Anticipated nursing care: findings from a qualitative study

What does this paper contribute to the wider global clinical community?

In recent years, concepts such as Missed Nursing Care [1, 2], Care Left Undone [3, 4], Unfinished Nursing Care [5, 6], Rationing of Nursing Care [7, 8], and Compromised Nursing Care [9], hereafter Missed Nursing Care (MNC), have been studied by several researchers and countries becoming an international field of interest.

Conceptually, MNC is defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed [1, 2]. MNC has been associated with the lack of resources and unbalanced skill-mix (e.g. [9‐13]), implicit and explicit team rules [14], nurses’ decision-making processes [8], increased number of patients (e.g., increased admissions [15];) and communication issues inside of the team (e.g. [2]). Amongst all the documented factors leading to MNC, time scarcity has been suggested to guide the decision of which intervention is a priority [6] among potentially competitive nursing interventions. As a consequence, some interventions have a greater risk of being postponed or omitted [14, 15], leading to negative outcomes [12]. For its relevance, MNC has been the focus for several researchers (e.g. [9‐13, 15]) aimed at understanding predictors and interventions that are capable of minimising its occurrence. However, in its research history the phenomenon of MNC was first identified by Kalisch [1] in a qualitative study where 25 focus groups were performed with nurses, nursing assistants, and unit secretaries in two hospitals. In this study, it was emerged the first operational definition of MNC, the elements of interventions missed on a regularly basis (e.g., ambulation, turning), and seven themes expressing the possible reasons for missing care emerged. Based on this work, Kalisch and colleagues further delineated the concept of MNC by performing a concept analysis [1].

Contrary to MNC, some anecdotal data and sparse evidence have documented the tendency of nurses to anticipate - instead of postponing or omitting - some nursing interventions. Concrete examples are night nurses waking patients cared for early in the morning; or nurses providing hygiene care very early in the morning, and preparing patients for the night by doing these activities before breakfast and just after dinner, respectively. There is also evidence of nurses conducting procedures in advance such as preparing medications by leaving them on bedside tables, starting the medication administration before the provisional time [16]. This anecdotal data, which seem to reflect rituals and routines that tend to be repeated over time [17, 18], are accompanied also by some empirical evidence. This is the case of leaving a medication at the patient’s bedside in advance [19]. Moreover, despite recommendations regarding that the administration of antibiotic prophylaxis in non-clean and implant surgery should take place within 60 min prior to incision, empirical evidence has reported that prophylaxis is administered more than 120 min prior to incision [20]. Furthermore, there are reports of peripheral cannulas being inserted in the Emergency Department in just admitted patients to ensure venous access; however, around 18.2% of them are later not used [21] suggesting therefore that these might have been positioned prematurely, without assessing the need for it.

On one side, the anecdotal and empirical examples available seem to highlight a phenomenon strictly consequent of a process of prioritisation of nursing care [22] where nurses attribute a rank order, importance or time towards competing alternatives, thus starting with some (e.g., administrating antibiotic prophylaxis) and ending with those documented at risk of being delayed or omitted. Along this line, it can be argued that researchers to date have focused their efforts on the delayed or omitted interventions (e.g. [5, 6, 22]): therefore, it is time to consider the entire process where some interventions are also provided in an anticipated manner to ensure that all are delivered. Moreover, on the other hand, nurses can decide to anticipate some nursing care according to their experience [23] or time-management issues, that have been also reported as anecdotal in nursing care [24]. Specifically, time management in nursing practice has been reported as an externally-defined set of practices [25] at need of more empirical research and analysis [25]: in fact, studies available are a few and documenting nurses who compensate for lack of time by developing strategies in an attempt to complete their work. However, no specific studies are documented to date by valuing the tacit knowledge of nurses [26] as to why they try to anticipate nursing actions (e.g., waking or mobilising patients early) by allocating these actions in a different time than that expected.

Understanding this phenomenon and its underlying mechanisms can improve the knowledge available regarding the process of prioritisation of nurses on how they actively negotiate care delivery in complex situations and where workloads and staffing are challenging [27]. Moreover, as with delaying or missing interventions, anticipating care can also have consequences on patients and the nursing care flow: therefore, discovering the possible consequences can increase the understanding of the impact of nursing care on patients. Contributing to advancing the knowledge in the field was the general aim of this study.

This study was aimed merging the phenomenon of delivering Anticipated Nursing Care, its antecedents and consequences as perceived by nurses. To date only anecdotical or sparse empirical evidence of the phenomenon have been reported in the literature (e.g., [18‐23]). Therefore, we have mirrored the work of the pioneer Professor Kalisch who merged the opposite concept, namely the Missed Nursing Care, with a study performed with a qualitative descriptive methodology which was the basis later of a concept analysis. Involving the nurses and giving to their experience voice with a qualitative study based upon individual interviews, have been considered important considering that nurses might feel guilty, powerless to correct the situation or fearful regarding unsatisfactory nursing practice [1, 2].

According to the findings, Anticipated Nursing Care implies not just an intervention performed before another as a consequence of the order attributed to interventions in the process of prioritisation or time-management [21, 24] aimed at managing time scarcity [46] and where a sort of chain is designed, and thus some interventions are implemented first and others later. By anticipating nursing care, nurses perform some interventions earlier than expected as implicitly or explicitly deliberated by themselves and not as a consequence of an external request (e.g., from patients). The fact that interventions are prematurely delivered mainly to stable patients reinforces that this phenomenon is not a consequence of a simple prioritisation where problems are categorised into those that require immediate actions and those that can be left because they are not urgent [22, 47].

Nurses have used different words to indicate the Anticipated Nursing Care phenomenon as “moving forward”, “anticipating” and “playing in advance”, suggesting that they try to adjust the flow of activities by doing something prematurely. Therefore, alongside MNC, where interventions are postponed and then missed [39], an opposite phenomenon seems to exists. Interestingly, the majority of anticipated interventions have the same risk of being delayed and/or postponed. According to studies available [48], the most frequent interventions to be delayed or missed have been reported as, in order, turning and positioning patients, performing oral hygiene and bathing, administering medications and reporting full data in the documentation. These have also emerged as anticipated in our study. On the other hand, interventions reported at lower risk of being missed or delayed such as vital sign monitoring, glucose controlling and skin care [48] have also been reported to be anticipated in our study. Furthermore, for patients that are more at risk of not receiving an intervention in time, while anticipated nursing care has emerged as more often delivered to stable patients and those who have a family member at their bedside, MNC has been reported to affect certain patients such as those that are older or with certain non-urgent diseases (e.g., dementia [49]). Less severely ill patients receive lower priority [50]. This seems to confirm that in the field of MNC and Anticipated Nursing Care, a potential source of discrimination among patients in need of nursing care might exist [51].

Two main reasons for Anticipated Nursing Care emerged, the first at the nurse level (individual or group) and the second at the unit level, all mirroring those already reported for the MNC phenomenon [1, 2, 7, 8]. Among them, individual values, such as professional nursing principles serving as a framework for standards, professional practice and evaluation [50] and individual or group attitudes, such as the relatively constant manner of thinking, feeling and behaving [52], that can all become norms as cognitive standards about the acceptability of a behaviour [53] have emerged.

Individual values and attitudes to be performant and to prevent MNC have emerged among the causes of Anticipated Nursing Care [8] suggesting that allocating early an intervention is mainly decided at the individual level by nurses according to their clinical reasoning and decision-making processes. Kalisch and colleagues, in their eminent works [1, 2] have identified the role of habits and values. On one hand, nurses can be driven individually and then as a group according to the moral obligation [50] to perform all activities planned, leading them to anticipate all that is possible and feasible. It is also possible that moral obligation is learned since nursing students’ education [54] through the example of expert nurses who anticipate the nursing care. On the other hand, it may be possible that the implicit norms of the Italian nursing practice of being recognised by colleagues and recognising themselves as ‘a good nurse’ is to be capable of performing all planned activities on time. In this context, alongside the moral obligation, there is also the need to be recognised as a ‘good nurse’. This can explain why, in the Italian context, despite the poor nurse-to-patient ratios (around 1:13 or more as documented in medical units, [27]), the MNC occurrence has been reported as similar to that documented in other countries where a more favourable nurse-to-patient ratio has been reported [13, 15, 48, 55‐57]. Moreover, with the increased number of patients, Italian nurses have been reported to reduce the MNC occurrence [27]: this paradox can be explained by the effect of some compensatory mechanisms relying on anticipating nursing care when faced with increased workloads.

All these possible explanations of Anticipated Nursing Care are supported by another reason, namely “leaving the patients and the unit in order”: in other words, the tendency of nurses to only find themselves at ‘peace’ after having performed all their tasks. This seems to be not only an indicator of good performance as an individual nurse but also a sign of team respect and commitment [58] to the incoming nurses responsible for the next shift. They will be exposed to the same work pressure where preventing any additional tasks from being postponed until the next shift, or better anticipating something, thus leaving time for unexpected needs, has become a group norm.

Being ready for the unexpected has been reported as a reason for Anticipated Nursing Care; by anticipating tasks, nurses attempt to reduce the risk of omitting or delaying interventions and allow the staff to feel safer when facing unexpected situations [10, 14]. Hospital care is characterised by increased acuity of patients, as well as increased volume of patients admitted from the emergency departments, suggesting that nurses shape their decision-making processes on the nursing work flows around this. Moreover, intertwined activities and work processes of other members of the team have been reported as a cause of Anticipated Nursing Care while communication issues have already been documented as a cause [12]. Findings emerged in our study seem to reflect a work process design where different teams and units impose their time to nurses that are under pressure to consequently adapt their work process to this pressure and not to the patients’ needs. Nurses have already been reported to be at risk of prioritising routine tasks over patients’ needs [59] and this might be determined by the need to coordinate the nursing process with other complex work processes of other teams.

Patients who received care in advance have been reported by nurses to be more satisfied and at less risk of being exposed to MNC. Patient dissatisfaction with nursing care has been associated with MNC [48] while receiving care on time or early can prompt the perception of being a high priority by nurses. Thus, differently to MNC, Anticipated Nursing Care has a positive effect at the patients’ level and at the nurses’ level, thus it is a phenomenon at risk of being perpetuated given its positive implications. However, nurses also recognised that by anticipating nursing care, the quality of care has an increased risk of being poor. In this line, disturbing sleep, as in the case of early waking, as well as threatening the daily rhythms of the patient (when having hygiene, when being mobilised, when going in to the bed), which are all part of the Fundamentals of Care [60, 61], have been reported.

Anticipated Nursing Care is present in clinical practice and occurs when nurses perform some interventions earlier than expected according to an implicit or explicit decision and not as a consequence of a request (e.g., from patients). Those at risk of receiving Anticipated Nursing Care are stable patients. Interventions at risk of being anticipated are medication administration, mobilisation and hygiene care, dressing changes, vital parameter monitoring, blood sampling and documentation. Individual values and attitudes regarding who should be considered a good nurse, as well as values and attitudes that become norms, such as always being ready for the unexpected or the need to leave the patients and the unit in order, have been reported as reasons leading to the Anticipated Nursing Care at the nurses’ level. Moreover, high workloads and the need to adapt the process of care to the intertwined activities and work processes of other teams and/or units have been reported at the unit level. Both negative, such as the decreased quality of nursing care, and positive effects, such as the increased satisfaction and the reduction of MNC, have been reported at the patients’ level. Future studies are needed to get insights into the processes whereby nurses make decisions about practices that bring forward care.