Nurses' Perceptions of Missed Care: A Critical Discourse Analysis

Purpose: This paper explores missed nursing care through nurses dialogues; examining their perceptions in regard to missed care occasions. 

Methods:  Using critical discourse analysis (CDA), the study explores the discourses of nurses as they describe the challenges they encounter in daily attempts to deliver what they consider to be quality patient care. These discourses are compared to the mandates of state and organisational policy prescribing clinical practice.  The boundaries of tension that are expressed by nurses within the milieu of missed care are explored through in-depth inteviews with 21 registered nurses working in two major metropolitan acute care hospitals in South Australia. Interviews are drawn from a larger study based on the work by Kalisch and Williams (2009) who used the MISSCARE Survey to identify what care is missed, and why it is missed. CDA is interested in social organisation and the interplay of people’s activities within it, the focus being on how they construe and internalise such activity. Nurses’ perceptions and realities become central to any investigation because their work is organized by more than their own intentions or motivations, with influences such as professional standards or organisational rules also locating their reality.

Results: Instead of identifying occasions of missed or omitted care, nurses spoke of constraints related to budget, staffing, skill mix and mandated policy as constraining their ability to complete care activities.

Conclusion: Factors emerged that suggest that missed care is the consequence of routinized and standardized practice, cited as cost effective care, at the expense of professional autonomy.