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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 327-336

Perspectives of Oncology Unit Nurse Managers on Missed Nursing Care: A Qualitative Study

1 Nursing and Midwifery Care Research Centre, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
2 Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

Date of Submission16-Aug-2017
Date of Acceptance22-Jan-2018
Date of Web Publication31-May-2018

Correspondence Address:
Fatemeh Ghaffari
Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apjon.apjon_6_18

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Objective: The main objective of this study was to explore factors affecting missed nursing care in oncology units from the perspective of nurse managers. Methods: Twenty nurse managers working at oncology units of referral teaching hospitals in Iran participated in this study. Data were collected through individual face-to-face and telephonic interviews using an interview guide. Focus groups were also conducted. Data were analyzed using conventional content analysis. Results: System structure, underlying factors, and barriers to missed-care reports were identified as factors that affect missed nursing care. Conclusions: Nurse managers should reduce the effects of nursing staff shortages and increased workloads in addition to providing materials and equipment. They need to distribute experienced staff according to the type of ward or patients' needs. Nurse managers should create a favorable environment for reporting missed nursing care by having an open relationship with nurses by teaching and emphasizing nursing practice. Moreover, using a nonpunitive managerial approach and minimizing the use of an apathetic management style can be helpful.

Keywords: Content analysis, Iranian nurses managers, missed nursing care, oncology, qualitative study

How to cite this article:
Dehghan-Nayeri N, Shali M, Navabi N, Ghaffari F. Perspectives of Oncology Unit Nurse Managers on Missed Nursing Care: A Qualitative Study. Asia Pac J Oncol Nurs 2018;5:327-36

How to cite this URL:
Dehghan-Nayeri N, Shali M, Navabi N, Ghaffari F. Perspectives of Oncology Unit Nurse Managers on Missed Nursing Care: A Qualitative Study. Asia Pac J Oncol Nurs [serial online] 2018 [cited 2021 Dec 2];5:327-36. Available from: https://www.apjon.org/text.asp?2018/5/3/327/233630

  Introduction Top

Given the large numbers of patients diagnosed with and treated for cancer annually, the toxicities associated with cancer therapies, and the substantial costs associated with treatment, high-quality cancer care is now a shared priority for policymakers, institutions, providers, and patients. Oncology unit nurses play a critical role in the delivery of care to hospitalized patients with cancer. The quality of care for cancer patients has received significant attention from a diverse array of stakeholders.

Despite nurse managers' efforts to provide high-quality healthcare management, concerns about patient safety [1] and quality of care [2] remain. A key factor affecting the quality of care is missed nursing care. Missed nursing care is defined as omitting or delaying the whole or a part of required care for patients.[3] The issue of missed nursing care is of particular importance in oncology units as cancer patients, and those who have low levels of immunity due to chemotherapy and similar treatments are mostly hospitalized there. Therefore, missed nursing care in such units may result in high mortality rates. Since nurse managers play an important role as part of the multidisciplinary team, they are in a crucial position to ensure that nursing interventions are implemented effectively. Effective execution of these interventions will resolve missed nursing care and thus provide an optimal environment for patients.[4]

Missed care not only affects the nursing practice but also system-wide management policies.[5] Nurse managers directly or indirectly encounter problems stemming from missed care. Managers' care evaluation efforts, communication with personnel, empowerment of nursing staff,[6] and handling of missed-care reports can affect the incidence of missed care.[7],[8] Nurse managers can identify factors that influence missed care in oncology units and counteract them; thus, they can prevent adverse effects on individuals or organizations. In this respect, managers play a key role in setting healthcare improvement principles and implementing necessary reforms to ensure safe healthcare for hospitalized patients with cancer.[4],[8] In addition, nurse managers are required to address incidences of missed care in oncology units to improve patients' health.[9] Globally, studies on missed care have investigated the following topics: the impact of teamwork on missed nursing care;[10] critical thinking, delegation, and missed care in nursing practice;[11] and compatibility between nurse managers' and staff's perceptions regarding missed nursing care and teamwork.[12]

Managers should be informed about missed nursing care in the units they manage. Furthermore, they play an important role in developing the quality of care administered to hospitalized patients with cancer as well as being essential decision makers. Thus, the question is: what are the perceptions of oncology unit nurse managers regarding the factors affecting missed nursing care? According to the latest reports, in 2008, there were 90,026 nurses working in Iranian health-care settings; 54,026 in general governmental hospitals; approximately 12,000 in military hospitals; 12,000 in social security hospitals; 6000 in private hospitals; and 6000 in prehospital emergency medical services. Only 1000 nurses work in oncology units.[13] Currently, Iran is facing nursing staff shortages, especially in oncology wards where it is estimated that the need is three times greater than the current number of nurses working in these units.[11] The majority of nurses and nurse assistants working in clinical centers hold Bachelor of Science in Nursing (BNS) degrees. However, most of the managerial positions are filled by nurses holding a master's degree. These nurses are commonly head nurses, educational supervisors, clinical supervisors, infection control supervisors, and chief nursing managers.[12] Iranian nurses face several undesirable situations, such as low social status, low income, high workloads, unreasonable working shifts, caring for many patients, as well as managerial problems such as a perceived lack of managerial support. These factors continuously influence the performance of nurses' basic duties, including comprehensive care of patients and providing patient comfort and safety specifically in oncology units, which altogether result in turnover intentions, nursing errors, and missed nursing care.[5],[6],[11],[14] Missed nursing care is among the factors that affect both the patient and the nurse her/himself. It may influence the patient's safety, satisfaction, and hospitalization period as well as the motivation, job satisfaction, absenteeism, and requests to change wards among nurses.[7],[14],[15],[16]

Despite the unfavorable outcomes of missed nursing care, this subject has not received the necessary attention from either nursing managers or the healthcare system as a whole. The existence of different clinical settings, the inability to predict incidents in such settings, the Iranian context, and the need for improved healthcare programs in Iran necessitates research on this topic. Thus, the present study aimed to determine factors affecting missed nursing care in oncology units from the perspective of nurse managers.

  Methods Top


This was an inductive qualitative content analysis study. Content analysis involved summarizing, describing, and interpreting data. Content analysis is also useful for determining the main themes from the text and assessing individual experiences and attitudes toward certain issues.[17]


Participants were selected using purposeful sampling with a maximum variation in sampling, which includes selecting participants according to age, gender, work experience, education level, and position. We enrolled participants from all nursing management levels, including chief nurse managers, supervisors, and head nurses, to evaluate missed nursing care in oncology units. Inclusion criteria were as follows: participants should be nurse managers with a BSN and at least 12 months' managerial experience who are employed on a full-time basis.

Samples were collected using purposeful sampling method with the maximum variant sampling (age, gender, work experience, education level, and position). Data collection continued until data saturation. The samples involved 20 nursing managers including matron, clinical supervisor, educational supervisor, and head nurse with Baccalaureate (BNS) and Master's (MS) degrees. They worked at hospitals affiliated to Tehran University of Medical Sciences. They had at least 12 months of work experience as managers.

Data collection

Data collection and analyses proceeded concurrently until data saturation was achieved. Data were collected through audio-recorded face-to-face interviews using an interview guide and probing questions. Researchers went to the oncology units of hospitals, introduced themselves, and presented the goal of this study. After they obtained permission from the hospital manager regarding the time and location of the interviews, they talked to the nursing managers. Researchers obtained the telephone numbers of participants to determine if there were any focus group secessions. Researchers mainly consulted with chief nurse managers to select a suitable participant. Interviews began with general questions and progressed to more detailed questions based on participants' responses. Initial questions were as follows: “What do you think about missed nursing care in oncology units?” and “As a nurse manager, what factors are involved in missed care for hospitalized patients with cancer?” A total of twenty interviews were conducted; each interview lasted for approximately 20–35 min. A subsequent telephonic interview of 10–20 min was conducted with each participant to supplement categories that emerged during data analysis. As focus groups enabled a discussion on disputed issues that emerged during interviews, two focus groups were conducted. Groups consisted of 3–4 nurse managers from two different management levels from different hospitals. One focus group was conducted for the top managers such as supervisors and chief nurses, whereas the other was for head nurses who have had personal experience with the phenomenon of missed care.

Focus group discussions took place at the end of the working shift in the office of either the head nurse or the researcher. The outcome of the focus group sessions was the approval of the emerged codes and individual interview information. Quotations were translated from Farsi to English before writing this manuscript.

Data analysis

The qualitative data analysis package MAXQDA10 was used for the initial stages of coding. MAXQDA10 is used for text analysis to create and categorize codes, and link research notes to codes.[16] Data were analyzed using content analysis following Graneheim and Lundman's method. The qualitative content analysis is a commonly used method in nursing. Through content analysis, it is possible to organize textual information into manageable content-related categories.[18] It can be an important tool for understanding emotions, perceptions, and health or education of participants.[16] First, interviews were transcribed verbatim and read several times to obtain an understanding of the whole process. Subsequently, the text was divided into meaning units, which were condensed. Condensed meaning units were abstracted and labeled with codes. Codes were then sorted into categories and subcategories based on comparisons regarding their similarities and differences. Finally, themes, as expressions of the latent content of the text, were formulated.

Ethical approval

This project was approved at the Nursing and Midwifery Care Research Center of Tehran University of Medical Sciences (registration number 18204). Participants were informed of the objective of the study and that they could withdraw whenever they desired; written informed consent was obtained from all participants. Participants were assured of the confidentiality of their data and were granted anonymity in all documents related to the research. The time and place of interviews were set according to participants' preferences. They were allowed to obtain the study results if desired. All ethical norms and rules pertaining to the use and publication of texts were followed.


To ensure the rigor of the data, we used different methods according to Guba's criteria.[17] Measures to ensure the trustworthiness of the study included the researcher's long experience (12 months) in the field, using various interview methods to obtain comprehensive data, eliciting in-depth and analytical descriptions, and maximum sampling variation. We analyzed the data independently and compared emerging themes together. Whenever there were a disagreement, discussions, and clarifications continued until a consensus was reached. In addition, a summary of the interviews was returned to the participants for member checking, and it was confirmed that researchers represented the participants' perspectives. We also conducted external verifications of the themes and categories. All results were given to two educational supervisors and head nurses who did not participate in the research, and their conclusions were compared with the present results. To do so, we sent parts of interview texts with their codes and emerged categories to observers with qualitative study experience to confirm the comments of participants and to prevent putting our views in coding.

  Results Top

Participant characteristics

Study participants included 20 oncology unit nursing managers. Their organizational levels included chief nurse managers, clinical supervisors, educational supervisors, and head nurses with bachelor's (BS) and master's (MS) degrees. Participants were chosen from three hospitals affiliated with the Tehran University of Medical Sciences. These hospitals are located in different regions of Tehran (the capital of Iran), and they accept patients from different provinces and varying socioeconomical levels. Participants' mean age was 34.13 ± 6.02 years. Head nurses, educational supervisors, clinical supervisors, and chief nurse managers who participated in this study were identified as “HN,” “ES,” “CS,” and “CNM,” respectively, in the result section. Other participants' characteristics are depicted in [Table 1].
Table 1: Biographical information of the participants

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Qualitative analysis

Study findings provided the definition of missed care according to the nurse managers, as well as factors relating to missed nursing care in oncology units, which were classified as system structure, contextual factors, and barriers to reporting missed care. Themes and subthemes are presented in [Table 2].
Table 2: Themes and subthemes

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Missed care from nurse managers' perspectives

Nurse managers defined missed care as “arbitrary elimination of care,” extended “delays in healthcare service provision,” or “ineffective compensatory measures.” One educational supervisor said, “Missed care occurs when care is forgotten advertently or inadvertently, and its elimination impairs the patient's treatment process.”

Another participant said, “When I see delays in nursing care practices, like reporting medical tests to the physician, sending requests for specialized consultations, ineffective implementation of the physician's orders such as diagnosis procedures and orders from other colleagues (such as physiotherapists or consulting doctors), I consider all of them examples of missed care” (HN).

System structure

Results of this study showed that organizational factors related to missed nursing care in oncology units include under-pressure staff, physical, and material structures, and the impact of structures on managerial roles.

Under-pressure staff

According to nurse managers', staff shortages, time constraints, and performing repetitive and time-consuming jobs can result in missed nursing care for hospitalized patients with cancer.

Staff shortages

Managers described staff shortages as the main factor causing missed care, noting, in particular, the major shortage of professional and assistant nurses, especially during the afternoon and night shifts. Unsuitable or delayed substitution of personnel during nurses' leave periods or absence increases the workload. Moreover, the healthcare agency's substitution policies, such as the use of unqualified personnel (e.g. relief nurses and nursing students) and enforcement of mandatory overtime during consecutive shifts, also results in missed care as revealed by delays or failures in service provision. Using inexperienced individuals as relief personnel is ineffective and imposes a high workload on experienced nurses. Inexperienced individuals lack knowledge on the location of equipment and tools, routine practices in the oncology ward, and patients' healthcare needs; they also spend considerable time obtaining such information from other staff members. “Relief nurses are not prepared to work in other wards as they are often clock-watchers” (CNM).

These wards also employ nursing students to compensate for staff shortages. According to participants, overconfidence among compensatory staff, acquisition of skills on a trial-and-error basis, and doing favors for managers to gain promotion cause irreversible damage to patients and the healthcare agency. Managers believe that the concurrent work and study among students and their inexperience regarding routine care threaten patient safety and reduce the extent and quality of healthcare services. “We often have to cover our shifts with nursing students. This is disastrous. These people are not yet ready for clinical work” (HN).

Healthcare agencies also temporarily employ new graduates with no work experience in oncology units. Due to the improbability of obtaining permanent employment and their temporary tenure, graduates lack organizational commitment and feel no obligation to fulfil their responsibilities. Scheduling personnel for consecutive shifts without breaks or leave on a mandatory basis is regarded as healthcare labor policy. “Most of our wards are full of temporary personnel. You cannot count on them. They do not feel committed to patients” (CS).

Nurses also delegate some or all their work to patients' companions (family members play the role of a companion in Iranian Hospitals) whose presence beside the patient's bed enables them to carry out healthcare procedures, interventions, or other care. This issue threatens patient safety due to the lack of knowledge regarding healthcare among companions. “Now, every patient has a companion at their bedside. Most of the patient's routine cares are assigned to them. They tire nurses by asking too many questions or preventing some healthcare services” (CS).

Nonspecialized staff, such as assistant nurses or nursing service personnel, also assist nurses, which further compromises service quality. “When I visit the wards unannounced, I see patient care technicians administering medicine. [They] have little knowledge about drug dosage, administration, or side-effects” (CNM).

Nursing staff shortages not only affect the quality or quantity of healthcare but also decreases nurses' motivation regarding comprehensive care provision or care based on scientific principles. This leads to forgetfulness, work overload, stress during their shifts, exhaustion, task conflict, and turnover intention. “Nurses are usually depressed and irritable due to their heavy workload. They are clearly fatigued when I take over the ward each morning” (HN).

Time constraints

Time constraint is the second key factor affecting missed care in oncology units. Nurses experience time constraints due to their multiple responsibilities, which include coordinating requested consultations, setting appointments for diagnostic procedures, and reporting to physicians, physiotherapists, nutrition advisors, nurse managers, and patients' families, among others. They spend an excessive amount of time admitting or discharging patients, balancing high nurse-patient ratios, and performing administrative and nonnursing tasks.

“Sometimes, it is necessary to send a patient to a well-equipped clinic for a CT scan or MRI. Nurses spend too much time making the necessary arrangements for such” (CS).


Documentation of nursing care using different forms is time-consuming and this results in summarized reports, a reluctance by nurses to refer to patients' files, and failure to provide efficient healthcare. “In a ward, I saw that a patient should have remained nil per os while the nurse had given him food without referring to his file” (CS).

Physical and material structures

Nurses believe that the shortage and nonfunctionality of materials and equipment essential to the type of unit are among factors related to a healthcare provider's structure, which play an important role in missed nursing care for hospitalized patients with cancer.

Shortage of materials and equipment

Outdated equipment results in a failure by nurses to provide healthcare services. Lack of state-of-the-art equipment for diagnostic procedures and treatment purposes or a shortage of efficient personnel causes the transfer or referral of patients to another facility. Sometimes, nurses compensate for equipment shortages by procuring equipment from other wards or through the patient's family. Moreover, regardless of shifts, nurses experience shortages of medical supplies. Delayed access to prescribed medicines during a given shift results in drug administration during the following shift. “When a patient is sent out for a CT scan or MRI, it takes an awful lot of time for them to return. This often factors missed administration of medicine and recording of vital signs” (HN).

The role of structure in managerial roles

Participants emphasized the role of nurse managers in incidences of missed care. Inefficient management is an obvious issue in cases of imposed programming that disregards issues such as nurses' efficiency, experience, skills, interests, patients' needs, and ineffective monitoring and follow-up systems. Inefficient managers cannot provide conditions for reporting, resolving, and preventing the recurrence of missed care. Most nurse managers try to plan functionally for the shortage of personnel who can adapt to the situation. Due to their workload, nurses cannot completely monitor and care for each patient, resulting in a higher chance of missed nursing care. Most senior nurse managers lack effective supervision methods based on scientific principles and do not use standard nursing checklists. Negligence is a commonly identified issue when preparing supervision reports for senior managers. Oncology nurse managers are expected to take note of poor performance or failure of equipment and facilities during their ward visits. However, they must often act according to nurse's reports and apparent issues, and thus, fail to resolve deficiencies. “Supervisors in all shifts make rounds in the wards. They see the problems and needs of those wards and receive reports to this effect. But it looks like things are written down only on paper. We have not seen any outcome from the rounds” (HN).

Underlying factors

Our results showed that noncomprehensive care and a failure to internalize a caring attitude are among the basic factors affecting missed nursing care in oncology units according to nurse managers' perspectives.

Noncomprehensive care

Neglecting the cancer patient's needs during care is one of the key factors of noncomprehensive care. When nurses do not pay attention to all elements of holistic nursing care focused on patients' needs, care becomes perfunctory, and the nursing process is neglected.

Perfunctory care

Perfunctory care is the most important contextual factor leading to missed nursing care in oncology units. Perfunctory care contributes to missed care due to the following factors: minimal patient contact, routine-oriented care, failure to check patients' details and administering medication only with respect to the bed number, failure to report necessary care during shift changes, failure to send patients' test samples to the laboratory and delays in following up results, performing only visible care, and passing responsibilities to others. Perfunctory care also contributes toward neglecting patient safety, ignoring patients' requests, placing medicine at the patient's bedside because they are asleep or not in the ward, and receiving orders over the phone and not recording them or obtaining colleagues' approval before carrying them out.

“Sometimes, I have seen numerous cases in which a patient rings the bell and no one attends to them … they even switch off the bell” (CS).

Unprocessed care

Another contributor to missed nursing care is the failure to thoroughly implement the nursing process in oncology units. Participants reported that nurses are unwilling to follow the nursing process due to insufficient knowledge of both nursing practices and theories, a lack of motivation and skills, or existing organizational barriers such as inefficient supervision and management of staff shortages. “Nurses use the nursing process during their internship only, and that is mainly on paper, that is, student assignments. It is not applied for the patient's benefit” (CS).

The patient's condition

Multiple factors contribute towards extra workload for nurses in oncology units, including patients' inability to explain their healthcare needs due to old age, low education levels, or being in a critical condition, as well as the inability by patients to practice self-care, among numerous other care needs. Nurses face many challenges when caring for cancer patients in a critical condition. These include coordinating patient care among many doctors, following consecutive orders from doctors, and communicating with the patient's family and care managers. These challenges further result in missed or delayed care. “When a critical patient is in the ward, the nurse has to allocate substantial time to him and also care for other patients. A messy ward is annoying… On many occasions, I have noticed that it's harder to educate aged patients about self-care due to time taking process” (EN).

Patients sometimes avoid aggressive medical procedures due to insufficient knowledge about its significance. Excessive time spent to inform patients, obtaining consent, and sometimes postponing these practices lead to missed care in oncology units. Care can also be missed when patients are reluctant to explain problems relating to their genitalia, do not adequately explain the problem, or are unwilling to allow a nurse of the opposite sex to care for them due to cultural restrictions. The patient's reluctance to receive some healthcare services or specify their needs to nurses in the presence of visitors also results in missed or delayed care. “On many occasions, while doing rounds in the ward, I noticed that a female patient had not allowed her IV cannula to be changed by a male nurse…We had a patient who had not told a female nurse that his genitals were itching. This caused him to contract acute herpes” (HN).

Failure to internalize a caring attitude

Many nurses do not have a caring attitude; they often want to act like physicians and simply assess radiological and laboratory findings, forgetting that a nurse's role involves caring. Therefore, they do not feel accountable to the patient. “Many newly educated nurses like to act like doctors. They hang a stethoscope from their neck and examine the patient. This is while they have forgotten their very role; that is, nursing care” (CNM).

Most participants believed that teamwork enhances productivity and nurses' skills, knowledge, and attitudes, which altogether may result in a better understanding of nurses' roles by doctors, and ultimately lower incidences of missed care. In contrast, a variety of other reasons, such as nurses' uncertainty regarding doctors' orders and a nonteam attitude toward healthcare, contribute to low confidence and disillusionment among nurses. “Failure to transfer the physician's orders to the nursing file due to writing orders at the time of shift handover, failing to coordinate patient visitation times with the nurse, and the nurse's failure to participate in therapeutic and caring decisions are key factors leading to missed care” (HN).

Barriers to reporting missed care

Barriers to reporting missed care in oncology units were classified into two categories: management barriers and personal characteristics.

Management barriers

Most managers believed that they are not informed of missed-care incidences, stating that accurate reporting of missed care by nurses would prevent the recurrence of it. False reports hamper the treatment process, increase the workload of other nurses and medical teams, threaten patient safety, increase the duration of patients' hospital stay, and can lead to recurrent hospitalizations, which can increase the cost of treatment incurred by patients and healthcare agencies.

Participants mainly recognized the barriers to report missed care as a cover-up by nurses due to the consequences of misreporting (e.g., legal problems such as possible job loss, patient complaints, or losing the chance of development in their job), inappropriate behavior by managers, strained relationships between managers and nurses, and an indifference or failure to react to reports. Nonetheless, participants believed that opportunities to report missed care could be increased if managers do not treat missed care as a crime but support reporters and create a nonpunitive environment.

“Nurses are hardly willing to report missed care incidents. They may have avoided reporting missed care for fear of job restructuring, or punishment in the form of suspension or dismissal” (CNM).

Another barrier to reporting missed care by nurses in oncology units is cover-ups by managers who fear being held accountable by the patient, senior managers, and the healthcare agency. “In most cases, I ignore missed care cases because I have reservations or do not want to be implicated or held accountable to the patient… on many occasions, after I reported (missed care) to the supervisor, not only did they not solve the problem, but also interrogated me” (HN).

Personal characteristics

Some personal characteristics such as fear of losing the patient's or colleagues' trust, low professional accountability, a lack of moral commitment, low confidence, and insufficient knowledge and skills regarding reporting missed care are considered the main barriers to nurses' reluctance towards reporting missed care in oncology units. “When my ward's nurse forgot to prepare the patient for the operating room and this forced cancellation of the surgery, she said “I do not care because this has happened anyway” (HN).

  Discussion Top

Participants in this study defined missed nursing care as an arbitrary elimination of care, extended delays in offering healthcare services, and ineffective compensatory measures against missed care. In a study by Kalisch, missed care was defined as the omission or delay in any part of nursing care needed by the patient;[19] however, the irreparability of missed care was not mentioned. This discrepancy may be attributable to factors such as cultural differences between the two study populations, differences in the types of facilities, variations in workforce training, and other systematic and nonsystematic factors that differ between Iran's oncology nursing field and that of other countries. Sochalski defined arbitrary elimination of care as a rationed nursing care, referring to the nurses' provision of care only when needed by patients.[16] Thus, the definitions of missed nursing care coined by Kalisch and Sochalski overlap to some extent.

Our findings showed that oncology nurse managers consider staff shortages and time constraints to be the most important factors within the healthcare agency's structure. In Iran, there are too few nurses per bed, which imposes heavy workloads on nurses in these environments.[20] Sufficient staff and organizational and managerial support are key to improve healthcare services and patient satisfaction.[7],[19],[21] Many studies have stressed the significance of the relationship between the level of nursing and the quality of nursing care 2, patient outcomes 16, and missed nursing care.[7] Newly educated personnel and nursing students are often utilized by nurse managers to compensate for staff shortages. One of the policies of the Iranian health system is to use senior nursing students to compensate for nursing shortages.[15] Our findings showed that such compensatory approaches are ineffective and cause serious damage to Iranian healthcare agencies.[22],[23] Nursing students and newly graduated personnel typically experience disillusionment, job dissatisfaction, burnout, and attrition due to their inexperience, feelings of redundancy, and sense of powerlessness.[22]

Compensatory approaches by nurses, such as delegating many of their nursing responsibilities to patients' companions and service personnel, are associated with serious threats to patient safety. The possibility of missed nursing care by these nurses is particularly high at night due to fatigue and a lack of designated break areas.[16] One of the compensatory measures taken by nurses to overcome staff shortages is assigning most of the patient's caring needs to their companions. In Iranian teaching hospitals, nurses frequently request the patient's family to stay and take care of the patient's needs, including evacuating the urine bag, bathing, and feeding the patient. This poses a threat to the patient's safety because companions are not educated or trained to take care of these needs.[24] Similarly, in other countries such as Lebanon and Turkey, many nursing responsibilities are delegated to patients' companions. In these countries, companions are considered as reserve healthcare providers and are partially assigned nursing responsibilities by nurses.[25] However, in Iran, companions are not trained for disease management and quality patient care. At times, their presence leads to overcrowding in the patient's room, thus, delaying emergency services. They also hamper the treatment process through unnecessary interference. In this study, some participants indicated that the underestimation of the nurse's role, arbitrary care without permission from nurses, and excessive interference with nursing activities occur due to the use of service personnel for nursing purposes.[24],[26]

Time constraint is another important contributor toward missed nursing care in oncology units, which is generally associated with a lack of contact with the patient, hasty and careless services, and delayed care provision. Schubert reported a meaningful relationship between patient outcomes and the ratio of nursing care (e.g., failure to perform nursing duties) due to time constraints to staffing levels.[15] In addition to the heavy workload, high patient-nurse ratios and the delegation of nonnursing responsibilities to nurses reduce the time allocated by nurses to patients and subsequently, the quality of nursing care declines.[27] The participants regarded perfunctory care as one of the main factors contributing to missed care. They attributed irresponsibility, indifference, and low professional commitment among nurses as reasons for the provision of perfunctory care.[2] Nurses attempt to boost the quantity of services provided to satisfy authorities within the system. Nurses' ignorance of patients' healthcare needs and mainly providing services with visible outcomes are associated with a sharp decrease in the quality of healthcare. These findings are consistent with the results of a study by Rafii et al.[28] Moreover, participants considered noncomprehensive care as another contextual factor leading to missed care in oncology units. Aimed at holistic care provision, the nursing process can play a key role in preventing missed care and increasing the quality of care.[3],[27] The implementation of the nursing process is a challenge in Iran, which calls for appropriate actions to be taken 27. The nursing process, which is defined as attendance to patients as a whole and taking care of their exclusive and universal needs, would result in wellness, enhanced quality of life for patients, and good nursing services.[27],[29]

According to participants, the failure to internalize a care-oriented attitude plays an important role in missed care. Failure to attend to patients' needs, avoidance of necessary care-related services, arbitrary prioritization of care services, daydreaming, and a lack of commitment toward patients and systems are the product of a noncaring attitude toward patient care. Institutionalization of a care-oriented attitude is essential to improve the quality of nursing care.[2] Since the nursing profession specifically involves serving vulnerable people, it requires motivated and hardworking personnel. Ensuring a sense of responsibility toward patient needs and concerns is a key factor in professional commitment and the willingness to provide care within a team.[23] This is in line with our finding that the failure to report missed care leads to recurrent missed care. A team response aimed at reducing the burden of personal responsibilities, providing managerial support for those who report errors, and training personnel regarding the objectives of reporting errors are effective in preventing recurrent missed care.[30]

Despite nurses' awareness of negligent practices, they often refuse to report missed care because of the fear of others' reactions and punitive measures.[31] Other factors affecting the failure to report missed nursing care include the fear of being blamed, powerlessness, and fears related to the consequences of admitting missed nursing care.[19] Other researchers have shown that after reporting the error, the earliest reaction by nursing managers is to punish the responsible nurse, which clearly results in unreported errors.[32],[33] Kabirzadeh et al. considered that errors and missed nursing care certainly take place in Iranian caring programs, but in most cases, outcomes are not improved when these errors or omissions are not reported to uphold the credit of nurses and nursing managers or to avoid being punished.[34] In contrast, researchers also believe that reporting professional errors is necessary for patient safety.[35] No specific reporting systems to record errors and missed nursing care exist.[32] Prevention measures can be taken to avoid potential outcomes related to not reporting errors and missed nursing care by designing a system which can change the option of reporting from “not to report” to “voluntary report.”[34] Participants in a study by Vaismoradi have indicated that they feel resentful and discouraged to report missed care when their efforts to report errors are undermined by managers.[36] Unfair practices by managers may lead to distrust and disillusionment among employees, which in turn result in depression symptoms as well as a decrease in the quality and safety of healthcare services.[37]

  Conclusion Top

Nurse managers can use the findings of the present study to identify factors affecting missed nursing care in hospitals and take measures to counteract them. Our results showed that nurse managers should put in more effort to reduce the pressure caused by oncology staff shortages and high workloads to reduce and prevent missed nursing care for hospitalized patients with cancer. This can be achieved through workforce distribution in wards according to the workload and experience of nurses. Oncology nurse managers can reduce the possibility of missed nursing care in units that require special care or have high numbers of patients by avoiding employing nursing students in these units. Providing the necessary materials and equipment can also be effective in decreasing the incidence of missed nursing care. In addition, nurse managers can reduce the possibility of missed nursing care by educating nurses about the nursing process and emphasizing its importance.

The study showed that nurses are faced with managerial and personal barriers in reporting missed care in oncology units. Nurse managers can provide suitable conditions to reduce missed nursing care by ensuring an open relationship with nurses, using nonpunitive management approaches, and avoiding an apathetic management approach toward missed nursing care. In addition, other effective approaches to reduce missed nursing care include a reasonable analysis of missed care and attempts to prevent it, as well as educating nurses about the reporting process.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Shali M, Ghaffari F, Joolaee S, Ebadi A. Development and psychometric evaluation of the patient safety violation scale in medical oncology units in Iran. Asian Pac J Cancer Prev 2016;17:4341-7.  Back to cited text no. 1
Atashzadeh Shoorideh F, Pazargadi M, Zagheri Tafreshi M. The concept of nursing care quality from the perspective of stakeholders: A phenomenological study. J Qual Res Health Sci2012;1:214-28.  Back to cited text no. 2
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Fatemeh Ghaffari


  [Table 1], [Table 2]

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