| |

Received: 21 November 2019    Revised: 26 January 2020    Accepted: 2 February 2020

DOI: 10.1111/jonm.12972

SPECIAL ISSUE PAPER

Good practices to reduce unfinished nursing care: An

integrative review

Raul Cordeiro PhD, Associate Professor1,2  | Maria João Pires Rodrigues RN,

Associate Professor1 | Ricardo Daniel Serra RN, Registered Nurse3 | António Calha PhD,
Associate Professor1,2

1
Polytechnic Institute of Portalegre (IPP),
Portalegre, Portugal
2
VALORIZA - Research Centre for
Endogenous Resource Valorization,
Portalegre, Portugal
3
Unidade Local de Saúde do Norte
Alentejano, Polytechnic Institute of
Portalegre (IPP), Portalegre, Portugal
Correspondence
Raul Cordeiro, Polytechnic Institute of
Portalegre (IPP), Portalegre, Portugal.
Email: raulcordeiro@ipportalegre.pt
Abstract
Aim: To identify the evidence of good practice interventions aimed at reducing unfin-
ished nursing care in the hospital context.
Background: Unfinished nursing care is a common problem related to nursing prac-
tice, essentially due to time scarcity. Although there are several researches about
the problem, there is not much on how to deal with it and on how to develop good
practices that can mitigate the unfinished nursing care.
Evaluation: This study is an integrative review of the literature. After searching data-
bases, we selected seven articles that met the inclusion criteria.
Key Issues: The good practices identified to mitigate the unfinished nursing care
were as follows: adequacy of human resources, nurse-to-patient ratio and workload
distribution; improvement of the working environment with increased teamwork;
and effective communication among all health professionals.
Conclusion: An adequate number of nurses can ensure the timely provision of care
and mitigate unfinished nursing care. Efficient communication between the multi-
professional team, as well as recognition of professional merit, personal and organi-
sational accountability, also contributes to mitigate unfinished nursing care.
Implications for Nursing Management: Health organisations should staff their units
adequately and ensure a well-balanced workload distribution, and promote healthy
work environments that foster personal accountability, adequate communication be-
tween all professionals and recognize professional merit.

KEYWORDS

hospital, missed nursing care, patient safety, unfinished nursing care

1 |  I NTRO D U C TI O N
A recent area of nursing investigation highlights the unfinished nursing
care as relevant for patient safety. It can be understood as an error
of omission because the totality, or just part, of the care needed by
the patient is not provided (Kalisch, Landstrom, & Hinshaw, 2009). It
is essentially due to time scarcity. As a result of time scarcity, nurses
prioritize the care they provide to their patients, which may then lead
to unfinished nursing care (Jones, Hamilton, & Murry, 2015). There is
no consensus on which is the best terminology would be, in order to
best define these unfinished cares. In literature, we may find expres-
sions, such as ‘missed nursing care,’ ‘unfinished care,’ ‘care left undone,’

J Nurs Manag. 2020;00:1–7. wileyonlinelibrary.com/journal/jonm© 2020 John Wiley & Sons Ltd     1 |
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2       CORDEIRO et al.
‘implicit rationing of nursing care,’ ‘task incompletion’ and ‘unmet nursing
care needs’ (Jones et al., 2015). In this paper, we address the problem
using the umbrella term ‘Unfinished Nursing Care’ proposed by Jones
et al., (2015).
Some of the causes associated with unfinished nursing care are
related to factors such as lack of nursing human resources (Cruz,
Monsivás, Rivera, & Oviedo, 2017) and the total amount of working
time, especially working overtime (Cho et al., 2016). Whatever the
reason when care is not provided, it represents a severe risk for pa-
tient safety (Jones et al., 2015).
Some of the consequences for the patients that are reported
in some studies include medication errors, urinary tract infections,
patient's falls, pressure ulcers, critical incidents, poor quality of the
assessment and patient readmissions (Recio-Saucedo et al., 2017).
Despite having an international dimension, this is a study area which
is relatively recent and with little evidence about the strategies to
mitigate it (Jones et al., 2015).
Therefore, the objective of the present literature review was to
identify evidence of good practice of oriented interventions, and to
reduce unfinished nursing care in hospital settings.
2 |  M E TH O D O LO G Y
We have developed an integrative review of the literature because
there was an opportunity to include the theoretical and empirical
literature through a methodological approach (Mendes, Silveira, &
Galvão, 2008), (Sousa, Marques-Vieira, Severino & Antunes, 2017).
The research process began with the delimitation of the central issue,
and identifying the descriptors that were the basis of the selection of
articles (Sousa et al., 2018). The methodological sequence of steps
that were followed are as follows: (a) a problem was identified and
a research question was established; (b) a criterion for including and
excluding articles, studies and other published works was defined;
(c) a search based in a research equation was conducted; (d) diverse
publications on the research subject were critically examined, and
relevant information of the phenomenon under analysis was ex-
tracted; and 5) the information contained in the analysed works was
then categorized, synthesized and presented (Table 1).
TA B L E 1   Research protocol
The information gathering was guided by the following research protocol:
     
P Participants Who was studied?
I Interventions What was developed?
(C) Comparison Might exist or not?
O Outcomes Results, effects or consequences
D Study design How the evidence was obtained?
• Main question: What good practice interventions are developed
in order to reduce unfinished nursing care in hospital settings?
• Objective: Identify evidence of good practice interventions to re-
duce unfinished nursing care in a hospital setting.
• Research Equation: Care left undone OR missed nursing care OR
unfinished nursing care AND hospital AND patient safety NOT
child
• The following databases were researched: Emerald, Sage
Premier, EBSCO Saúde (Cinahl Plus, MedLine with Full Text,
Nursing ReferenceCenter, Psychology and Behavioral Science,
SportDiscus).
• Research time horizon: 2015–2018.
• Inclusion criteria: Studies with nurses or patients, in hospital con-
text, about good practices developed to reduce unfinished nurs-
ing care.
• Exclusion Criteria: Studies with paediatric populations, outside
the hospital context; studies by other health care professionals
who are not nurses; and those that do not study unfinished nurs-
ing care.
Based on the search equation, 237 articles were identified
(Figure 1), 105 duplicates were eliminated; of the remaining 132,
106 were eliminated based on title and abstract; the remaining 26
were analysed for inclusion criteria, and on reading, only 7 met the
inclusion criteria defined.
3 | R E S U LT S
After reading and analysing the articles, 7 fulfilled the inclusion
criteria (Table 2). Of these 7, 2 were originally from South Korea, 1
from the United States, 2 from Australia, 1 from China and 1 from
Israel. They were published in 2015 (one article), 2016 (one article),
2017 (two articles) and 2018 (three articles). From the analysis of the
selected articles, three categories of information emerged, two of
which are divided into two and six subcategories, respectively:
• Causes and types of unfinished nursing care (1, 2, 4, 5, 7)
• Good practices related to work environments (2, 4, 5, 7):
  Keywords
Nurses or patients Care left undone; Missed
Unfinished nursing care mitigation nursing care; Unfinished
nursing care; Hospital;
  Patient safety
Identification of good practices of
oriented interventions to reduce
missed nursing care
Qualitative study: integrative review of
the literature
CORDEIRO et al. |
      3

F I G U R E 1   Flow chart of article- •Research on data bases: Emerald, Sage Premier, EBSCO Saúde (Cinahl Plus,
selection process MedLine with Full Text, Nursing
ReferenceCenter, Psychology and Behavioral Science, SportDiscus)
B.On •Estudos originais em inglês.

•Eliminated duplicates (105).

•Eliminated based on title and abstract according to the inclusion/exclusion
237articles criteria (106).

•Reading.
•Eliminated 19.
26 articles

•Reading, analysis, information cathegorization and synthesization.

7 articles

TA B L E 2   Identification of selected
Nr Authors
articles
1 Cho et al
2 Chapman et al
3 Cho et al
4 Srulovici &
Drach-Zachary
5 Xu et al
6 Duffield et al
7 Hye et al
Periodic
International Council of
Nurses
International Council of
Nurses
Journal of Nursing
Scholarship
International Journal of
Nursing Studies
International Journal of
Nursing Studies
Journal of Clinical Nursing
Journal of Nursing
Scholarship
Method
Cross-sectional study
Cross-sectional study
Observational study
without control group
Cross-sectional study
Cross-sectional study
Cross-sectional study
Descriptive, correlational
study

a. Communication (7);
b. Teamwork (2);
c. Personal and organisational responsibility (4);
• Good practices related to human resources (1, 3, 5, 6):
a. Increased number of nurses (1);
b. Adequate number of nurses (1, 3);
c. Appropriate number of nurses from the perspective of the pa-
tient and nurses (3);
d. Workload (5);
e. Addition of nursing support workers to ward staff (6).
4 | D I S CU S S I O N
4.1 | Reasons for unfinished nursing care and types
of unfinished nursing care
Knowing that nurses are essential to achieving positive health out-
comes, any obstacle to care, which the patient needs, jeopardizes
the quality of the care, resulting in lack of health care and a risk
to the patient's health (Jones et al., 2015). As shown in Figure 2,
this can be attributed to lack of human resources, lack of material
resources and an inappropriate communication (McMullen et al.,
2017).
4.2 | Working environment
The characteristics of the working environment are directly related
to the amount of unfinished nursing care (Park, Hanchett, & Ma,
2018). Liu et al. (2018) also demonstrated, in a study with a popu-
lation of 1542 nurses from 23 hospitals, that the working environ-
ment is directly and indirectly related to the patient's safety and
that nurse's workload relates indirectly to patient safety. Such work
environments affect the nurses’ mental and physical health, due to
the stress caused by work overload, low professional status, diffi-
cult relationships at the work place, problems with the professional
roles (Park et al., 2018). These results support the idea that a poor
work environments affect the nursing team and the patient's safety,
 |
4       CORDEIRO et al.
leading to burnout and high levels of unfinished nursing care (Park
et al., 2018), (Liu et al., 2018). A correlation between work environ-
ment (Bragadóttir, Kalisch, & Tryggvadóttir, 2017), safety climate
(Schubert et al., 2012), and unfinished nursing care had already been
established in other studies.
The involvement of nurses in hospital affairs, as well as the as-
signment of non-care-related tasks to nurses whose role is to provide
care, was also associated with an increase in unfinished nursing care
(Park et al., 2018), (Liu et al., 2018). The more the involved nurses in
hospital affairs, the more likely the occurrence of unfinished care
activities (Park et al., 2018): the units with better interprofessional
relations were less likely to miss care activities.
A poor communication of information from the previous shifts
or notes taken when the patient was admitted, or a poor commu-
nication to other services, or lack of communication within the
nursing team or with the medical team is cited as further reason for
unfinished nursing care (Chapman, Rahman, Courtney, & Chalmers,
2016). Unfinished nursing care tasks most frequently identified by
Chapman et al. (2016) were ambulation, positioning and oral hygiene.
According to Srulovicie and Drach-Zahavy (2017), personal and
ward accountability have a strong negative correlation with the un-
finished nursing care. Personal accountability can be understood as
the perceived, explicit or implicit, expectation that a professional will
answer for his or her actions. Ward accountability can be understood
as the collective expectations of decisions and behaviours. The most
noted unfinished nursing cares were oral hygiene; providing food to/
feeding the patient, emotional support to the patient and family; and
helping patients with toileting needs when asked (Srulovici & Drach-
Zahavy, 2017) (Figure 3).
The high-prevalence unfinished nursing care identified by Liu
et al. (2018) are as follows: comfort and communication with the
patient, ambulatory/moving activities and teaching the patient/
family.
4.3 | Human and material resources
According to Cho, Kim, Yeon, You, and Lee (2015) and Chapman
et al. (2016), teams lacking adequate human resources and appro-
priate material resources, have higher numbers of unfinished nurs-
ing care. Excessive workload can also have a deleterious effect
on patient safety and may be related, among other reasons, to an
inadequate distribution of patients per nurse (Liu et al., 2018). It
is considered that it is important to find the appropriate balance
between patients’ needs and staffing in order to provide safe pa-
tient care. However, there is no methodological consensus on how
health care professional's workload should be measured given the
difficulty of taking into account the variability of the work envi-
ronment across health units. Although Cho et al. (2015) have not
identified the nurse-to-patient ratio as a reason for unfinished
nursing care, it is known from the past studies that the main factor
influencing unfinished nursing care can be traced to an inadequate
nurse staffing level (Kalisch, Tschannen, & Lee, 2009).
In a study comparing the prevalence of unfinished nursing care
in units with an adequate number of nursing staff with units with
a low nursing staffing, Cho et al. (2015) concluded that the prev-
alence of unfinished nursing care was higher in units with a low
nursing staffing. Nursing care is prioritized where the vital signs
assessed are detrimental to the basic care, such as feeding, oral
hygiene or hygiene care.
The lack of human resources generates a conflict between the
nurses’ professional accountability and the delivery of appropriate
care to patients. It implies, among others, the definition of priorities,
in which the most and least important procedures are classified and
that are determined by the benefit each option might provide to the
patient (Srulovici & Drach-Zahavy, 2017).
4.4 | Good practices of oriented interventions, to
reduce unfinished nursing care in hospital setting
Good practices to reduce unfinished nursing care can arise from work
environment and human resource (as shown in Figure 4). These are rec-
ognized pathways that link nursing care with patient outcomes, arising
not only from the selected literature but also from other sources.
4.5 | Work environment
Some of the identified good practices that might mitigate un-
finished nursing care are related to the working environment in
which the health care is provided (Figure 4). A good working envi-
ronment is strongly associated with low levels of unfinished nurs-
ing care (Park et al., 2018). In such context, effective teamwork
is a mitigating factor in unfinished nursing care (Chapman et al.,
2016). However, an appropriate communication is needed in order
to develop effective teamwork (Chapman et al., 2016), (Park et al.,
2018), not only between nurses but also with physicians (Park
et al., 2018). Communication, as a means of information diffusion,
promotes bonds between different staff members and allows
them to share the concerns about patients. (Chapman et al., 2016).
There is a positive correlation between unfinished nursing care
and burnout among nurses. This seems to play a mediating role
between the hospital organisation and patient safety (Liu et al.,
2018). An intervention tested by Kalish, Xie, and Ronis (2013) to
improve nursing teamwork proved to have a positive impact on
unfinished nursing care.
Even though the causes of missed nursing care are mostly of an
organisational nature, the personal characteristics of those who
deliver the care should not be overlooked. The personal account-
ability for unfinished nursing care may be a mitigating factor, de-
spite heavy overloads. The nurses’ personal values should ensure
that the nurse delivers the care needed in line with professional
ethics and conduct (Srulovici & Drach-Zahavy, 2017). On the one
hand, the accountability of the organisation and the rules of con-
duct seem to have a small effect on the reduction in unfinished
CORDEIRO et al. |
      5

F I G U R E 2   Identified causes of
Work environment:
unfinished nursing care
• Inadequate communication;
• Personal and organisational
accountability;
• Working overtime
Human resources: Material resources
• Low number of nurses • Lak of material
staffing;
• Low nurse-per-patient
ratio

Unfinished
Nursing
Care

F I G U R E 3   Types of unfinished nursing

care Unfinished Nursing Care

Oral hygiene care;

Comfort care;
Food to/feeding the patient;
Communication with the
Mobilization/ambulation Patient/family emotional
patient;
activities; support;
Mobilization/ambulation
Oral hygiene care. Assist in sanitary needs
activities;
(Chapman et al, 2016). immediately upon request
Patient/family education
(Srulovici & Drach-Zahavy,
(Liu et al, 2018)
2017).

nursing care. On the other, the personal accountability of nurses
seems to be strongly correlated with decrease in unfinished nurs-
ing care. Therefore, increasing the accountability of health care
professional could have a mitigating effect on unfinished nursing
care coming along, however, with organisational responsibility
for the mitigation of time constrains and unanticipated situations
that interfered with regular care. Such increased professional ac-
countability should be accompanied by a merit-recognition system
(Srulovici & Drach-Zahavy, 2017).
Kalisch and Lee (2012) demonstrated that the staffing levels
between magnet and non-magnet hospitals are of no difference. In
magnet hospitals, the rates of unfinished nursing care were lower
than in non-magnet hospitals. This could be because of the organisa-
tion's work environment and culture (Kalisch & Lee, 2012).
4.6 | Human resources
According to Cho et al. (2015), an increase in nurse staffing is associ-
ated with a decrease in unfinished nursing care, and the probability
of omitting care related to positioning, hygiene, oral hygiene and pa-
tient surveillance is highly reduced. The omission of these care tasks
may lead to pressure ulcers, pneumonia and falls (Cho et al., 2015).
Although there was a reduction in unfinished nursing care related to
the physical dimension of the patient, Cho et al. (2015) did not iden-
tify a reduction in the omission of emotional supportive care to the
patients. The increase in unregulated nursing support workers does
not reduce unfinished nursing care. The replacement of nurses by
these workers can lead to problems related to an increased workload
of nurses due to task delegation and their subsequent supervision
(Duffield et al., 2018). From the patient's perspective, unfinished
nursing care is also perceived as a problem associated with adverse
events, poor communication and poor patient satisfaction (Cho,
Mark, Knafl, Chang, & Yoon, 2017). They also consider that the sub-
stitution of nurses by unregulated nursing support workers does not
contribute to an increase in the quality of care provided (Duffield
et al., 2018).
As noted by Kalisch, Tschannen, et al. (2009), there is a strong
correlation between staffing adequacy to patients needs and un-
finished nursing care. Although Cho et al. (2017) did not identify
 |
6       CORDEIRO et al.

F I G U R E 4   Identified good practices to

Human resources: Work environment:
reduce unfinished nursing care
• Staffing nursing teams • Teamwork promotion;
with an adequate • Improved communication
number of nurses between the
• Adequate nurse-per- multiprofessional team
patient ratio; members;
• Balanced distribution of • Personal and
work between nurses. organisational
accountability
• Award merit.

Unfinished
Nursing
Care
reduction

the nurse-to-patient ratio as a factor related to unfinished nurs-
ing care, Liu et al. (2018) concluded that a higher nurse-to-patient
ratio correlates with a reduction in unfinished nursing care. Staffing
a health care service with an adequate number of professionals is
a complex task, and a slight increase in professionals, especially if
they are professionals without specific training, does not contrib-
ute to the improvement of care and reduction in unfinished nursing
care (Liu et al., 2018). Using staffing methods, such as nurse hours
per patient (NHPP), could improve nurses’ workload and influence
nurse-sensitive outcomes (Chapman et al. 2016). However, Jones,
Willis, Amorim-Lopes, and Drach-Zahavy (2019) state that such
methods are imprecise and, therefore, results predicting staffing
needs are also imprecise. This happens because such methods fail to
capture the contextual variation. Safer and more effective levels of
registered nurses can provide shorter lengths of stay, reduced read-
missions and reduced adverse outcomes. Such facts could be used
to offset the costs related to increasing registered nurses staff lev-
els and reduce hospitals’ net costs. Administrators must shift their
understanding of nurses as a cost centre to a valuable and critical
service with benefits for the patient and the hospital, that is both
directly and indirectly (Blouin & Podjaseck, 2019).
5 |  LI M ITATI O N S
Since this is an integrative literature review, the limitations are in-
herent to the studies analysed. The results of the analysed studies,
except for one, were based on self-assessments made by nurses,
which results in subjective results. Also, the fact that nurses need to
recognize certain care as unfinished, or omitted, may influence self-
assessment. The gold standard for assessing unfinished nursing care
is, still, direct observation. Because it is too expensive and difficult
to perform, self-assessment is the most common method used. The
analysed populations, although large numbers, may reflect the work-
ing and cultural conditions of the countries where the studies were
developed. It is well known that the training and working reality of
nurses differ greatly from one country to another. Therefore, the
results may not be generalizable and should be perceived within the
context from which they were extracted.
6 | CO N C LU S I O N S
The identification of unfinished nursing care provides useful infor-
mation for nursing management to improve the care provided by
nursing staff concerned for quality and safety.
The results show that the most frequently, unfinished nurs-
ing care are related to hygiene and comfort care, positioning
and mobilization, discharge planning and patient/family educa-
tion, and communication and emotional support to the patient.
These are independent and proper nursing care tasks that should
not be missed or left undone during hospitalization. The origin
of this problem is multiple, but it can be traced to time scarcity.
An association was found between unfinished nursing care and
scarcity of human resources, work environment and poor team
communication.
The adequacy of nurse staffing represents a key aspect di-
rectly related to patient care outcomes. Health organisations
should therefore ensure adequate nurse staffing for a timely de-
livery of care. Because work overload, and consequent burnout,
is a cause of unfinished nursing care, the distribution of work by
nurses must be balanced and the use of overtime used sparingly.
This research did not identify an appropriate nurse skill mix for
each type of health unit. Staffing a service or health facility with
an adequate number of nurses may not be adequate. The nurse's
education, training, experience, their skills, and nurse-to-patient
ratio should also be considered when staffing a service or health
unit. This seems to be a complex task, and none of the studies
mentioned the best way to do it. Therefore, further research in
this area may be appropriate.
The work environment is strongly associated with unfinished
nursing care. Health organisations should promote a healthy work
CORDEIRO et al.
environment that fosters personal and organisational accountability
and recognize professional merit. The communication between pro-
fessionals from the same professional group and/or different profes-
sional groups should be strengthened and developed.
Although one of the analysed studies identified the lack of mate-
rial resources as a cause of unfinished nursing care, it did not indicate
any mitigating measures for this cause.
It is implicit that nurses’ decision-making ability to set priorities
affects what nursing care remains to be provided. However, none of
the studies addressed this issue or offered any explanation for how
nurses prioritize care, although Cho et al. (2017) stated that care that
affects the physical or biological dimension of the patient is a prior-
ity when providing nursing care.
E T H I C A L A P P R OVA L
This review was coordinated by Professor Raul Cordeiro, PhD,
Polytechnic Institute of Portalegre, Portugal (University of Applied
Sciences). The ethical rules in force at the Polytechnic Institute of
Portalegre in relation to this type of studies were scrupulously fol-
lowed. All authors were involved in all stages of the study.
ORCID
Raul Cordeiro  https://orcid.org/0000-0002-0037-6919
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How to cite this article: Cordeiro R, Pires Rodrigues MJ,
Serra RD, Calha A. Good practices to reduce unfinished
nursing care: An integrative review. J Nurs Manag.
2020;00:1–7. https​://doi.org/10.1111/jonm.12972​