
==== Front
Nurs Open
Nurs Open
10.1002/(ISSN)2054-1058
NOP2
Nursing Open
2054-1058
John Wiley and Sons Inc. Hoboken

10.1002/nop2.70042
NOP270042
NOP-2024-Feb-0385.R4
Empirical Research Qualitative
Empirical Research Qualitative
Nurse experiences and perspectives with missed nursing care during COVID‐19: A qualitative study
Rochman et al.
Rochman Monica https://orcid.org/0000-0002-8709-2416
1 2 mfrochman@widener.edu

Mount‐Campbell Austin 2 3
Fernald Catherine Shull 2 3
1 Widener University School of Nursing Chester Pennsylvania USA
2 Christiana Hospital Newark Delaware USA
3 Independent Researcher, Newark, Delaware USA
* Correspondence
Monica Rochman, Widener University School of Nursing, One University Place, Founders Hall, Room 323, Chester, PA 19013, USA.
Email: mfrochman@widener.edu

17 9 2024
9 2024
11 9 10.1002/nop2.v11.9 e7004222 8 2024
15 2 2024
03 9 2024
© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Abstract

Aim

This study aimed to determine clinical nurse and nurse manager perspectives on missed nursing care (MNC) during the COVID‐19 pandemic.

Design

This study utilized a qualitative exploratory descriptive design.

Methods

Data were obtained through focus groups and virtual interviews. Purposive sampling was used to select nurse and nurse manager participants in COVID‐19 units and the Emergency Department in one large healthcare organization in the northeastern United States of America.

Results

A total of 15 nurses and nurse managers participated in the study. Results revealed five categories: medication delivery, turning patients, double checks, communication and rapport, and patient surveillance.

Conclusions

A variety of factors contributed to the perceptions and experiences of MNC of COVID‐19 patients during the early stage of the pandemic. The COVID‐19 crisis put additional and unparalleled pressure on a strained nursing workforce. Hospital leaders are responsible for ensuring their frontline nurses have the resources they need to feel supported in their roles regardless of the presenting circumstances.

Implications for the Profession

Nurse leaders should employ evidence‐based strategies such as promoting and championing teamwork to support staff and reduce incidences of MNC during crises. Our current work may serve as a basis for informing future revisions of pre‐pandemic measurement tools when applied in a pandemic‐specific context.

Reporting Methods

This manuscript adheres to the standards for reporting qualitative research (SRQR); a synthesis of recommendations.

Public Contribution

There was not patient or public contribution for this study.

COVID‐19
missed nursing care
pandemic
quality and safety
State of Delaware 10.13039/100025212 Delaware IDeA Network of Biomedical Research Excellence 10.13039/100013429 National Institute of General Medical Sciences 10.13039/100000057 U54‐GM104941 source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:17.09.2024
Rochman, M. , Mount‐Campbell, A. , & Fernald, C. S. (2024). Nurse experiences and perspectives with missed nursing care during COVID‐19: A qualitative study. Nursing Open, 11 , e70042. 10.1002/nop2.70042
==== Body
pmc1 INTRODUCTION

In a pandemic, nurses will likely find themselves in an environment with competing demands that create goal conflicts due to time and resource constraints. This results in the need to balance crisis management and professional nursing standards of care (American Nurses Association, 2020). Nurses must ration their attention and use their clinical judgment to prioritize patient care activities across patient assignments when resources are limited. Evidence suggests that nurses prioritize care based on patient needs and may not complete other required responsibilities such as ambulation, emotional support, or patient teaching (Kalisch & Williams, 2009). These issues reflect the challenges experienced by healthcare organizations and nurses during COVID‐19 due to problems with scarcity.

This problem of scarcity accelerates the incidence of missed nursing care (MNC) through clinical priority setting, which may result in care left undone. MNC, also referred to as tasks left undone, unfinished nursing care, or implicitly rationed care, is defined as any aspect of required patient care that is delayed or omitted, either in part or completely (Kalisch & Williams, 2009). These incidents are common universal phenomena experienced in healthcare organizations, and pre‐pandemic estimates of the prevalence where one or more tasks are left undone are between 55% and 98% internationally (Jones et al., 2015). MNC can affect patient and nurse outcomes (Chaboyer et al., 2021; Hessels et al., 2019; Jones et al., 2015). Given the known impact of MNC on patient safety and quality during routine care, it is vital to investigate the potentially significant influence of a pandemic on the delivery of nursing care.

2 BACKGROUND

Several cross‐sectional studies in recent years investigated the concept of MNC during the COVID‐19 pandemic within varied settings and results utilizing the MISSCARE Survey developed previously (Kalisch & Williams, 2009). A comparative study of MNC was conducted in Sweden during the first wave of the pandemic (von Vogelsang et al., 2021). Findings revealed few differences between pre‐pandemic and pandemic elements of MNC; nurse perceptions of patient safety and quality of care remained the same pre‐pandemic. However, another study conducted in critical care units in Sweden in pre and pandemic periods found a significant increase in mouth care missed between study periods (Falk et al., 2022). A similar study that utilized the Arabic version of the MISSCARE survey observed that MNC significantly increased nursing the pandemic; however, the highest elements of MNC (ambulation) were similar to pre‐pandemic perceptions (Alfuqaha et al., 2023), Nymark et al. (2022) aimed to investigate MNC and patient safety during the first wave of the COVID‐19 pandemic. This study used a cross‐sectional, comparative design. The authors found that reported instances of MNC were similar when compared to a reference sample of nurses from the same unit prior to the start of the pandemic. The authors concluded that the novelty of the COVID‐19 patient was likely responsible for these findings (Nymark et al., 2022).

A cross‐sectional study of 135 nurses in Iran working in COVID‐19 units investigated the reasons for and type of care missed in their sample. Frequently missed items included emotional support, patient feeding, and patient teaching. Unbalanced patient assignments and acute changes in patients' conditions displayed significance for reasons MNC (Hosseini et al., 2023).

Gurková and colleagues (Gurková et al., 2022) conducted a cross‐sectional study in the Czech Republic using the MISSCARE survey and Practice Environment Scale of the Nurse Work Index. Findings revealed a higher reported frequency of missed elements of fundamental nursing care (e.g. emotional support, turning the patient every 2 h, and oral care) in perceived unfavorable nurse environments. The prevalence of MNC in this sample was associated with overtime and nurses' perceptions of the ‘foundations of quality of care’ as measured by the Practice Environment Scale.

Adequate patient surveillance was identified as the most frequently reported MNC activity in a cross‐sectional study conducted with frontline nurses and nurse managers in the Philippines. However, overall, MNC was not common among this sample (Labrague et al., 2022). Another cross‐sectional study found that documentation and response to call lights were the tasks most frequently missed in their study of 536 registered nurses in Jordan. Communication issues and adequate staffing resources had the highest impact on MNC within this sample (Khrais et al., 2023).

Potential limitations of the quantitative research on MNC during the COVID‐19 pandemic have been that it has been conducted utilizing quantitative analyses of survey data with instruments developed before the pandemic. It is still being determined if these tools can adequately capture the elements of MNC during such a disruptive time in healthcare. Furthermore, while these study findings used the MISSCARE survey instrument, results were mixed; a qualitative approach may present descriptive information and identify other elements of MNC, which may complement recent findings.

One qualitative study investigated perspectives from 14 Registered Nurses in Iran to explain the causes of MNC from the Iran nurse perspective (Safdari et al., 2022). The investigators uncovered reasons for MNC, including unfinished care, care at the wrong time, incomplete care and incorrect care (Safdari et al., 2022). The same study team published a secondary study that categorized factors that formed MNC, which included care‐related, disease‐related, patient‐related, and organization‐related factors that contributed to MNC (Safdari et al., 2023). Despite these findings, these studies did not investigate elements of MNC that might have been unique to a pandemic environment.

Given the novel virus and the tremendous impact on healthcare delivery and nursing practice, understanding MNC within the context of a pandemic may help aid the development of pandemic‐specific assessments and interventions. This study aimed to describe nurses' perspectives on MNC for COVID‐19 patients during the early days of the pandemic.

3 METHODS

3.1 Design

The researchers used a qualitative descriptive design. Qualitative data were obtained via 60‐minute focus groups; additionally, two one‐to‐one virtual interviews were conducted with two clinical nurses who required flexibility with scheduling. This approach was selected to promote discovery and to ensure nurses' had the ability to expand on topics. It allowed for deep discussion that extended beyond the inherent bias and superficial questions found in the one‐sided approach of surveys (Halloway & Galvin, 2017). Further, as our goal is to learn from the nursing perspective, focus groups allow for discovery in an atmosphere built around openness and camaraderie; validating individual feelings and experiences when listening to others who had similar experiences related to a topic as sensitive as MNC (Papastavrou et al., 2014). Additionally, focus groups allow for real‐time probing and clarifying questions while allowing the research team to associate feelings, concerns, passion, etc. associated with the topic discussed (Halloway & Galvin, 2017). This level of context, personal interaction, and probing ability are able to enrich the data that can not be achieved by other more removed, impersonal, and ridged data collection methods such as surveys.

3.2 Study setting and sample

The study was conducted in a large health system in the Northeast United States with nearly 4000 nurses and nine COVID‐19 units. Purposive sampling was used to select clinical nurses and manager participants who treated patients with COVID‐19 either on COVID‐19 units or in the emergency department. A purposive sampling strategy was appropriate because the phenomena of interest was directed towards nursing care of COVID‐19 patients (Halloway & Galvin, 2017). Inclusion criteria were: (a) Registered Nurses who provided direct patient care to COVID‐19 patients or (b) registered nurse managers on a COVID‐19 unit or in the Emergency Department and, (c) the ability to attend a session outside of scheduled work time. Exclusion criteria were: (a) Registered Nurses who did not provide direct patient care to COVID‐19 patients', or (b) registered nurse managers not on a COVID‐19 unit or in the Emergency Department.

3.3 Recruitment procedure

Recruitment took place between July 2020 and August 2020. Two rounds of recruitment emails were sent two  weeks apart to all Registered Nurses and nurse managers working on COVID‐19 designated inpatient units or the emergency department to invite them to participate in the study. The principal investigator followed up privately with respondents to the recruitment email and screened candidates to ensure they met eligibility requirements. Potential candidates who responded were given a study number and asked to choose their available pre‐scheduled dates to meet for in‐person focus groups. The participant study number was only known to the principal investigator. The focus groups were pre‐scheduled on the hospital campus and were scheduled at varying times to allow participation with a variety of shifts. Participants who desired to take part but preferred to do a virtual interview due to scheduling or social distancing concerns were offered the option of a one‐to‐one virtual interview. Our final sample of 15 participants consisted of nurses and nurse managers.

Clinical Registered Nurses and nurse manager participants received $35.00 on a prepaid credit card; additionally, a meal was provided during focus groups. Participant benefits were provided as compensation for the time associated with the focus groups or virtual interviews.

3.4 Data collection

Two 60‐min in‐person focus groups took place on hospital campuses. Study investigators and nurse participants adhered to state and federal masking with social distancing guidelines as outlined per institutional policy. Two virtual interviews occurred via Microsoft Teams and lasted 50–60 min in August 2020. A qualitative researcher on our team conducted all interviews. This was done due to the researcher's qualitative experience and the  fact that the nurses would consider this person a third‐party as this investigator was not part of the nursing department. Interviews were conducted following a semi‐structured discussion prompt. Both collection techniques offer different advantages. Focus groups benefited from group think and camaraderie among the participants. One‐on‐one virtual interviews benefited from increased anonymity (Polit & Beck, 2017). To achieve data saturation, we employed a systematic approach, continuously comparing new data from both focus groups and individual interviews to existing categories. Specifically, after analyzing the data from each session, we reached a point where no new categories were identified, indicating that saturation was achieved. Discussion prompts were utilized during the focus group and virtual sessions to engage participants in conversations related to their experiences while providing care for COVID‐19 patients. These discussion prompts were created in collaboration with the study team to uncover the experiences of front‐line nurses during the first wave of COVID‐19. Tell me about your experience with missed care or unfinished care while caring for COVID‐19 patients

Tell me about how you prioritize when providing care for COVID‐19 patients.

All interview sessions were digitally recorded using two separate audio devices and transcribed by a third‐party organization. The co‐investigator also took field notes throughout each session, as it is crucial for capturing non‐verbal cues and context that may not be evident in audio recordings (Polit & Beck, 2017). Field notes, transcriptions, and audio recordings were used from all interviews and focus groups during data analysis, with all data being combined regardless of interview type.

3.5 Data analysis

We ascribed to studying the perceptions of practitioners operating at the ‘sharp end’ of the system from a human factors perspective (Cook & Woods, 2018). Practitioners and, in this case, nurses, at the sharp end, physically interact with patients. Since our data was the perceptions of nurses caring for patients with COVID‐19 during a pandemic, we used a bottom‐up approach, which allows the data to inform a perception of the Work‐as‐Done by practitioners (Dekker, 2006). An iterative coding process method was used based on the work of Glaser and Strauss's constant comparison; this is when raw data is sorted, organized and structurally grouped according to their aligning attributes (Brixey et al., 2007). A single investigator analyzed the data using NVivo12, iteratively memoing until a coding scheme or code book could reliably be developed; a single node was not escalated to a code, that is, multiple participants had to comment or confirm a similar experience (Brixey et al., 2007). The virtual sessions were one‐on‐one. Both session types used the same discussion prompts. They were analyzed in the same methods as the focus groups; the audio recording of the session was transcribed and then iteratively removed until representative categories emerged (Brixey et al., 2007). This coding process utilized both the transcriber's field notes and audio transcripts. The virtual participants had the same motivation and willingness to discuss their job tasks and processes during the pandemic's peak and how it impacted their workload and patient care. Naturally, as there was only one individual in the virtual interviews, these participants lacked the ability to commiserate or remind other participants about stories related to our discussion prompts. The investigator worked with a research assistant and performed an inter‐rater reliability check of the codebook by coding a random sample of 10% of the data, eventually resulting in a Cohen's Kappa of 0.83 (Saldana, 2021). The investigator then used the code book to analyze the remaining data, discovering the emergent categories. Glaser and Strauss's constant comparison method emphasizes the ongoing comparison of data to refine categories by continuously evaluating whether new data fits into existing categories or whether new categories need to be developed. The one‐to‐one interviews provided some more depth that was needed for this process, and for each category, it was determined that data saturation had been obtained after no new data were being uncovered in the focus groups or one‐to‐one interviews that would lead to the creation of new categories (Aldiabat & Le Navenec, 2018).

3.6 Rigour

Credibility was established by creating a cordial environment through the interviews and focus groups by a third‐party investigator outside the nursing department. This third‐party researcher also allowed sufficient time to collect data to obtain an in‐depth understanding of perspectives. Credibility was also established by reviewing preliminary results through peers at a nursing professional governance council (Polit & Beck, 2017). The results were confirmed to be consistent with the nurses' experience in the council, prompting many to share affirming stories of their experiences. Confirmability was established by measuring coding accuracy through interrater reliability (Saldana, 2021). To ensure confirmability, we discussed in detail the study setting, data collection and analysis methods and the development of categories that the research team reviewed and agreed upon (Polit & Beck, 2017). All interview sessions were digitally recorded via two separate digital audio recorders and transcribed through a third‐party organization. The co‐investigator took field notes throughout the session, including reflexive thoughts to decrease bias, supplement audio recordings and potentially act as a backup if issues with the audio recordings arose (Polit & Beck, 2017).

3.7 Ethical considerations

Approval was obtained via the REDACTED Institutional Review Board REDACTED where the study was conducted prior to study implementation and followed the ethical principles of the Declaration of Helsinki (World Medical Association, 2013). The study adhered to these principles by ensuring respect and beneficence for all participants. No conflicts of interest were identified that would impact the integrity or credibility of the research. Informed consent was obtained to ensure no harm and that anonymity would be maintained in the presentation of the results. Data will be stored safely in alignment with institutional guidelines. During focus groups and virtual interviews, participants were informed of the study's aim, and that participation was voluntary and that they were able to decline participation at any time. Participants were informed that all information collected during the interview would remain confidential and known by the study team only and that the study results   may be disseminated through publication and/or presentations. Focus group participants and the two online interviewees were asked to verbally consent to participate in the study using an approved verbal consent script; this increased participant privacy protection as there was no written documentation attaching them to the study.

4 RESULTS

A total of 15 clinical nurses and nurse managers participated in the study. Demographic characteristics were not collected or recorded to preserve the anonymity of the participants as fears of repercussions permeated the nursing culture at this institution and due to the sensitive and ethical implications of MNC. The final analysis revealed the generation of five categories related to the aim of this study. Representative quotes are provided, quotes may be altered for clarity or succinctness, careful consideration was taken to maintain the participants' language, meaning and tone, accurately.

The data revealed the following five categories related to MNC of COVID‐19 patients: (a) medication delivery, (b) turning patients, (c) double checks, (d) communication and rapport, and (e) patient surveillance.

4.1 Medication delivery

For many patients, nurses' workflow revolves around the critical task of medication delivery. Medication delivery would often be delayed due to time constraints and shifts in prioritization of care. Due to the added complexity of COVID‐19 patients, nurses often cared for one patient as other patients' medications became past due. Participants reported on numerous occasions that they could spend up to 4 h in a single room at a time. They would emerge, having sweated through their PPE, either behind on caring for other patients or needing to thank a fellow nurse who had proactively provided care for their patients.

‘[Its's] 10:00 AM and you wanted to get to a patient [whose meds were due at] 8 [am], [but] you're in another patient's room at 10:00…so they might not get the med until 12:00’.

Furthermore, nurses caring for COVID‐19 patients noted an immediate shift to prioritize patients based on the required time for each task, starting with the fastest. Patients were seen from perceived easiest (or least amount of time required for care) to hardest (or most amount of time required for care, like administering medication), and non‐COVID patients were often prioritized.

‘So, if I have four patients that were all COVID positive, I would kind of look at how much time I could spend in each room. If one patient had like 12 meds to get, I will probably see that patient last because I have to go in to meds, bring that list, assessment, probably tidy up room, answer whatever questions I can have, toilet, and then I am out. So, I usually just look at my list and then see who has the least amount of meds because maybe I'll be in that room the shortest amount of time’.

4.2 Turning patients

Participants universally expressed concern about MNC related to skin assessments. Patients were turned less frequently, leading to worries about hospital‐acquired pressure ulcers. Patients were also turned less frequently to conserve PPE, as turning is a two‐person job and an extra exposure event.

‘I'm turning my patients, sometimes every 3–4 hours instead of the normal 2, I don't think I'm necessarily analyzing their skin in detail normally I would for every [patient] I take care of’.

Participants noted that time constraints forced the prioritization of urgent tasks versus turning patients.

‘The skin for us was basically, for four or five months, it was this sort of like if they get a pressure ulcer, not that we're allowing that, but we're more willing to tolerate it during COVID times, like at the peak of it. We weren't always necessarily turning every two hours, we were turning every three hours.

4.3 Double checks

Double checks occur when a nurse has a second nurse verify medication doses. A nurse's double‐checking of medication doses involves having another nurse verify them, which can result in increased workload and time consumption. This action may be overlooked, intentionally skipped, or inadequately performed due to constraints created by donning and doffing PPE or by inadequate staff.

‘Sometimes you'd look to find like someone in the hall to do a double check, and there was no one around, so you are like delayed because you need a double check, or you just, you know, skip it because you don't have the time’.

Nurses also commented on the difficulty finding other staff to perform adequate double‐checks due to lack of staff:

‘Very hard to find someone, we would do it through the glass’.

4.4 Communication and rapport

Participants discussed how nursing care incorporates holistic elements, and their inability to casually check in on their patients was diminished; participants were concerned the long hours alone with no visitors policies affect patients' mental health. Multiple focus group participants shared stories about how empathetic and guilty they felt about patients who diedalone, unable to have one last visit with family. The hospital's no visitor's policy had unexpected consequences related to treatment communication; patient families endlessly called as they were scared and desperate for information.

‘Missed care was communication with patients, because it definitely was a challenge’.

Nurses also commented that it was difficult to build and maintain rapport with their COVID‐19 patients, ‘it's something just going on and sometimes patients just want to talk and it's like there is no time for that anymore. Everything is so rushed that there is not really even time to build that rapport that you are used to building with patients because it is in and out’.

4.5 Patient surveillance

Participants reported intentionally limiting time in and deprioritizing COVID‐19 rooms [patients] due to the nature and number of tasks required to care for these patients. After patient handoff, nurses typically prioritize their work based on the highest level of acuity. However, with COVID‐19 patients, there was an immediate shift to prioritize tasks based on the time required for each. Patients were attended to in order from the perceived easiest (least time required) to the hardest (most time required), often prioritizing non‐COVID patients first. For example, one nurse stated:

‘If I have the first four rooms and three of the four are COVID, I'm going into the room that's not COVID to see what I have to do first and get everything I can before I get dressed, for the next 30 hours’.

Another nurse remarked on the decision‐making process associated with patient care for COVID‐19 patients:

‘You prioritized your care based on time constraints rather than how sick they are’.

Nurses also reported avoiding COVID‐19 rooms just a single task, for example, responding to intravenous pumps:

‘If an IV pump was beeping or something…you do not go in a room for just to do one thing’.

Bedside assessments were skipped in favor of personal safety. RNs also reported that some team members (from other disciplines) would not physically examine patients or go into the room to assess:

‘For weeks at a time, [some care team members] never laying hands on the patient physically, particularly physician consultants…specialty nurses, wound care nurses not coming up and going into the room’.

5 DISCUSSION

This study describes nurses' perspectives on MNC for COVID‐19 patients during the first wave of the pandemic. It is the first qualitative study to explore MNC with nurse managers and clinical nurses in the ICU, medical and ED settings during this time period in the United States. Our findings uncovered five categories of MNC for COVID‐19 patients which included medication delivery, turning patients, double checks, communication and rapport and patient surveillance.

Our research uncovered findings similar to those of several recent studies conducted during the COVID‐19 pandemic. Turning patients (at least every 2 h) was a frequently reported missed element of care essential to preventing skin breakdown, which could lead to hospital‐acquired pressure ulcers (Falk et al., 2022; Gurková et al., 2022; Stayt et al., 2022). Turing patients is an essential aspect of MNC, which has previously been reported (prior pandemic measures) as a frequently cited aspect of care that was missed (Kalisch et al., 2009). Patient communication and essential emotional support for the patients and family were also missed (Gurková et al., 2022; Hosseini et al., 2023; Stayt et al., 2022).

An interesting and foreseeable finding was MNC related to patient surveillance which was impacted by a shift in the decision‐making process for prioritizing  COVID‐19 patients. Nurses in this study reported purposely limiting time in COVID‐19 rooms and completing bedside assessments due to time constraints, consequently impacting patient surveillance. Similar to our study, Labrague et al. (2022) identified adequate patient surveillance as the most frequent MNC element for COVID‐19 patients in their quantitative study. In an acute care setting, surveillance is defined as a process to identify threats to patient safety and health through purposeful and ongoing monitoring (Pfrimmer et al., 2017).

Nurses typically prioritize patients by the highest level of acuity to address imminent clinical concerns (Patterson et al., 2011). However, the first COVID‐19 wave created goal conflicts that altered patient prioritization based on time and best utilization of resources rather than patient acuity level. Nurses in the study reported prioritizing patients that required the least amount of time over care to the most time required for care. Labrague et al. (2022) also found that nurses prioritized nursing tasks based on communication and planning rather than tasks related to clinical needs. In this study, medication delivery was also impacted by prioritization of care, where nurses reported administering medication up to 4 hours when they were past due. Similarly, in one qualitative study investigating United Kingdom Registered Nurses' experiences and perceptions of patient safety, nurses reported incidents of suboptimal and missed care related to medication management (Stayt et al., 2022). However, other studies using the MISSCARE survey during COVID‐19 did not report significant delays in medication administration (Labrague et al., 2022; von Vogelsang et al., 2021).

A unique finding in our study was the MNC category of double‐checking medications by nursing staff. Double‐checking involves two nursing staff who can verify patient and medication information before administering medication to the patient (Koyama et al., 2020). This is routine nursing practice and standard safety practice for high‐risk drugs and is intended to reduce medication errors. Nurses reported that PPE conservation and staffing constraints contributed to missed double checks. The conflicts of PPE conservation coupled with the increased workload due to lack of staff meant that searching for another nurse for a double‐check was no longer a simple task. Interestingly, there needs to be more high‐quality studies to support double‐checks on the impact of medication administration errors; however, studies have yet to investigate the phenomenon during COVID‐19 (Koyama et al., 2020).

5.1 Practice implications

Historically, acute care hospitals and frontline nurses have been challenged with complex workflow processes and stretched resources that impact MNC. The onset of COVID‐19 and the subsequent exacerbated stress of the evolving situation, potentiated further risk of this phenomenon (Gurková et al., 2022). During the first wave of the pandemic, the working conditions for nurses highlighted the need for urgent leadership focus on multiple fronts. First, it is essential to incorporate current findings to facilitate an organizational climate that supports nursing staff adapts quickly to change and emergency situations. The expertise and support of strong nursing leadership are vital to promoting nurse empowerment and quality of care. Leadership practices have significantly impacted nursing performance and patient outcomes (Blizzard & Woods, 2020; Cummings et al., 2018; Ystaas et al., 2023). Specifically, relationally focused leadership styles, such as transformational, servant, and emotionally intelligent leadership, increase nurse empowerment, teamwork, support, and well‐being (Cummings et al., 2018). Transformational leadership inspires and motivates nurses by fostering a shared purpose and commitment to patient care, encouraging professional development and innovation, leading to higher job satisfaction, teamwork, and a patient safety culture that can reduce care omissions (Ystaas et al., 2023). Conversely, task‐focused leadership, such as transactional leadership, which relies on structured tasks, rewards, and penalties, can enhance adherence to standards of care and protocols but may not address underlying issues of MNC (Cummings et al., 2018).

Relationally focused leadership approaches are grounded on emotional intelligence (EI) to influence outcomes and empower staff (Blizzard & Woods, 2020; Cummings et al., 2018; Ystaas et al., 2023). EI equips individuals with the ability to quickly evaluate stressful work environments, enabling them to guide and support their staff during crises. Strong leadership requires empathy, and those nurse leaders closest to frontline nurses are best positioned to influence and guide the team through a psychologically safe approach, providing meaningful, specialized, and value‐added care while potentially minimizing the moral distress of MNC.

A balance of nurse/patient ratios with the existing nurse skill mix has been studied extensively as being linked to quality patient care and outcomes (von Vogelsang et al., 2021). However, that is not guaranteed amid crises such as a pandemic to avoid MNC events. Evidence suggests that nursing teamwork affects MNC, whereas there was less reported MNC when teamwork was stronger (Kalisch & Lee, 2010). Therefore, additional frontline nurse and nurse leadership training to facilitate teamwork and coaching staff in prioritizing necessary patient care is essential to maintain focus in a crisis. This can be achieved through a combined lens of intentional patient safety and a supportive ‘no‐blame’ environment (Labrague et al., 2022). This, coupled with leadership emergency response and consideration of training to maintain quality care, is essential to thwart poor patient outcomes.

Another opportunity is to engage frontline nurses in connecting their current experiences to future, similar disruptions in nursing practice by re‐imagining nursing practice. Through a lens of curiosity while respecting regulatory requirements and evidence‐based practice, evaluating existing workflows for efficiency is essential. This can be accomplished by fostering nursing innovation to streamline work by adopting new healthcare technologies and ensuring that long‐held practices are based on scientific evidence. Feedback from those who have experienced the work environment firsthand is key to engagement and purposeful change (Gurková et al., 2022). Finally, there is the potential for nurse leaders and frontline nurses to need more congruence between their perceptions of the work environment and MNC (Kalisch & Lee, 2012). Hospital leaders are responsible for ensuring their frontline nurses have both the resources and clear communication they need to feel supported in their roles. Open, transparent communication will establish mutual trust and respect within teams to create a supportive environment for both patients and employees.

6 LIMITATIONS

This study has several limitations. These include findings from a single healthcare institution that cannot be generalized to other settings. However, the institution where the study was conducted cared for a majority of participants in the state. Demographic characteristics were not collected or recorded to preserve the anonymity of the participants at the institution where they worked, which is another limitation. Data were collected between July 2020 and August 2020, before administering vaccinations, and when Delta was the prominent variant. This study was conducted during a time of crisis and with many unknowns; as such, we were able to capture nurses' experiences and perceptions in the moment and not be confounded by hindsight bias. As with all interview‐based research, investigators are limited by the willingness of participants and skill of the moderator to elicit honest accurate accounts. Specifically, our participant population of nurses has been found in other studies, to be sensitive to missed care such that nurses may not have freely admitted to these occurrences (Papastavrou et al., 2014). As this study aimed to understand the nurse's perspectives of MNC, we did not take a mixed methods approach. Although quantitative research might have helped correlate some of our findings, we wanted to keep the data as qualitative because quantitative data would not effectively represent our participants, emotions, experiences, or perspectives. This qualitative study is complementary to the already published quantitative studies on MNC during the pandemic, as it expands that literature and provides the stories behind the data.

7 CONCLUSIONS

MNC is a universal phenomenon experienced in healthcare on a global level; this is not unique to one institution. This phenomenon is potentially dangerous and has been shown to impact patient care outcomes. The recent pandemic likely increased the prevalence and types of MNC, but to what extent is currently unknown. Our study adds to the emerging literature addressing MNC during a pandemic and its potential impact on quality patient care. Nursing culture, teamwork, mental health, and job satisfaction can affect patient safety and better or worse outcomes. Nurse leaders should employ evidence‐based strategies to facilitate teamwork to support staff and reduce incidences of MNC. This study identified the category of double checks not previously reported in the literature. Additional studies across multiple institutions are needed to add to the evidence describing MNC during pandemics. Furthermore, additional studies addressing the facilitators of caring for COVID‐19 patients can aid in developing pandemic‐specific interventions that consider clinician mental health and adjustments needed to care delivery during volatile pandemic events.

Future research could focus on developing mixed‐method nursing care studies during a pandemic that focus on maintaining the quality of care and include infectious disease measures.

AUTHOR CONTRIBUTIONS

Monica Rochman: conceptualization (lead), project administration (lead), methodology, supervision (lead), validation (supporting), resources (lead), writing‐original draft(lead) and review and editing (lead). Austin Mount‐Campbell: data curation (lead), methodology (lead), software (lead), conceptualization (supporting), validation (lead), writing‐original draft (equal)and review and editing (equal). Catherine Shull Fernald: conceptualization (supporting), writing‐original draft (supporting) and review and editing (supporting).

FUNDING INFORMATION

This work was supported by the Delaware Accelerating Clinical and Translation Research (ACCEL), and Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health (grant number U54‐GM104941) and the State of Delaware. The funders had no part in data collection, analysis, interpretation, or manuscript development.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

Approval was obtained via the Health System Institutional Review Board (no. 40091) where the study was conducted prior to study implementation.

Supporting information

Table S1.

ACKNOWLEDGEMENTS

The authors would like to thank the clinical Registered nurses on the frontline during the height of the pandemic. The authors would also like to thank the Widener University Scholarship Community.

DATA AVAILABILITY STATEMENT

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.
==== Refs
REFERENCES

Aldiabat, K. M. , & Le Navenec, C. L. (2018). Data saturation: The mysterious step in grounded theory methodology. The Qualitative Report, 23 (1 ), 245–261.
Alfuqaha, O. A. , Alhalaiqa, F. N. , Alqurneh, M. K. , & Ayed, A. (2023). Missed nursing care before and during the COVID‐19 pandemic: A comparative cross‐sectional study. International Nursing Review, 70 (1 ), 100–110. 10.1111/inr.12795 35947610
American Nurses Association . (2020). Crisis of standards of care: COVID‐19. https://www.nursingworld.org/~496044/globalassets/practiceandpolicy/work‐environment/health‐‐safety/coronavirus/crisis‐standards‐of‐care.pdf
Blizzard, L. , & Woods, S. L. (2020). The relationship between the implicit rationing of nursing care and emotionally intelligent leadership style. The Journal of Nursing Administration, 50 (12 ), 623–628. 10.1097/NNA.0000000000000949 33181524
Brixey, J. J. , Robinson, D. J. , Johnson, C. W. , Johnson, T. R. , Turley, J. P. , Patel, V. L. , & Zhang, J. (2007). Towards a hybrid method to categorize interruptions and activities in healthcare. International Journal of Medical Informatics, 76 (11–12 ), 812–820. 10.1016/j.ijmedinf.2006.09.018 17110161
Chaboyer, W. , Harbeck, E. , Lee, B. O. , & Grealish, L. (2021). Missed nursing care: An overview of reviews. The Kaohsiung Journal of Medical Sciences, 37 (2 ), 82–91. 10.1002/kjm2.12308 33022855
Cook, R. I. , & Woods, D. D. (2018). Operating at the sharp end: The complexity of human error. In Human error in medicine (pp. 255–310). CRC Press.
Cummings, G. G. , Tate, K. , Lee, S. , Wong, C. A. , Paananen, T. , Micaroni, S. P. , & Chatterjee, G. E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85 , 19–60. 10.1016/j.ijnurstu.2009.08.006 29807190
Dekker, S. W. A. (2006). Resilience engineering: Chronicling the emergence of confused consensus. In E. Hollnagel , D. D. Woods , & N. Leveson (Eds.), Resilience engineering: Concepts and precepts. Ashgate.
Falk, A. C. , Nymark, C. , Göransson, K. E. , & von Vogelsang, A. C. (2022). Missed nursing care in the critical care unit, before and during the COVID‐19 pandemic: A comparative cross‐sectional study. Intensive & Critical Care Nursing, 72 , 103276. 10.1016/j.iccn.2022.103276 35672210
Gurková, E. , Mikšová, Z. , & Šáteková, L. (2022). Missed nursing care in hospital environments during the COVID‐19 pandemic. International Nursing Review, 69 (2 ), 175–184. 10.1111/inr.12710 34433226
Halloway, I. , & Galvin, K. (2017). Qualitative research in nursing and healthcare (4th ed.). Wiley Blackwell.
Hessels, A. J. , Paliwal, M. , Weaver, S. H. , Siddiqui, D. , & Wurmser, T. A. (2019). Impact of patient safety culture on missed nursing care and adverse patient events. Journal of Nursing Care Quality, 34 (4 ), 287–294. 10.1097/NCQ.0000000000000378 30550496
Hosseini, Z. , Raisi, L. , Maghari, A. H. , & Karimollahi, M. (2023). Missed nursing care in the COVID‐19 pandemic in Iran. International Journal of Nursing Knowledge, 34 (3 ), 179–184. 10.1111/2047-3095.12390 36029159
Jones, T. L. , Hamilton, P. , & Murry, N. (2015). Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International Journal of Nursing Studies, 52 (6 ), 1121–1123. 10.1016/j.ijnurstu.2015.02.012 25794946
Kalisch, B. J. , Landstrom, G. , & Williams, R. A. (2009). Missed nursing care: Errors of omission. Nursing Outlook, 57 (1 ), 3–9. 10.1016/j.outlook.2008.05.007 19150261
Kalisch, B. J. , & Lee, K. H. (2010). The impact of teamwork on missed nursing care. Nursing Outlook, 58 (5 ), 233–241. 10.1016/j.outlook.2010.06.004 20934078
Kalisch, B. J. , & Lee, K. H. (2012). Congruence of perceptions among nursing leaders and staff regarding missed nursing care and teamwork. The Journal of Nursing Administration, 42 (10 ), 473–477. 10.1097/NNA.0b013e31826a1fa4 22968120
Kalisch, B. J. , & Williams, R. A. (2009). Development and psychometric testing of a tool to measure missed nursing care. The Journal of Nursing Administration, 39 (5 ), 211–219. 10.1097/NNA.0b013e3181a23cf5 19423986
Khrais, H. , Alsadi, M. , Oweidat, I. , & Ahmad, M. (2023). Determinants of missed nursing care in Jordanian hospitals during COVID‐19 pandemic. Nursing Open, 10 (3 ), 1565–1573. 10.1002/nop2.1407 36250917
Koyama, A. K. , Maddox, C. S. S. , Li, L. , Bucknall, T. , & Westbrook, J. I. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ Quality and Safety, 29 (7 ), 595–603. 10.1136/bmjqs-2019-009552
Labrague, L. J. , de Los Santos, J. A. A. , & Fronda, D. C. (2022). Factors associated with missed nursing care and nurse‐assessed quality of care during the COVID‐19 pandemic. Journal of Nursing Management, 30 (1 ), 62–70. 10.1111/jonm.13483 34590383
Nymark, C. , von Vogelsang, A. C. , Falk, A. C. , & Göransson, K. E. (2022). Patient safety, quality of care and missed nursing care at a cardiology department during the COVID‐19 outbreak. Nursing Open, 9 (1 ), 385–393. 10.1002/nop2.1076 34569190
Papastavrou, E. , Andreou, P. , & Vryonides, S. (2014). The hidden ethical element of nursing care rationing. Nursing Ethics, 21 (5 ), 583–593. 10.1177/0969733013513210 24399832
Patterson, E. S. , Ebright, P. R. , & Saleem, J. J. (2011). Investigating stacking: How do registered nurses prioritize their activities in real‐time? International Journal of Industrial Ergonomics, 41 (4 ), 389–393.
Pfrimmer, D. M. , Johnson, M. R. , Guthmiller, M. L. , Lehman, J. L. , Ernste, V. K. , & Rhudy, L. M. (2017). Surveillance: A nursing intervention for improving patient safety in critical care environment. Dimensions of Critical Care Nursing: DCCN, 36 (1 ), 45–52. 10.1097/DCC.0000000000000217 27902662
Polit, D. F. , & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Wolters Kluwer Health.
Safdari, A. , Rassouli, M. , Elahikhah, M. , Ashrafizadeh, H. , Barasteh, S. , Jafarizadeh, R. , & Khademi, F. (2023). Explanation of factors forming missed nursing care during the COVID‐19 pandemic: A qualitative study. Frontiers in Public Health, 11 , 989458. 10.3389/fpubh.2023.989458 36778543
Safdari, A. , Rassouli, M. , Jafarizadeh, R. , Khademi, F. , & Barasteh, S. (2022). Causes of missed nursing care during COVID‐19 pandemic: A qualitative study in Iran. Frontiers in Public Health, 10 , 758156. 10.3389/fpubh.2022.758156 35493392
Saldana, J. (2021). The coding manual for qualitative researchers (4th ed.). Sage Publishing.
Stayt, L. C. , Merriman, C. , Bench, S. , Price, A. , Vollam, S. , Walthall, H. , Credland, N. , Gerber, K. , & Calovski, V. (2022). ‘Doing the best we can’: Registered nurses' experiences and perceptions of patient safety in intensive care during COVID‐19. Journal of Advanced Nursing, 78 (10 ), 3371–3384. 10.1111/jan.15419 35986583
von Vogelsang, A. C. , Göransson, K. E. , Falk, A. C. , & Nymark, C. (2021). Missed nursing care during the COVID‐19 pandemic: A comparative observational study. Journal of Nursing Management, 29 (8 ), 2343–2352. 10.1111/jonm.13392 34097799
World Medical Association . (2013). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310 (20 ), 2191–2194. 10.1001/jama.2013.281053 24141714
Ystaas, L. M. K. , Nikitara, M. , Ghobrial, S. , Latzourakis, E. , Polychronis, G. , & Constantinou, C. S. (2023). The impact of transformational leadership in the nursing work environment and patients' outcomes: A systematic review. Nursing Reports, 13 (3 ), 1271–1290. 10.3390/nursrep13030108 37755351
