, Vryonides, 2014), routinism and taking care of VIP patients (Rooddehghan, Yekta, Nasrabadi, 2016) as well as unavailability of medication after hours (Henderson et al., 2016). Other reasons for missed care reported in the studies were professional constraints (Kalfoss, 2017) such as lack of motivation of nurses (Dehghan-Nayeri, Ghaffari, Shali, 2015), feelings of frustration and dissatisfaction (e.g., Gravlin, Bittner, 2009), forgetting the role of nursing (Dehghan-Nayeri et al., 2018), and „it’s not my job“ syndrome (Kalisch, 2006).

Consequences of missed or rationed care

Several consequences were reported, mainly regarding the negative outcomes for patients (Gibbon, Crane, 2018), in the context of impaired patient safety (Dehghan-Nayeri, Ghaffari, Shali, 2015; Wolf et al., 2017), for instance, impaired skin integrity (Winters, Neville, 2012), increased incidences of patient falls (Willis et al., 2016) or medication errors (Dehghan-Nayeri et al., 2018). Furthermore, patient satisfaction decreases (e.g., Winters, Neville, 2012) which is often a result of the impaired development of a therapeutic relationship between nurses and patients (Moore et al., 2016). Furthermore, due to delays in admitting patients to care units, patients needed to be kept outside the wards, in corridors or treatment rooms, until space was available for them (Henderson et al., 2016). Other consequences were related to nursing outcomes, e.g., nurses felt guilty or sad when they could not complete the necessary nursing care activities for their patients, or they could not deliver proper care (e.g., Rooddehghan, Yekta, Nasrabadi, 2016) resulting in an overall dissatisfaction among nurses (Papastavrou, Andreou, Vryonides, 2014). Missed care also negatively affects nurses in the context of the development of burnout syndrome and fatigue as well as causing anxiety (Dehghan-Nayeri, Ghaffari, Shali, 2015; Wolf et al., 2017) resulting in the decision to leave the position or nursing profession entirely (e.g., Gravlin, Bittner, 2009). Gibbon and Crane (2018) also described the influence of missed care on nursing students´ career aspirations. Students are more likely to be inclined to choose the acute care settings instead of long-term settings. Likewise, students had negative feelings about nursing and nursing care in general. Besides, students´ awareness of missed care negatively impacts their professional socialization.

Barriers in reporting missed care

Only two studies examined the barriers in reporting missed care (Dehghan-Nayeri, Ghaffari, Shali, 2015; Dehghan-Nayeri et al., 2018). Both explored this topic from the perspective of Iranian nurses. One of the serious barriers in reporting missed care was the fear of confrontation with nurse managers, particularly given the legal ramifications of missed care (Dehghan-Nayeri, Ghaffari, Shali, 2015). Also, inappropriate behaviour by nurse managers was mentioned to be a significant reason not to report missed care. On the contrary, personal characteristics of nurses such as low confidence, lack of moral commitment, insufficient knowledge and skill regarding reporting missed care (Dehghan-Nayeri et al., 2018) or lack of empathy (Dehghan-Nayeri, Ghaffari, Shali, 2015) were described as powerful barriers that resulted in not reporting missed care.

Strategies on how to prevent missed or rationed care

Two of the qualitative studies emphasized the importance to empower teamwork within care units (Gibbon, Crane, 2018; Wolf et al., 2017). One of the effective strategies how to prevent this occurrence of missed or rationed care in acute care settings could also be increasing nursing staff numbers to ensure the standard of nursing care provided is upheld (Henderson et al., 2016; Wolf et al., 2017). Despite the fact, that the strategy is to hire more nurses, it seems to be a global problem obscured by several factors such as decreased motivation among nursing students as well as low salaries or poor conditions in the nursing work environment. Wolf and colleagues (2017) recommend improving the work environment of nurses and making it more satisfactory and supportive as one of the main preventive strategies. Besides, making the care more routinized (making rounds) could be a way how to avoid missed or rationed care (Gibbon, Crane, 2018). Henderson and colleagues (2016) emphasize the need to influence the unwillingness of medical staff to provide care after hours that causes complications when delegating tasks.


Through our research done by reviewing various qualitative studies, we focused our attention on missed and rationed care. Our findings suggest the need to focus on nursing students during their clinical training because of their awareness of the phenomenon causing the negative view of nursing practice and the profession in general. At last but not least, it is important to provide nurse managers with the phenomena with the aim to plan the strategies on how to prevent, reduce or eliminate missed or rationed care. Still, there is a gap in the literature related to patients´ perspective of the phenomena. Considering that in the Slovak and Czech Republic there is growing interest in this issue, knowledge of this area can, therefore, help the nurses, nursing students and nurse managers to know more about missed or rationed care especially concerning the activities that take place, their reasons, consequences and strategies on how to prevent them. This is important because of the negative impact of the phenomena mainly on patient outcomes.


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Mgr. Dominika Kalánková

Ústav ošetrovateľstva JLF UK
Malá Hora 5
036 01 Martin
Slovenská republika

Received: 21st April 2020
Accepted: 11th Maj 2020