International Journal of Nursing Studies 139 (2023) 104448

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ns

Toward understanding nurses' decisions whether to miss care: A discrete

choice experiment
Nasra Abdelhadi ⁎, Anat Drach-Zahavy, Einav Srulovici
The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Background: Studies of missed nursing care suggest that it results from ward-level, patient-related, and task-type
Received 10 September 2022 factors, while nurses' decision-making style was scarcely studied. Studying the effect of nurses' decision-
Received in revised form 17 January 2023 preference structures, namely a pattern of joint ward and patient factors, on missed care may also contribute
Accepted 19 January 2023 to understanding the phenomenon.
Objectives: To examine the relationships between decision-preference structures and missed care and the mod-
Keywords:
erating effects of decision-making styles and task type in these links.
Discrete choice experiment
Missed nursing care
Design: A discrete choice experiment with a between- and within-participants design.
Decision-making style Participants: A sample of 387 registered nurses working in acute medical surgical wards in Israel.
Task type Methods: Based on the protocol for discrete choice experiments, a survey was developed to assess the decision-
Situational factors preference structure, considering five factors: overload, presence of head nurse, clinical complexity, difficult pa-
Nurses tient, and presence of relatives. Participants were randomly assigned to four task-type conditions and completed
a survey regarding their task. Decision-making style was assessed using a validated questionnaire.
Results: Extensive workload (b = −0.46; p = 0.001), difficult patient (b = −0.20; p = 0.001), and patient clin-
ical complexity (b = −0.10; p = 0.006) were negatively linked to the probability of missed care. The interaction
between workload and task type (b = 0.252; p = 0.017) indicated that the probability of missed care under ex-
tensive compared with regular workload was lowest for developing a discharge plan and highest for providing
emotional support. The interaction of patient complexity and task type (b = 0.230; p = 0.013) indicated that
the probability of missed care in developing a discharge plan and medication administration was lower for pa-
tients having high compared with low clinical complexity. The interaction between difficult patient and task
type (b = −0.219; p = 0.044) indicated that the probability of missed care in emotional support, developing
a discharge plan, and patient's mobility was lower for difficult than for non-difficult patients. Finally, the interac-
tion between workload and decision-making style (b = − 0.48; p = 0.001) indicated that the probability of
missed care under heavy compared with regular workloads was lower for the dual-preference or the dominantly
intuitive styles.
Conclusions: This design enabled examining the prioritizing processes nurses use when deciding about whether
to miss care. The likelihood of missing more in structured tasks is lower under a heavy overload and when
patients appear difficult or clinically complex. Dual-preference styles or dominantly intuitive styles are more
suitable for the routine high workload.
© 2023 Elsevier Ltd. All rights reserved.

What is already known • Most previous studies on missed nursing care have relied heavily on
structural theories that posit that nurses miss care because of external
• Missed nursing care is a product of many factors including the organi- forces, particularly scarce resources.
zation, the patient, and the task.
What this paper adds

• A nurse's decision-making process plays a key role in limiting missed

⁎ Corresponding author at: The Cheryl Spencer Department of Nursing, University of
Haifa, 199 Aba Khoushy Ave., Mount Carmel, Haifa 3498838, Israel.
E-mail addresses: nasrahade@yahoo.com (N. Abdelhadi), anatdz@research.haifa.ac.il
(A. Drach-Zahavy), esrulovici@univ.haifa.ac.il (E. Srulovici).
nursing care; the discrete-choice-experiment design facilitates under-
standing of nurses' decision-making processes by examining prefer-
ence structures rather than singular attributes.

https://doi.org/10.1016/j.ijnurstu.2023.104448
0020-7489/© 2023 Elsevier Ltd. All rights reserved.
2 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
• Structuring nursing tasks can help limit missed care, as more struc-
tured tasks are less likely to be missed; this is particularly true when
overload is heavy or patients are characterized by high clinical com-
plexity or labeled “difficult.”
• Nurses' decision-making personal style matters: while the dual-
preference or dominantly intuitive decision-making styles are supe-
rior for reducing missed care in extensive overloads, the dominantly
analytical decision-making style is superior under regular overload.
1. Introduction
1.1. Missed nursing care
Missed nursing care—nursing tasks delayed, omitted, or incomplete
(Jones et al., 2020; Jones et al., 2015; Chaboyer et al., 2021)—is highly
prevalent. A majority of nursing personnel (55–98%) reported leaving
at least one task undone, even when viewed across countries, hospitals,
and wards (Jones et al., 2015; Chaboyer et al., 2021; Mandal et al., 2020).
Because of the potential harm of missed nursing care for patients,
nurses, and organizations, it is a global concern (Jones et al., 2020;
Chaboyer et al., 2021; Mandal et al., 2020; Kalánková et al., 2019). For
patients, missed nursing care was associated with poorer quality of
care (Jones et al., 2020; Mandal et al., 2020), higher incidence of adverse
events (Jones et al., 2015; Mandal et al., 2020; Mynaříková et al., 2020),
increased length of stay and hospital readmissions (Jones et al., 2020;
Chaboyer et al., 2021), and lower levels of patient satisfaction (Jones
et al., 2015; Mandal et al., 2020; Recio-Saucedo et al., 2018). It was
also associated with poorer nurse outcomes, including impaired job sat-
isfaction (Jones et al., 2015; Mandal et al., 2020), increased turnover and
intentions to leave the job, and higher levels of moral distress, role con-
flict, and job burnout (Ausserhofer et al., 2014; Papastavrou et al., 2014;
Uchmanowicz et al., 2020; Alsubhi et al., 2020; Clark and Lake, 2020).
Thus, missed nursing care has negative implications also for the organi-
zation, for example, in terms of increased financial costs (Jones et al.,
2015; Alsubhi et al., 2020; Kalisch et al., 2009; Kalisch et al., 2013; See
et al., 2020). Therefore, it is important to understand how decisions
about which tasks to perform and which to miss are made by nurses
at the patient's bedside.
This study examines missed nursing care through a decision-making
lens. This perspective is important because traditional empirical research
on missed nursing care is grounded in structural theories, suggesting that
nurses respond primarily to economic and organizational factors (Jones
et al., 2020), thereby neglecting nurses' agency and the specific role nurses
play in deciding which tasks to complete and which to omit.
1.2. Nurses' decision-making
Clinical decision-making in nursing has been typically described by
two distinct processes: intuitive and analytic decision-making. The
Table 1
The personal decision-making styles.
Low intuitive decision-making style
Low analytic decision-making style Disengaged
• present minimal involvement in their tasks and decision-making
processes
High analytic decision-making style Dominantly analytic
• High cognitive control and awareness;
• Adopting a systematic, step-by-step procedure, generating tentative
hypotheses about the patient's condition, and weighing the decision
alternatives before
choosing the one that fits best in light of the evidence collected
former, also known as Type 1 thinking, describes processes that are
fast and holistic, involve low cognitive control and low-conscious-
awareness, and thus enable high capacity. The latter—analytic
decision-making, also known as Type 2 thinking—describes processes
that are reflective and slow, involve high cognitive control and high con-
scious awareness, and thus are resource-demanding (Croskerry, 2013).
The nursing profession has traditionally been seen as intuitive rather
than analytic (Nibbelink and Brewer, 2018). Apparently, intuitive
decision-making processes are based on identification of patterns, ac-
quired through experience (Croskerry, 2013; Nibbelink and Brewer,
2018). They serve nurses well in their daily routine of caring for pa-
tients, enabling them to complete most of their daily tasks (Nibbelink
and Brewer, 2018). Yet intuitive decision-making processes are also
the primary source of errors, and perhaps of missed nursing care, par-
tially due to experience-based preconceptions (Croskerry, 2013;
Nibbelink and Brewer, 2018).
As it became increasingly evident that neither intuitive nor analyti-
cal decision-making adequately describes human decision-making, a
third approach to decision-making has been discussed in the nursing lit-
erature: the cognitive continuum theory (Hammond, 1988; Cader et al.,
2005; Hammond et al., 1987). This states that a decision is rarely either
intuitive or analytic; effective decision-making requires that the two
decision-making processes act in concert (Starcke and Brand, 2012).
Whereas intuitive decision-making functions as the default, analytic
decision-making supervises intuitive decision-making. Apparently, the
analytic system “knows” the rational rules that the intuitive system is
prone to violate and thus can intervene to correct erroneous intuitive
judgments (Kahneman and Klein, 2009).
Intuitive and analytical decision-making processes, and their combi-
nations, have been established as universal ways of making choices; yet
nurses may vary in their personal decision-making styles, reflecting
their habits in making decisions, or their fairly stable way of interpreting
and responding to decisions (Driver, 1979; Harren, 1979). These differ-
ences are thought to represent personal preferences and not differences
in intuitive/analytical capacity or ability (Reber et al., 1991). Four main
personal decision-making styles have been described: Dominantly intu-
itive, dominantly analytic, dual preference, and disengaged (Croskerry,
2014; Shiloh et al., 2002; Jokić and Purić, 2019; Bjørk and Hamilton,
2011; Fletcher et al., 2012; Epstein et al., 1996) (Table 1).
2. Research model
2.1. Nurses' preference structures
The research model (Fig. 1) is informed by the missed nursing care
(Kalisch et al., 2009; Schubert et al., 2007) and cognitive continuum
(Hammond et al., 1987) theories. The model begins by acknowledging
that nurses make decisions during complex decision-making encoun-
ters in which several attributes, sometimes at odds with one another,
are considered in parallel. These complex circumstances are referred
High intuitive decision-making style
Dominantly intuitive
• low cognitive control and awareness;
• a medium degree of organization
• Typical use of quick and unconscious processes, such as
associative memory
Dual preference style
• High ability to flexibly shift from an analytic to an intuitive
decision-making process, and vice versa.
• Apply logical reasoning and remain open-minded while
also responding quickly to some situations intuitively
without erring.
 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
Fig. 1. A double moderation research model.
to as preference structures combining different attributes in order to de-
scribe the subjective trade-offs between alternative contextual factors
that affect the decision made (Nishimura and Ok, 2018). For example,
whether to delay medication administration or to develop a discharge
plan for a patient may depend on work overload (Jones et al., 2015;
Chaboyer et al., 2021) but also on the presence of the head nurse and/
or the patients' relatives, as well as on the perception of the patient as
clinically complex or emotionally demanding (Abdelhadi et al., 2020).
Recent emerging empirical evidence indicated that factors in the
work context, or in relation to a specific patient, serve as red flags for
nurses, encouraging them to shift from intuitive to analytic decision-
making, resulting in less missed nursing care (Abdelhadi et al., 2020).
The specific encounter-level attributes encompassing nurses' decision
preferences were chosen based on a designated qualitative study
(Abdelhadi et al., 2020). The specific attributes are:
Workload. Scholars of missed nursing care agree that the most pow-
erful factors related to this phenomenon are decreased resources in
terms of staffing levels and diminished labor resources (Jones et al.,
2015; Mandal et al., 2020; Griffiths et al., 2018), inappropriate skill
mix (Griffiths et al., 2018), lack of material resources (Jones et al.,
2015), and patient acuity (Jones et al., 2015; Mandal et al., 2020).
Patient's clinical complexity. The nurse's perception of a patient's
medical status might range from simple to complex, based on the
number of chronic conditions the patient has, the medications the
patient takes, or their prior usage of healthcare resources (Higashi
et al., 2007; Ash et al., 2001; Charlson et al., 1987). Studies demon-
strated that a patient's clinical complexity was associated with de-
creased missed nursing care (Jones et al., 2015).
Difficult patients. These patients are defined as those whose behav-
iors make the healthcare provider–patient encounter particularly
3
distressing and arouse negative emotions (Mamede et al., 2017;
Schmidt et al., 2017). Apparently, nurses perceive patients on a con-
tinuum between “likeable” and “difficult” (Mamede et al., 2017). It
might be intuitively logical to suggest that nurses enjoy spending
more time with likable or grateful patients. Alternatively, nurses
may believe that more likeable patients will be more accepting of
missed care. Indeed, research has shown that negative emotions
trigger avoidance behaviors (Dolan, 2002), and experiencing anger
during an encounter was found to decrease risk estimates, thereby
leading individuals to ignore possible negative outcomes of their de-
cisions (Lerner et al., 2003; Lerner, 2001). Within healthcare set-
tings, treating “difficult patients” has been associated with
impaired clinical decisions (Croskerry, 2013; Mamede et al., 2017),
clinical mistakes (Schmidt et al., 2017), and neglect behaviors,
namely not providing adequate care (Pickering et al., 2017).
Presence of the patient's relatives. Physicians spend more time com-
municating with patients in visits where relatives are present than
in visits where the patient is alone (Shields et al., 2005; Kang and
Choy, 2015). Thus, we suggest that nurses will demonstrate less
missed nursing care when patients are accompanied by relatives be-
cause nurses might perceive the relatives as potential monitors
(Ferris and Rowland, 1983; Hills et al., 2019; Coats et al., 2018)
who will call the nurse if missed care results in a complication, and
therefore make every effort to complete their tasks.
Presence of the head nurse. Missed nursing care may be reduced by
head nurses monitoring nurses' care and ensuring that tasks are
completed (Shirey et al., 2008; Miltner et al., 2015). Nurses could
also be more aware of action–outcome contingency if the head
nurse is present (Hammond et al., 1987) and thus tend to complete
their tasks. Finally, head nurses may pitch in and provide care that
would be otherwise missed (Drach-Zahavy and Dagan, 2002).
4 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
Although the above findings have merit, they are mainly based on
nurses' narratives or correlational findings. This is where cognitive con-
tinuum theory (Hammond, 1988) can help in explaining how, why, and
under what circumstances missed nursing care occurs. Accordingly, the
model proposes two intervening mechanisms—the type of task and
the nurse's decision-making style—that might moderate the relation-
ships between patients' and wards' decision-making preferences and
missed nursing care.
2.2. Moderating role of task type in the relationship between nurses'
decision-making preferences and missed nursing care
The model depicted in Fig. 1 also suggests that task type can moder-
ate the relationships between decision-preference structures and
missed nursing care. The missed nursing care literature, in line with cog-
nitive continuum theory, argues that certain tasks are more prone to be
missed than others (Jones et al., 2015). In line with this literature, main-
taining patients' physical health is usually prioritized by nurses,
whereas basic care, patient education, and emotional support are
more likely to be delayed (Mandal et al., 2020; Mynaříková et al.,
2020; Griffiths et al., 2018; Bagnasco et al., 2020; Vincelette et al.,
2019), and that tasks that are more time-consuming, whose duration
is difficult to estimate, or whose requirements cannot be reduced by
working around them are likely to be overlooked or delayed (Schubert
et al., 2013). Accordingly, cognitive continuum theory proposes a task
continuum ranging from well-structured to ill-structured tasks. While
well-structured tasks enable task decomposition into definable parts
and have a clear criterion for success (Dane and Pratt, 2007;
Thompson et al., 2004), ill-structured tasks describe judgmental rather
than intellectual tasks having many feasible solutions (Thompson
et al., 2004). To grasp the range of well-structured and ill-structured
tasks, we selected four tasks for the current study. Patient mobility
and medication administration represented well-structured tasks, as
nurses know how to perform them by following a clear, step-by-step
procedure (Ausserhofer et al., 2014; Schutijser et al., 2019; Liu et al.,
2019). By contrast, discharge planning and emotional support represent
ill-structured tasks, as they are more emotional and holistic, making
them harder to deconstruct, and have many options or solutions for per-
forming them (Ausserhofer et al., 2014).
Although direct effects of well-structured and ill-structured tasks on
missed nursing care have been reported (Jones et al., 2015; Zeleníková
et al., 2020), the moderating role of task type on the relationship be-
tween the encounter attributes of the patient and the ward and missed
nursing care has yet to be examined. In accordance with cognitive con-
tinuum theory (Hammond et al., 1987), we propose that well-
structured tasks activate the analytic decision-making process, meaning
that information is processed slowly but systematically in a careful,
step-by-step manner, resulting in fewer instances of missed nursing
care irrespective of the patient and context attributes (Cader et al.,
2005; Hammond, 1996). Ill-structured tasks, by contrast, trigger the in-
tuitive decision-making process, indicating that information is proc-
essed rapidly and holistically but is more sensitive to contextual and
patient-related factors that might signal to the nurse that the patient's
quality of care may be at risk (Cader et al., 2005; Hammond, 1996).
Thus, the task and patient's and ward's encounter attributes may serve
as red flags to lead the nurse to attend to the patient and complete
their care. Therefore, we suggest that the link between the attributes
and the likelihood to miss care will be stronger for ill as compared
with well-structured tasks.
2.3. Decision-making style as moderating the relationship between nurses'
decision-making preferences and missed nursing care
The differences between nurses' four personal decision-making
styles (i.e., dominantly analytic, dominantly intuitive, dual preference,
and disengaged) may predict decision outcomes (Shiloh et al., 2002;
Marks et al., 2008; Pacini and Epstein, 1999; Witteman et al., 2009)
such as whether to miss care. However, we are interested here in the
moderating role of decision-making personal style in the relationship
between the nurse's preference structures and missed nursing care. Re-
search on decision-making suggests that nurses should respond to com-
plex circumstances with either a more holistic style (i.e., intuitive style)
(Grant and Langan-Fox, 2014) or by remaining open-minded and
smoothly juggling intuitive and analytical styles (i.e., dual decision-
making style) (Shiloh et al., 2002; Jokić and Purić, 2019; Fletcher et al.,
2012; Epstein et al., 1996). As nurses apply these styles, they can more
wisely allocate their resources between the concomitant demands in
the preference structure, function more efficiently, and engage in
fewer missed nursing care incidents. By contrast, nurses characterized
by a dominantly analytical style may find working in the overstretching
demands characteristic of nurse-preference structures especially toxic.
These nurses may prioritize one attribute over another, diverting high
awareness and reflective attention to one attribute while neglecting
the others (Croskerry, 2013), and therefore engaging in higher levels
of missed nursing care overall. Last, nurses characterized by disengaged
styles are inattentive to their decisions overall, resulting in the highest
level of missed nursing care.
3. Study aims and hypotheses
The main aim of this study was to examine the relationships be-
tween decision-preference structures and missed care and the moderat-
ing effects of decision-making styles and task type in these links (Fig. 1).
To this aim, the following hypotheses were derived:
Hypothesis 1. Nurses' decision-making-preferences will be related to
the likelihood of completing or omitting care such that high patient clin-
ical complexity, presence of patients' relatives, and presence of the head
nurse will be negatively associated with the likelihood to miss care,
whereas perceiving a patient as difficult and having a heavy workload
will be positively associated with the likelihood to miss care.
Hypothesis 2. Tasks categorized as well structured (i.e., patient mobil-
ity and medication administration) will weaken the link between the
attributes and the likelihood to miss care compared with tasks catego-
rized as ill structured.
Hypothesis 3. Dual-preference or dominantly intuitive decision-
making styles will weaken the link between preference structures and
the likelihood to miss care compared with dominantly analytic or disen-
gaged decision-making styles.
4. Methods
4.1. Design
The study used a discrete choice experiment (please see Section 4.2
for a description of the discrete choice experiment), between- and
within-participant design. The within-participant component of the de-
sign constituted the variability within nurses in their preferences across
scenarios. Participants were presented with two decision-making pref-
erences and asked to choose which one they prefer. Each alternative had
a different set of attributes and attribute levels, based on the results of a
previous qualitative study (Abdelhadi et al., 2020) that sought to iden-
tify the main attributes that guided nurses in choosing which care to
omit or postpone (Table 2). The between-participants component of
the design included examining the variability in nurses responding to
the discrete choice experiment, given their decision-making style
(dominant analytic, dominant intuitive, dual preference, or disen-
gaged). Additionally, to ease the burden on participating nurses, each
nurse answered the discrete choice experiment survey for one of four
tasks (i.e., medication administration, patient mobility, developing
 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448 5

Table 2 focused on the nurse's likelihood of whether to provide or omit care in

Discrete choice experiment: Attributes and attribute levels. a particular encounter, and it was assumed that the nurse's decision crit-
Attribute Attribute level ically depended on how well these characteristics are concomitantly
Workload Regular workload (occupancy rate <100%)a
taken into account (Ryan, 2004; Tockhorn-Heidenreich et al., 2017; De
OR Bekker-Grob et al., 2012). Therefore, discrete choice experiments
Extensive workload (occupancy rate >100%) allow a more detailed investigation of the trade-offs between the differ-
Presence of head nurse Head nurse in the ward ent attributes in comparison to traditional regression analyses (De
OR
Bekker-Grob et al., 2012; Chudner et al., 2019; Mangham et al., 2009).
Head nurse is not in the ward
Presence of relatives Relatives are next to the patient Although discrete choice experiments were initially introduced to
OR healthcare economics and policymaking as a way to assess customer
No relatives next to the patient preferences (De Bekker-Grob et al., 2012; Chudner et al., 2019;
Difficult patient Patient stimulates negative emotions Mangham et al., 2009), they have been gradually extended to consider
OR
Patient does stimulate positive emotions
also the providers' preferences (Ryan, 2004).
Patient clinical complexity Patient has high levels of comorbidity Following the discrete choice experiment protocol (Ryan, 2004;
OR Louviere et al., 2010), the survey included eight scenarios, each present-
Patient has low levels of comorbidity ing two possible sets of options to omit care (option A or option
a
Levels of regular and extensive workload were determined based on the findings of a B) (Fig. 2). Each set of options represents a combination of the five attri-
qualitative study (Abdelhadi et al., 2020). butes that nurses consider vital in deciding whether to omit care
(Abdelhadi et al., 2020), and each attribute has two levels. In accordance
with the discrete choice experiment protocol recommendations, the at-
discharge plans, or providing patients emotional support); thus, only tributes and levels were chosen based on a qualitative study (Abdelhadi
differences between participants could be examined for task type. We et al., 2020), including (1) Patient clinical complexity: high versus low
followed all the recommended steps for discrete choice experiments, in- levels of patient comorbidity, (2) Difficult patient: patient stimulating
cluding selecting key attributes and assigning levels to them; develop- negative emotions versus positive emotions, (3) Presence of the patient's
ing an experimental design, scenarios, and surveys; administering relatives: yes or no, (4) Workload: regular (occupancy rate <100%) ver-
surveys to elicit preferences; and analyzing data (Lancsar et al., 2017). sus extensive workload (occupancy rate >100%), and (5) Presence of the
head nurse: yes or no (Table 2). Combining the five attributes and two
4.2. Discrete choice experiment levels yielded 32 (or 2 (Kalánková et al., 2019)) possible scenarios for
paired combinations of attributes. To avoid the high cognitive burden
Discrete choice experiments are an attribute-based measure of ben- that this full factorial design can cause, and in line with the experiment
efit, embedded in two complementary assumptions: (a) that healthcare protocol (Nittas et al., 2020; Hensher et al., 2005; Aizaki and Nishimura,
interventions, services, or policies are defined by the encounter charac- 2008), we developed an orthogonal fractional factorial design of eight
teristics (or attributes); and (b) the degree to which each of these char- scenarios using the Ngene software (ChoiceMetrics, 2014). The scenar-
acteristics is taken into account in a concomitant manner determines an ios' combinations were paired using a fold-over design (Burgess and
individual's preference. In this study, the discrete choice experiment Street, 2005).

In which case would you delay emotional support to the patient and help another patient in

the ward?

Prefer A Ward with Patient with low Head nurse is No relatives Patient
occupancy rate levels of not in the ward next to the stimulates
above 120% comorbidity patient negative
emotions

Prefer B Ward with Patient with high Head nurse is Relatives are Patient does not
occupancy rate levels in the ward next to the stimulate
below 80% comorbidity patient negative
emotions

In which case would you delay emotional support to the patient and help another patient in

the ward?

Prefer A Ward with Patient with high Head nurse is Relatives next Patient does not
occupancy rate levels of in the ward to the patient stimulate
above 120% comorbidity negative
emotions

Prefer B Ward with Patient with low Head nurse is No relatives are Patient stimulate
occupancy rate levels not in the ward next to the negative
below 80% comorbidity patient emotions

Fig. 2. Example of scenario combinations.

6 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
4.3. Sample
The sample included 387 registered nurses from various acute-care
hospitals working in internal medicine or surgical hospital wards in
Israel and at least a 75% full-time equivalent. Nurses were randomly
assigned to the task-type condition: 99 completed the discrete choice
experiment for the medication administration task, 97 for the patient-
mobility task, 97 for developing-the-discharge-plan task, and 94 for
the emotional-support task. The sample size was adequate according
to Louviere et al. (2010) recommendation of 48 participants per task
(responding to the eight-scenario design explained above) to give a pre-
cise estimate for the main effect of each attribute level on missed nurs-
ing care given the five attributes and two levels in our study, at the
conventional 5% significance level.
Data were collected via snowball sampling between July 2020 and
January 2021 through social media networks (e.g., Facebook nursing so-
cial groups). We chose this sampling method because we wanted to in-
clude as many participating nurses as possible, not limiting ourselves to
peripheral or central hospitals. Furthermore, we intentionally avoided
recruiting participants through hospitals' officials in order to ensure
the credibility and confidentiality of the responses. Those agreeing to
participate entered an online link to the Qualtrics software and were
asked to complete the electronic questionnaire. After they completed
the electronic questionnaire, nurses were asked to share the link with
colleagues who met the inclusion criteria. Nurses were offered a coffee
and pastry gift card for their participation.
4.4. Measures
4.4.1. Missed nursing care
Missed nursing care was assessed via the survey. Nurses were asked
to answer, for each scenario, for which option (A or B) they would more
likely omit performing the specific task. Thus, they were forced to make
trade-offs between attributes and their levels to choose between the
two alternative options for which they would omit or delay care (Fig. 2).
4.4.2. Task type
Task type included four nursing activities: providing emotional sup-
port, developing a discharge plan, patient's mobility, and medication ad-
ministration. These tasks were chosen based on results of a previous
qualitative study (Abdelhadi et al., 2020), as they represent both ill-
structured (i.e., emotional support and developing discharge plan) and
well-structured (i.e., patient's mobility and medication administration)
tasks. Nurses were randomly assigned to one of the four task types and
completed the corresponding experiment.
4.4.3. Decision-making style
Decision-making style was measured with the validated Unified Scale
to Assess Individual Differences in Intuition and Deliberation (USID). This
two-scale questionnaire was originally developed to assess analytic and
intuitive personal decision-making styles (Pachur and Spaar, 2015). Six-
teen items assessed the analytic style (e.g., “Developing a clear plan is
very important to me”), and 16 items assessed the intuitive style
(e.g., “When I make a decision, I trust my inner feeling and reactions”).
Nurses were instructed to imagine a work situation that they had faced
and to rate each item on a 5-point Likert scale (ranging from 1 “I
disagree” to 5 “I 100% agree”) to indicate how they would have
decided in that situation. Cronbach's internal reliabilities were α =
0.94 and α = 0.87 for the analytic and intuitive subscales, respectively.
For the current study, and in line with previous studies that found
that individuals are characterized by both decision-making styles
(Shiloh et al., 2002; Jokić and Purić, 2019; Fletcher et al., 2012; Marks
et al., 2008; Witteman et al., 2009; Lu, 2015), the original questionnaire
scales were then categorized into four decision-making styles, based on
the median score of the original scales: dominantly analytic (high ana-
lytic/low intuitive), dominantly intuitive (low analytic/high intuitive),
dual preferences (high analytic/high intuitive), and disengaged (low
analytic/low intuitive).
4.5. Ethical considerations
Ethical approval was granted by the university's ethics committee
(#142/18). Nurses were provided a full explanation of the study's
aims, including their right to quit, and assured of confidentiality.
4.6. Data analysis
Nurses' preference structures for attributes were analyzed with a
conditional logistic model that included 3096 choice tasks. This model
estimates choice probabilities as a function of the attributes of the alter-
natives under consideration (Craiu et al., 2016; Long, 2004); namely, it
compares the probability of selecting an alternative from among a set
of attributes defining those alternatives (Hauber et al., 2016). To test a
moderation model, first, all attributes were entered into the model,
and then the interaction terms Attributes × Task type and Attributes ×
Decision-making style were entered. All analyses were conducted in
SAS version 9.4, and the p-value was set at 0.05. Post-hoc analysis,
using Fisher's LSD, of the above interactions was conducted.
4.7. Model specification
The analysis of the discrete choice experiments data assumes that a
nurse who chooses alternative A over alternative B perceives alternative
A to provide greater utility (i.e., U) than alternative B (Hauber et al.,
2016). The utility function of the interactions according to the condi-
tional logit model was specified as follows:
U njt ¼ β1  workloadnjt þ β2  precence of head nursenjt þ β3
 presence of relativesnjt þ β4  difficult patient njt þ β5
 clinical complexitynjt þ β6  workload  task typenjt þ β7
 precence of head nurse  task typenjt þ β8
 presence of relatives  task typenjt þ β9  difficult patient
 task typenjt þ β10  clinical complexity  task typenjt þ β11
 workload  decision‐making stylenjt þ β12
 presence of head nurse  decision‐making stylenjt þ β13
 presence of relatives  decision‐making stylenjt þ β14
 difficult patient  decision‐making stylenjt þ β15
 clinical complexity  decision‐making stylenjt þ εnjt :
where Unjt is the utility of nurses n derived from selecting incentive
alternative j in choice task t, β1 to β15 are parameters to be estimated,
and εnjt is the error term that is assumed to be independently and
identically distributed following a Type 1 extreme value distribution.
5. Results
5.1. Sample characteristics
The 387 participating nurses were mostly women (74%, n = 286),
holding a bachelor's degree (59%, n = 227), and working a 100% full-
time equivalent (68%). Their ages ranged from 23 to 65 years (mean =
35.97; standard deviation (SD) = 8.59), and their years of practice
ranged from 1 to 45 (mean = 19.54; SD = 11.70). Furthermore,
whereas 62% (n = 240) had earned a nursing advanced training certif-
icate, only 12% (n = 47) held a managerial role (Table 3).
5.2. Internal consistency of the discrete choice questionnaire
To test the internal consistency of the measure and the rationality of
participants, we added one scenario that, according to the study's hy-
potheses, was superior to the alternative in every domain (Johnson
et al., 2019). Yet, since there is no ideal validity testing, we conducted
 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448 7

Table 3 the likelihood of missed nursing care: Workload × Task type (b =

Descriptive statistics for the study sample (N = 387). 0.252; p = 0.017), Patient clinical complexity ×Task type (b = 0.230;
Characteristic Mean (SD)/N (%) p = 0.013), and Difficult patient presence × Task type (b = − 0.219;
Gender (female) 286 (73.9%)
p = 0.044). To understand the nature of the interactions, post-hoc anal-
Age (in years) 35.97 (8.59) yses, using Fisher's LSD, were conducted.
Years of practice as a nurse (in years) 19.54 (11.70) First, for the interaction between workload and task type, post hoc
Education analyses demonstrated that the tendency to miss care was higher
Registered nurse 36 (9.3%)
under heavy than under regular workloads: the greatest disparity be-
BA 227 (58.7%)
MA 118 (30.5%) tween these was found for emotional support (b = −0.66; p-value =
PhD 6 (1.6%) 0.000), and the lowest for developing a discharge plan (b = −0.28; p-
Advanced nursing training certificate (yes) 240 (62%) value = 0.000). In addition, we observed no significant differences in
Full-time equivalent missed nursing care between the different task types under a regular
75% 81 (20.9%)
80–99% 43 (11.1%)
or a heavy workload. Yet the tendency to miss care under a heavy work-
100% 263 (68%) load was higher for patient mobility and emotional support than for dis-
Managerial role (yes) 47 (12.1%) charge planning (b = 0.182, p = 0.090 and b = − 0.200, p = 0.060,
respectively). Under a regular workload, the tendency to miss care
was higher for patient mobility than for emotional support (b =
an analysis to examine participants who failed to choose the inferior op- −0.27, p = 0.080).
tion in this scenario (Sargent, 2005; Holm et al., 2016). The analysis re- Second, for the interaction between patient complexity and task type,
vealed no significant differences between those who did and those who the probability of missed care in developing a discharge plan and medica-
did not choose the inferior option in this scenario. Thus, all participants tion administration was lower for patients characterized by high than by
were included in the final analysis. low clinical complexity (b = −0.21; p = 0.003; b = −0.22, p = 0.003,
respectively). Additionally, for high-clinical-complexity patients, the
5.3. Main effect of attributes on nurses' preference structures of missing care probability of missing a mobility task was higher than for missing a med-
ication administration task (b = 0.30; p = 0.042).
Table 4 presents the results of a conditional logit model evaluating Finally, for the interaction between patient difficulty and task type,
the likelihood of missed nursing care using the five attributes (model for emotional support (b = −0.308; p < 0.001), developing a discharge
1: main effects). Three of the five were significantly and negatively plan (b = −0.257; p < 0.001), and patient mobility (b = −0.228; p =
associated with missed nursing care: heavy workload (estimate = 0.002), nursing care had a lower probability of being missed for difficult
−0.46; p = 0.001), difficult patient (estimate = − 0.20; p = 0.001), than for non-difficult patients. However, no significant differences in
and patient clinical complexity (estimate = − 0.10; p = 0.006). medication administration were found between difficult and non-
Namely, the probability of missed care was lower for a heavy than for difficult patients.
a regular workload, when caring for patients having high comorbidity
compared with patients having low comorbidity, and when caring for 5.5. Interactions between preference structures (attributes) and decision-
patients labeled “difficult” (i.e., stimulating negative emotions) com- making style on nurses' missed nursing care
pared with non-difficult (i.e., stimulating positive emotions).
Only one significant two-way interaction, between preference struc-
5.4. Interactions between preference structures (attributes) and task type tures (attributes) and decision-making style on the likelihood of miss-
on nurses' missed nursing care ing care, was found (Table 4, model 2): Workload × Decision-making
style (b = − 0.48; p = 0.001). A post-hoc analysis (Fisher's LSD)
Results of the two-way interactions between task type and the five demonstrated that under a heavy workload, nurses characterized by
attributes, representing task structure, are presented in Table 4 (model dual preferences (b = −0.24; p = 0.029) or dominantly intuitive styles
2). Three of the five interactions were significantly associated with (b = −0.24; p = 0.021) were less likely to miss care than nurses char-
acterized by a disengaged style. In comparison, under a regular work-
Table 4 load, when compared with nurses characterized by a disengaged style,
Moderation conditional logistic models of the effects of attribute, task type, and decision- nurses characterized by a dominantly analytic style had the lowest
making style on probability of missed care. probability of missing care (b = −0.63, p = 0.001), followed by nurses
Attribute Model 1 Model 2
characterized by the dual style (b = − 0.39; p = 0.013) and nurses
Attributes only Attributes and characterized by the dominantly intuitive style (b = − 0.31; p =
interactions 0.033). Additionally, nurses characterized by a dominantly intuitive
Estimate p-Value Estimate p-Value style were more likely to miss care than nurses characterized by a dom-
inantly analytic style (b = 0.31; p = 0.038). No other significant inter-
Workload −0.461 <0.000 −0.356 <0.001
Complexity −0.101 0.006 −0.168 0.087 actions between workload and decision-making style were found.
Head nurse −0.043 0.241 −0.025 0.793
Relatives 0.018 0.959 0.015 0.872 6. Discussion
Difficult patient −0.209 <0.000 0.068 0.486
Workload × Task typea 0.252 0.017
By combining decision-making theory and discrete choice experi-
Complexity × Task typea 0.230 0.034
Head nurse × Task typea 0.074 0.481 ment methodology, we examined missed nursing care, drawing a com-
Relatives × Task typea 0.120 0.269 plex and nuanced picture of how, when, and why nurses miss care.
Difficult patient presence × Task typea −0.219 0.044 Apparently, nurses don't just react to external factors, such as overload
Workload × Decision-making styleb −0.485 >0.001
or a lack of resources, in their overt or covert decisions to miss care
Complexity × Decision-making styleb −0.147 0.154
Head nurse × Decision-making styleb −0.104 0.311 (Jones et al., 2020; Holm et al., 2016). Instead, the findings partially sup-
Relatives × Decision-making styleb −0.068 0.534 ported the hypothesized model (Fig. 1), demonstrating that nurses' de-
Difficult patient × Decision-making styleb −0.295 0.007 cisions are influenced by complex structural preferences that interact
a
Reference group = medication administration task. with task type and personal decision-making style. Importantly, three
b
Reference group = disengaged decision-making style. of the five attributes were predictors of lower likelihood to miss care:
8 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
extensive workload, difficult patients, and complex patients. These find-
ings are not new, and they join robust findings from recent research re-
views (Jones et al., 2015; Mandal et al., 2020; Abdelhadi et al., 2020;
Griffiths et al., 2018). The novelty of our findings lies in the interaction
effects found relating to the moderating role of task type and personal
decision-making style in the relationship between the preference struc-
tures (i.e., attributes) and the likelihood of missing care. We were thus
able to contribute in a number of ways to the current literature.
First, contrary to Hypothesis 1 and previous research, perception of a
patient as difficult was linked to the likelihood of reduced missed nursing
care (Mamede et al., 2017; Schmidt et al., 2017; Smith and Zimny, 1988;
Gerrard and Riddell, 1988). Medication administration was the only ex-
ception: no significant differences were found between difficult and
non-difficult patients. A methodological or theoretical explanation could
clarify this discrepancy. In theory, understanding a difficult patient and
providing them full care may be the best way to handle the situation effi-
ciently and move on to the next patient (Gillette, 2000; Karahuseyınoglu
and Oguzoncul, 2021). There is some evidence that nurses can de-escalate
difficult behaviors by offering instrumental or emotional support
(Karahuseyınoglu and Oguzoncul, 2021). Furthermore, this result may
be due to our novel discrete choice experiment design, which allowed
us to examine the relationship between nurses' decision preferences
and missed care, instead of the relationship between difficult patients
and missed care alone. Namely, when considering different encounter fac-
tors together, treating difficult patients' needs immediately might be the
most efficient way to maximize the nurse's resources.
Second, our findings indicated, in line with our Hypothesis 1 and
previous findings, that a patient's clinical complexity results in more
comprehensive care and lower likelihood of missed nursing care
(Jones et al., 2015; Pavedahl et al., 2022). However, our study adds to
previous findings by revealing that nurses' decision-making about
whether to miss care of clinically complex patients varies depending
on task type. Namely, in partial support of Hypothesis 2, when consider-
ing nurses' decision-preference matrix as a whole, rather than patient
complexity as a single factor, higher clinical complexity was associated
with a lower likelihood of missed care for medication administration
and discharge-planning tasks, but not for emotional support or
patient-mobility tasks. These findings provide partial support for the
continuum cognitive theory (Cader et al., 2005; Hammond et al.,
1987), arguing that nurses may give priority to well-structured tasks
when caring for patients characterized by high clinical complexity.
This theory suggests that the higher the task-structure level, the greater
the chance that analytic decision-making processes will be facilitated,
which will result in a more comprehensive patient-care plan and
fewer nursing-care gaps. That medication administration is a well-
structured task with detailed procedures that require nursing compli-
ance, especially for patients with high clinical complexity, may shift
the nurse's attention toward analytic decision-making and therefore re-
duce missed care (Jones et al., 2015; Chaboyer et al., 2021; Mandal et al.,
2020; Schubert et al., 2021).
At first glance, the fact that nurses prioritize developing discharge
plans for patients with higher clinical complexity may seem contrary
to the cognitive continuum theory (Hammond, 1988; Cader et al.,
2005; Hammond et al., 1987), since discharge planning can seem to
be an ill-structured task. Yet, recently, health-system policymakers
have realized that ill-structured discharge plans can lead to adverse
events after discharge, hospital readmissions, and subsequent medical
costs (Kripalani et al., 2014; Zhu et al., 2015; Smith et al., 2018;
Fredrickson and Burkett, 2019). It has therefore been necessary to struc-
ture discharge plans by monitoring the consequences of missed discharge
plans and the discharge planning time (Zhu et al., 2015; Maramba et al.,
2004). Perhaps our finding that nurses prioritize developing discharge
plans for patients characterized by high clinical complexity reflects
these trends. Interestingly, when caring for patients with high clinical
complexity, patient mobility, a seemingly well-structured task, was not
prioritized by nurses. Perhaps task type encompasses not only task
structure but features such as complexity, consequences, and monitoring
level (Afsar and Umrani, 2020; Chen et al., 2022). Thus, because omitting
or delaying a patient's mobility task can have long-run adverse conse-
quences, this task is unlikely to activate the analytical decision-making
process and may thus be overlooked (Jones et al., 2015; Ausserhofer
et al., 2014) regardless of the patient's clinical complexity. In addition,
emotional support was not prioritized even for clinically complex pa-
tients, since its ill-structured nature could not divert attention to analytic
decision-making processes, leading to missed care (Jones et al., 2015;
Cader et al., 2005; Hammond, 1996; Chegini et al., 2020).
Third, our findings indicated that work overload was linked to lower
likelihood of missed nursing care (Jones et al., 2015; Pavedahl et al.,
2022). However, our study adds to previous findings by revealing that
nurses' likelihood to miss care in heavy- versus regular-overload circum-
stances varies depending on task type, with developing discharge plans
missed the least, and providing emotional support missed the most
under extreme workloads. As mentioned earlier, recent policy changes
have resulted in discharge planning becoming more structured than ex-
pected, and a fortiori than providing emotional support (Zhu et al.,
2015; Maramba et al., 2004). Thus, the combined effects of heavy work-
load and a well-structured task may signal nurses to stop, consider, and
make more analytical decisions in order to avoid missing nursing care.
By contrast, mobility was less prioritized under a heavy than under a reg-
ular workload, even though it seemed to be a well-structured task. Task
type may include characters more than structures, such as complexity,
consequences, and monitoring levels (Afsar and Umrani, 2020; Chen
et al., 2022). Putting off or delaying the mobility care of a patient is likely
to have adverse long-term consequences, which is unlikely to activate an-
alytical thinking (Jones et al., 2015; Ausserhofer et al., 2014).
Fourth, our findings provided important insights into nurses' per-
sonal decision-making styles as moderating the relationship between
decision-preference structures and missed nursing care. In partial sup-
port to Hypothesis 3, the findings indicated that under heavy compared
with regular workloads, nurses with a dominantly intuitive or dual-
preference style functioned better: missed care was less common than
for nurses with disengaged decision-making styles (but not for nurses
with analytic decision-making styles). Under heavier workloads, an
intuitive decision-making style may allow nurses to provide quick,
efficient care, and to use their resources efficiently (Croskerry, 2013;
Hammond, 1988). In addition, nurses with a dual-preference decision-
making style are open-minded and switch between intuitive and
analytic styles when needed, allowing them to react flexibly. Therefore,
these decision-making styles seem better-suited to providing compre-
hensive care under heavier workloads (Nibbelink and Brewer, 2018;
Jokić and Purić, 2019; Fletcher et al., 2012; Epstein et al., 1996). Under
heavy workloads, we also found that an analytic decision-making style
did not outperform a disengaged decision-making style in attenuating
the link between decision preference and missed care. It is likely that
such a decision-making style requires more time and cognitive re-
sources to develop tentative hypotheses and to weigh options before
selecting the best one (Croskerry, 2013; Bjørk and Hamilton, 2011). In
addition, analyzing alternatives in a crowded environment can be
extremely stressful for the nurse, preventing them from being able to
perform their duties efficiently (Oshodi et al., 2019).
However, under a regular workload, a different picture emerged: as ex-
pected, nurses having an analytical style were least likely to miss care,
probably because they can use their resources optimally, calculate all the
alternatives, and make normative judgments (Shiloh et al., 2002). Nurses
with a dominantly dual-preference style were the second best at reducing
the likelihood of missed care, followed by nurses with a dominantly intu-
itive style. Disengaged nurses performed worst, regardless of their load
level, because they were less involved in their work (Shiloh et al., 2002;
Jokić and Purić, 2019; Fletcher et al., 2012; Epstein et al., 1996).
Finally, previous studies suggested that presence of the head nurse
(Abdelhadi et al., 2020; Srulovici and Yanovich, 2022) and family mem-
bers may have an important role in reducing missed nursing care
 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
(Abdelhadi et al., 2020). However, we found no evidence for those rela-
tionships in our study, through either main effects or interactions. The
study design may have led to these unexpected results given that we
measured these attributes at only two levels—the presence or absence
of head nurses/relatives. Their presence may be perceived either as re-
sources or as burdens, affecting the frequency of missed care (Hills
et al., 2019; Coats et al., 2018; Miltner et al., 2015). For example, nurses
may perceive relatives' presence as an unwanted interruption, increas-
ing their burden, resulting in missed care; or as a resource for decreasing
workload, and thus decreasing missed care (Abdelhadi et al., 2020).
Similarly, presence of the head nurse on the ward might be associated
with better patient care when they are perceived as a clinical leader
(Page et al., 2021; Purdy et al., 2010) but with deteriorated patient
care when they are perceived as punitive and as primarily monitoring
errors (Morsiani et al., 2017; Feather et al., 2015). Therefore, the insig-
nificant effects of head nurses'/relatives' presence might be interpreted
with caution and should be investigated further.
6.1. Strengths, limitations, and suggestions for further research
This study used a novel discrete choice experiment to shed light on
bedside nurses' decision-making processes regarding missing care.
This design may have helped illuminate nurses' nuanced decision-
making processes about when is omitting or delaying care more likely,
because (a) it simulates nurses' natural complex encounters, and (b) it
assesses nurses' decision preferences rather than singular encounter at-
tributes, thereby overcoming the limitations of ranking singular-
attribute data (Louviere and Woodworth, 1983). Despite their
strengths, discrete choice experiments have several limitations.
First, using structured scenarios might limit the generalizability of
the findings to real-world situations. Discrete choice experiments may
not capture all the complexities of real-world choices (Liu et al., 2019;
Berman et al., 2021). However, this limitation might be less serious in
our study because nurses' decision-preference patterns were based on
attributes and levels that emerged in a pilot qualitative study
(Abdelhadi et al., 2020) and matched those found in previous studies
(Jones et al., 2015) as recommended in the discrete choice experiment
protocol (Coats et al., 2018). Future studies should examine real-
world, bedside situations, to better understand nurse preferences and
to shed light on other factors involved in the likelihood to omit care.
Second, data collection through social media networks may be vul-
nerable to self-selection bias: users of such platforms may be systemati-
cally different from those who do not. Additionally, social media
networks do not necessarily contain the entire population of interest
(Morstatter and Liu, 2017; Mirabeau et al., 2013). Yet participants had
to meet the inclusion criteria to join the study, which should partially
overcome this bias. In this vein, we acknowledge that our sample was
younger than the nurses' population in Israel. However, as these repre-
sent the future generation of nurses, this limitation may not seriously
bias our conclusions. Furthermore, we did not collect data on the
nurse or about the ward in which the nurse worked (e.g., internal or sur-
gical ward). In first glance, one might expect differences in workloads
across wards, which might bias our findings. However, because person-
nel in the wards is standardized according to the type of ward, and given
that our workload measurement was subjective (e.g., nurse perceptions
about whether the workload was below or above 100% occupancy), this
limitation may not significantly affect our results.
Finally, consistently presenting some attributes before others might
bias the results. Yet it would be difficult for the individual if attributes'
order was to change. However, future studies should consider random-
izing the attributes across individuals.
6.2. Practical implications
The study's findings have important implications for hospital man-
agers and policymakers seeking to reduce missed nursing care's
9
devastating effects. As a first point, we find that certain decision-
making styles (primarily intuitive and dual-preference) are better
suited to decision-making and reduced missed care in heavy-
overload circumstances, whereas the primarily analytic decision-
making style for regular overload circumstances. This may indicate
that personal decision-making style could serve as a criterion for
selecting nurses and matching them with work environments that
are conducive to their performance. It would also be helpful if nurses
were trained in and equipped with techniques for shifting between
intuitive decision-making and analytical decision-making under var-
ious circumstances. Such training programs should encourage nurses
to identify those red alerts that require one to “stop and think” and to
deliberately enact an analytic decision-making style (Conroy, 2021).
Indeed, in a recent systematic review (Ludolph and Schulz, 2018) of
interventions to limit healthcare providers' intuitive decision-
making resulting in biases, around 70% of interventions were par-
tially or completely effective. The authors concluded that combining
cognitive strategies primarily aimed at improving people's critical
thinking skills with technological strategies that employ visual aids
to reduce errors, could reduce decision-making biases. Moreover,
nurses characterized by a disengaged decision-making style should
be identified, and nurse managers should provide them internal
and external motivational rewards for adopting critical thinking.
Second, despite findings suggesting that nurses struggling with diffi-
cult patients cannot effectively process clinical judgments (Mamede
et al., 2017; Schmidt et al., 2017; Smith and Zimny, 1988), our findings
demonstrated that when nurses try to maximize their resources and
provide optimal care for all patients, they attend to difficult patients'
needs better. In this regard, nurses should be trained to offer solutions
to difficult patients so that they are less likely to miss nursing care
(Gillette, 2000; Karahuseyınoglu and Oguzoncul, 2021). Providing
these patients empathy and trust is key to treating them (Gillette,
2000; Karahuseyınoglu and Oguzoncul, 2021).
Third, the findings suggesting that structured tasks are less likely to
be missed call for better structuring of nursing tasks for patients with
high clinical complexity, as missed care might have even more devastat-
ing consequences for them (Recio-Saucedo et al., 2018). The nursing
tasks of emotional support and patient mobility might be better struc-
tured so that these vulnerable patients do not experience missed nurs-
ing care. Consequently, nursing managers should provide nurses with
step-by-step instructions on how to break down tasks into sequential
steps, as well as the actions that should be taken and their expected out-
comes. Examples of how the task can be completed are provided as a
means of increasing nurses' understanding of the task and acting as a
model for how the task can be completed in general (Eiriksdottir and
Catrambone, 2011).
Finally, the findings that likelihood to miss care are not made in iso-
lation but instead reflect a complex decision preference call for inter-
vention programs that introduce nurses to complex situations, invite
them to reflect on their (sometimes conflicting) considerations, and dis-
cuss ways to optimize their resources so that more complete care is pro-
vided to all patients.
7. Conclusions
The present study employed a novel discrete choice experiment
design to highlight an understudied correlate of missed nursing care:
the nurse's decision-making processes and styles. Apparently, choosing
which care to omit or postpone is a complex decision, concomitantly
influenced by many factors, including the decision-maker's personal
style, the task type, and the nurse's decision-preference pattern,
encompassing ward and patient characteristics. These findings suggest
that hospital managers might limit the frequency of missed care by bet-
ter structuring tasks. Alternatively, given appropriate training, nurses
could learn how to better adjust their decision-making style to their
work context.
10 N. Abdelhadi, A. Drach-Zahavy and E. Srulovici / International Journal of Nursing Studies 139 (2023) 104448
Funding
This study was supported by the Cheryl Spencer Institute of Nursing
Research.
CRediT authorship contribution statement
Nasra Abdelhadi: Methodology, Software, Data curation, Writing –
original draft. Anat Drach-Zahavy: Supervision, Project administration.
Einav Srulovici: Supervision, Project administration.
Data availability
The datasets collected and/or analyzed during the current study are
available from the corresponding author on request. The corresponding
author had full access to all the data in the study and takes responsibility
for integrity of the data and accuracy of the data analysis.
Declaration of Competing Interest
No conflict of interest has been declared by the authors.
Acknowledgments
None.
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