Background: With the inflation of economic constraints on health care and demand to increase care quality, there is an increasing need to develop a clear understanding of what actions by health professionals are perceived as threatening quality care. Objective: To explore graduate nursing and pastoral care student’s perceptions of missed care in Norway. Research design: A qualitative study was employed with the formation of six focus groups. Data was analyzed via a thematic content of the discussions. Participants and research context: Thirty-one students attending a University College in Oslo participated. Findings: Five major themes and thirty subthemes were identified. Major themes included labor constraints, organizational contraints, professional constraints, communication constaints and emotional strain. Discussion: Findings of this study resonate with other research as well as with studies on missed nursing care. Findings also lend support to the definition of missed nursing care actions as required care that is omitted, either in part or whole, or delayed. Conclusion: The findings from this study extend understanding of what barriers health professionals perceive as inhibiting them from offering quality care. The focus groups provided a valuable flora for discussion regarding what participants perceived as missed.
Society is in a process of constant change in which the past couple of decades have seen unprecedented levels of structural health care reforms in pursuit of efficiency, effectiveness and wider access in most developed nations [
Missed nursing care is a new concept which is defined as any aspect of required patient care that is omitted (either in part or whole) or delayed and is described as an error of omission. This definition of missed care seemingly has commonalities with other terms used in the literature as suboptimal care, non-caring, uncaring, near misses and futile care [
In exploring aspects of missed nursing care, Kalisch [
In another study, Kalisch and Lee [
Kalisch, Landstrom and Williams [
In a more recent study, Kalisch, Hyunhwa and Friese [
Quirke, Coombs and Mceldowney [
Miller [
Atree [
One can summarize from these studies that missed nursing care is related to a complex variety of factors which are related to organizational structures, time, healthcare workforce, professional, material, educational and personal characteristics. What remains clear is that most authors agree that missed nursing care or suboptimal care is either avoidable or preventable [
Because it has been reported that attempts to understand students’ perspectives on what they perceive as missing care are seldom presented [
The study uses an exploratory qualitative design, in which qualitative data are collected, based on real-life experiences brought forth in focus group discussions. Focus groups were selected for enhancing the dynamics of discussions and ensuring that different perspectives would be expressed. The interactions and dynamics among focus groups members can generate important information in a data collection situation [
Purposeful sampling included students in post bachelor in cancer nursing, nephrology nursing, pastoral counselling, public health nursing, and Masters’ students in community health nursing attending a university college in southeast Norway. Participants were recruited by the researcher (MK) who visited classes at this institution and explained the purpose and procedure of the study at the beginning of their classroom lectures. Six focus groups were conducted and included the following: pastoral students (n = 4), two groups of nephrology students (n = 4, n = 5), a combined group of public health nurses and pastoral students (n = 8), and two groups of cancer students (n = 4, n = 6). Focus groups were conducted in a quiet room at the same university during April 2016-December 2016. Students were welcomed upon arrival and refreshments were served. The time span of the focus group sessions were between 40 minutes to one hour in length. Two researchers served as moderators where one led the questioning and the other observed verbal and non-verbal interaction. The first part of each session was used to provide ground rule information, remind participants about ethical considerations, and obtain written informed consent and sociodemographic information. Oral consent was also given to tape record the sessions. A short list of standardized questions and prompts were formulated in advance to move the open discussion which included meaning given to professional care. Aspects related to good caring have been published recently [
The study was approved by the research committee at the institution where the study took place. Participation was voluntary. Students were told that their refusal to take part in the study would have no consequences for their studies. Written consent to take part in the study was obtained and oral consent was given at the beginning of the focus groups to tape record the sessions and use the results in publications. An agreement was made that the tape recorder would be turned off during parts of the dialogue, if desired. Participants also received the email address and phone number of the researcher (MK) in case there was a need for contact [
Audio recorded interviews were transcribed in full by a professional transcriber and then translated into English by the researcher (MK). After all the six interviews were conducted, the analyses started with reading the transcribed interviews simultaneously in order to get a feeling of the whole. This holistic approach was taken in order to discern an overall and fundamental meaning of the experiences. Each interview was then condensed by highlighting passages of importance to the investigated phenomenon; by the first author (MK). This started a process of reflection and search for meaning in the text by extracting essential themes. Van Manen (1997) calls thematic analyses [
Of the 32 students, the majority were women with only 2 men participating. A large proportion were middle aged (40 - 60 years) (n = 26, 83.8%) and had worked up to 15 years (n = 11, 35.4%) as compared to those working more than 15 years (n = 4, 12.9%). Students working full time (n = 16, 51%) were approximately as many of those working half time (n = 15, 48.3%) and the majority were married with children (n = 22, 70.9%). All students were post-graduate students with a minimum of four years university education. Refer to
Findings revealed that missed care could be categorized into five main themes and thirty sub-themes. The major themes were: 1) labor constraints; 2) organizational constraints; 3) professional constraints; 4) communication constraints; and 5) emotional strain. An overview is presented in
A major theme that consistently emerged throughout the focus groups were factors related to labor constraints. This included workloads which featured time restraints, being too busy and not being able to carry out one’s duties in a good way as shown by the following comments: “It is tiring to have so much to do and not being able to carry out your tasks in a good way which gives the patient a
Variable | Number |
---|---|
Number of participants | 31 |
Gender* Women Men Age* 20 - 30 >30 - 40 >40 - 50 >50 - 60 >60 Marital Status* Unmarried Married Living together Divorced/separated Widowed Educational Background Nursing Counselling Years Working* 1 - 5 >5 - 10 >10 - 15 >15 Working Full time Half time Other Children* Yes No | 29 2 4 7 10 9 0 3 19 6 1 27 3 2 6 3 4 16 15 1 22 4 |
*Missing answers.
sense of worth. Sometimes, I think to myself, would I have done this if I was a family member? It is especially difficult with senile and nervous clients.” Some participants stated that they knew if they could take more time with specific clients this would be helpful, but due to limited time they were forced to perform acts that they knew were against the client’s best interest as the following comment portrays: “When working night shift and I have a nervous patients, I know if I could just take the time to sit with them, this would have helped, but instead I just say, I know you are nervous, but you need to sleep. I offer medication instead.” In some cases, such acts were against ethical standards as illustrated by
Labor Constraints Workload Inadequate staffing Time Difficult patients Withdrawal Technology |
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Organizational Constraints Leadership qualities Time allotment Rigid system Lack of caring philosophy and standards Lack of coordination Lack of opportunities for self-reflection |
Professional Constraints Professional attitudes Self-awareness Personality characteristics Not genuinely present Judgmental Cultural insensitivity Relationship with colleagues |
Communication Constraints Not acknowledging Not listening Not asking questions Self-interest Not advocating Labeling |
Emotional Strain Powerlessness Loss of professional identity Fatigue Self-protective behavior Irritability |
the following: “In the evenings there are so many patients you don’t have time. Instead, I set their medications on their night stands, for them to take themselves, which we aren’t really allowed to do.” Many discussed the aspect of time which was connected to inadequate staffing and moral distress as exemplified by the following: “You go home feeling you haven’t done a good job because there were so few staff. You have had to give priority to other things when you know that the patient needed other things. For example, in the nursing home, it can almost go three years between the times patients are out in the fresh air, because of staff shortage.” Other factors connected to labor constraints which were voiced included complaining colleagues, having too many new clients and the use of technology as illustrated by the following: “There is so much complaining from colleagues, this destroys a lot because we are so busy. We also get too many new patients, and then there is the new data program on top of this. All this takes our focus away from the patients.” Encounters with “difficult clients” was another factor discussed by many. Such clients were described as those who required more care than others. This resulted in having to set priorities and creating difficult feelings as illustrated by the following: “Non-caring is related to difficult patients who need more than others, which we are not comfortable with, and we think to ourselves is she ringing again?” Another stated: “Some patient’s require a lot of care and this results in less care for others, especially the quiet ones who say little and make little noise.” Others described how these encounters were related to distancing oneself from clients as illustrated by the following statement: “There are difficult clients where you try to create a good relationship and everything is always wrong. They bring up something you have said earlier again and again and accuse you of having labeled them in some way. They are so difficult to work with, I just have to withdraw from them and take deep breaths.” For others, asking colleagues for help when working with difficult clients was a better strategy as verbalized by one: “There are some patients who can be very provocative and I need to signal to my colleagues that I need a break. There are just some patients you don’t share good chemistry with.” Some participants also discussed how technology was related to their workload in relation to calculating time allotted for carrying out specific caring activities. Such strict time allotment resulted in not having time to acknowledge the uniqueness of the other and reduced time for assessing and observing needs as shown by the following comments: “In community nursing we have a technical device that allots how much time we can take with each patient and tells us what our duties are. We do it and don’t observe anything else.” Other issues related to technology were connected to overtreatment and loss of worth as exemplified by the following statement: “For some patients we just try to delay their dying, they are over treated. They just lie on their machines which continue to peep and this isn’t a worthy death. There is so much noise from the machines, no calmness and the patient doesn’t feel of worth.”
Various organizational constraints were considered by the majority of participants as creating barriers for good care. This included issues related to leadership qualities. Some described bad leadership as being related to the leader’s need to be liked by staff. One participant stated: “Bad leadership contributes to bad caring in that the leader wants to be friends with everyone. It is the working environment that allows this to happen. It is almost like the staff is more important than the patients.” Poor leadership was also discussed in relation to unethical behaviors which had the possibility to inflict harm as illustrated by the following comments: We had staphylococcus on our floor, and our leader said, “No, this isn’t so dangerous, we can’t use time on developing interventions for this because it would cost too much, even if this patient is affected with this.” Another verbalized: “When we write reports of nursing errors, they don’t get very far in the system, they only land on the leader’s desk.” Time allotted by administrative leaders to carry out activities was seen as a major hinder to good care as described by one participant: “I think, as nurses we have to learn new programs, new methods, new techniques all the time. It is almost like our leaders don’t expect us to care. We are only required to use our Ipod where we punch in and out, so our leaders can see how much time we have used with our clients. If you happen to use more time than was allotted, you are called on the carpet to find out why. In the end, you have to convince yourself and accept that you can’t give the little extra’s. In any case, you don’t ask the patient how they are feeling because it doesn’t go up in the calculations. Instead, you say to your client’s, ‘here everything is going okay, yes?’ It’s all about politics and economy.” Another participant stated: “In community health, administrators have calculated how much time it takes to put medicine in boxes. There just aren’t any minutes calculated to give good care. The word care is out of the system now.” A rigid system and lack of a caring philosophy were also described as constraints as shown by these comments: “The system is so rigid, it is difficult to give the little extra to the patients” and “Some institutions have not formulated a caring philosophy, standards or goals for care at all.” Lack of coordination, postponement of referrals, not feeling cared for by the system and lack of holistic planning were also discussed. As one participant expressed: “Where I work you can see those who do their job and others who simply postpone things. I have experienced people who have to wait many, many days to come to a dentist when they have extreme pain, because the leader feels a dentist is not necessary or messages get lost in the system. The system gives the person so little worth.” Others stated: “Many clients feel we don’t have enough time, so they voice only their practical needs and not what they are really concerned about” and “Inter-professional care is missing, and the person isn’t followed up. A client gets one treatment from one, and another treatment from another, which lacks any form of holistic planning, because each individual is intervening from their own perspective.” Another stated: “Bad care occurs when we as professional are not cared for ourselves by the system. We need space and room to reflect and share.”
Issues related to professional constraints were discussed by many participants. A prevalent issue included professional attitudes such as having ambitions which the client didn’t share, not creating opportunities for client decision making, or feeling uncomfortable when advice was not followed as illustrated by following comments: “We can have ambitions for others which they do not have for themselves. Thinking we are right the whole time is a barrier, and this occurs quickly and often.” Another theme was related to issues of self-awareness as shown by the following: “It is important not to think, I am here now and I will take care of you, and I completely take over and don’t allow the other to participate in making their own decisions” and “It is difficult with those clients who don’t follow our advice and make decisions based on their own beliefs. This makes uncomfortable and insecure.” Another stated: “We all have our own histories, it is important that that we have reflected over our own weak points and if one meets the same weaknesses in another, it is important to remember that the other is the most important one.”
Personality characteristics were also discussed by many participants. Issues related to lack of respect and moral sensitivity were also voiced: “I have worked with many people in various institutions and bad care is not only related to staffing, but also to the personalities of those working there.” Others stated: “There are so many things that hang together but some staff simply lack moral sensitivity” and “I had a patient who had just died and I was together with another nurse performing post mortem care. She just talked and talked and talked and of such silly things. I felt so uncomfortable, there was no respect from her side.” Moral insensitivity was also discussed in relation to choice as the following comments illustrate: “Bad care is related to ‘avoidance sins’ as I call them. One simply chooses not to see nor listen to the patient, and one chooses not give good care.” Other’s voiced: “Some people just can’t give good care. For example, I heard a nurse once say to a dying patient, it’s not so dangerous to take more pain medication because you are going to die anyway” and “Bad care is not showing respect for the patient and not doing what you know you ought to do, not doing your job thoroughly.” Many participants discussed not being genuinely present as another feature related to professional constraints. “Missing care is not acknowledging the patient’s needs. Just taking a bit more time is the difference between good and bad care. Being genuinely present. There are so many people who aren’t seen or heard or invited to take part in their own decisions.” Also, factors related to being judgmental were also discussed as illustrated by the following: “I had a nursing model in practice who had such a negative stance towards my patient from the first second she walked through the door. The patient was silent and she was bathed and clothed by her, but this was done in such a hard way. There just wasn’t any understanding. Afterwards, I tried to talk to her about this and she just said; “I am sorry but I have this patient up my throat, we just don’t have a good relationship together.” Issues related to cultural sensitivity were also expressed: “I think we have destroyed a lot with our views of cultural integration, with our kindness attitude, with the idea that we must tolerate everything. We also need to make demands. There is a lot of racism from the other side also” and “I pressed and encouraged a father from another culture to hold his premature daughter, he finally did and I felt that I had supported good caring. Instead, his wife came in and screamed at me and said that her husband felt traumatized having to hold the child. Perhaps this was good care for the baby but not for the father.” Another issue related to professional constraints concerned relationships with colleagues as shown by the following: “There are too many stressed staff, they don’t have control over their own lives. They walk fast, speak fast and it is the patient who suffers. One can observe one’s own colleagues as not being especially caring. However, I don’t think it is necessary to go directly to your leader about this. I mean that it is important to discuss what you are observing with your colleague and ask what is happening.” Another stated: “I feel especially for those who are alone and have mental problems. But I feel some nurses are only concerned with being rigid, setting boundaries and no one seems to have the capacity to listen to their histories.” Some participants also discussed the need to ask colleagues for help as well. “When caring, one can experience difficult situations and sometimes we just avoid the patient. We need to be more competent in collaborating with each other and asking for help. We need to try to help each other give care instead of trying to forget or say, “I just can’t cope with this” and simply withdrawing.
A major theme that consistently emerged were factors related to communication. Such factors included not acknowledging the client as a person by not listening and not asking questions as shown by the following statements: “Working in a health station, I have a checklist of so many things I have to ask about, that I concentrate on asking only these questions, and I don’t see the person in front of me.” Another proclaimed: “Suboptimal care is not listening to what the patient is trying to say, it is when you speak over their heads, and you drive them in the corner with your own thoughts.” Other participants described restricting communication by not creating openings for dialogue as illustrated by the following: “It is bad care asking people how they are when you don’t have time to listen to what they say. It’s better just not to ask.” Another participant stated: “My role model in practice says they do not ask the big questions because they don’t have time to meet these problems.” For some participants, not taking time to listen was also described as being connected to one’s own self-interests as exemplified by the following: “I think about those that can’t listen to their clients. They just talk and talk about what they are interested in themselves. We don’t create the openings so the other can really talk about their own concerns.” Other communication issues included not voicing one’s own beliefs and advocating on the patient’s behalf as illustrated by the following: “Bad care is when we don’t take the initiative and dare say our own meanings to the doctors’ regarding our patients. After all, it is we who know the patient best. This is wrong.” Another communication issue was related to labeling clients which was stigmatizing. As illustrated by these comments: “I work with colleagues who label patients and say, this patient is like this and this, and what has happened is his own fault. This has happened because he hasn’t tried to take care of himself” and “Language has power, big power. I work with women who are prostitutes. Why should they be labeled prostitutes? They are women and working with what they do because of necessity.” Another participant described how she herself felt stigmatized: “I had a patient who needed to be more physically active and she told me I was torturing her. Nothing was ever good enough for her and so it is difficult to care because you have only two hands and must plan.”
Lastly, many participants also described feelings related to emotional strain such as feelings of powerlessness and loss of professional identity. The following comments illustrate these points: “I feel like an industry worker. Also, you connect your patients’ to the machines and disconnect them and you don’t even have time to talk with them. It’s a bad feeling having to go home knowing that you have done only what you had to give priority to” and “I feel that we are just the doctors extended hand. We take blood tests, wash beds, accompany doctors on rounds, make sure they sign their orders, attend meetings, are secretaries, kitchen help, and safety guards. There is very little nursing. I am tired of it.” Others described fatigue as connected to self-protective behaviors like avoidance. “One can simply get tired of people generally, you meet so many different people, children and families in just a short span of time. You have kind of reached your own limit.” Others stated: “It is important to meet people where they are, but some days you are just too tired, you just say” “do this and this and this and then come back. It is almost a survival strategy so you can keep holding on. You need to protect yourself because you can go over the edge and end up burned.” As described by another: “We had a physical therapist who came for consultation at school a couple hours a week. I asked her if she could put a message on her door when she would be available. She said no, because too many people would seek help.” However, various participants also observed tiredness as a form of apathy observed in their colleagues as shown by the following: “I think some of the colleagues I work together with have worked too long, they are older and are apathetic but they don’t see this themselves. This isn’t good for the patients or for themselves.” Some participants also described feelings of irritability with colleagues and viewing colleagues as meeting their own needs as shown by the following: “Some days you work together with a colleague you don’t share good energy with and both of you end up complaining and blaming each other.” Another stated: “I feel sometimes that my colleagues are trying to meet their own needs disguised in professionalism. I work in a prison and I think sometimes the interventions are based on their own interests like hikes in the mountains and rafting with inmates. For example, there are many existential issues which aren’t met at all.”
In this study different understandings of the meanings given to missing care were expressed by postgraduate nursing and pastoral students. Five themes and thirty sub-themes emerged from the focus group discussions. The major themes included labor constraints, organizational constraints, professional constraints, communicative constraints and emotional strain.
Many of the descriptions confirmed experiences impacted by workloads, inadequate staffing and limited time as reported by others [
Many participants described not having time to be genuinely present in the situation which was also related to not acknowledging the client as a unique individual and not assessing specific needs. These findings are especially noteworthy. Poor assessment, inadequate exploration, delays in diagnosis, treatment and referral, and lack of recognition of the importance of deterioration have been shown to have detrimental consequences for clients and their families [
Much empirical work report health professional’s insensitivity to patients’ needs which was also described in the present study. Such insensitivity was grounded in professional attitudes, such as not being genuinely present, lack of self- awareness, and personality characteristics as found by others [
Various participants also described how their care was related to teamwork and relationships with colleagues as shown in the study by Kalisch and Lee [
Various participant’s voiced how negative role behavior impacted their care. This was related to behavior observed in colleagues, leaders, and student role models. The influence of role models on student’s caring behaviors is well documented. For example, Fang and colleagues [
The majority of participants described ways in which leadership qualities and organizational obstacles influenced their caring encounters. Findings seem to confirm an air of dehumanization, fragmentation and focus on doing more “faster” with unsustainable staffing and excessive demands on fewer practicing. This growing emphasis on productivity was also cited in Miller’s research [
Participants also discussed a lack of caring philosophies and standards absent in organizational structures. Healthcare organizations must critically examine the absence and presence of professional values and whether incongruence between what is espoused, and what is done, propagates less ethical actions. This also includes leaders being consciously aware of how their own ethical standards and actions, influence staff and client outcomes, such as not stopping staphylococcus outbreaks and not acting upon reports of poor quality care as pointed out in in this study. A major task of administrative leaders at all levels is handling complaints of unethical and disruptive behavior and dealing with it immediately. Health care organizations and facilities also need to have codes of conduct defining acceptable and nonacceptable caring behaviors, establishing a process for managing unacceptable behaviors and enforcing codes of conduct even under economical contraints.
Tadd and Read [
Observational studies have found that dignity may also be influenced by health professionals communicative style as supported by our study [
Notably, rude language and hostile behaviors were voiced by some participants. Such behaviors are reported to foster medical errors, contribute to poor patient satisfaction and adverse outcomes [
Feelings of emotional strain were discussed by the majority of participants. Feelings of powerlessness, loss of professional identity, fatigue, irritability and the need for self-protective behavior were themes often voiced. Others have reported how nurses report dissatisfaction and low morale as they cope with time constraints and staffing shortages which were also discussed by participants. For example, Cummings and colleagues [
In sum, findings of this study resonate well with other research as well as with studies on missed nursing care [
The study is limited because of convenience sampling and a small sample consisting of a majority of women, although their age spans differed greatly, limiting the generalizability of the findings. Furthermore, participants were recruited from only one institution although they lived and worked in many geographical areas in Norway and had backgrounds in community health nursing, cancer nursing, nephrology nursing, public health nursing and pastoral care. The probing questions captured a glimpse of the obstacles in giving care at a particular point in the professional experience of each participant. This could be a limitation reading the rapid and constant changes occurring in health systems. However, the focus groups provided a valuable flora for discussion related to what participants perceived as missed care. A relevant follow up study might be to use the same design with students from another country or countries to validate the international nature of the study issue. The names given to the major themes and sub-themes were discussed by two independent researchers, yet the selected terminology used in classifying themes and sub-themes denote specific nursing knowledge. However, interpretations of the themes and sub-themes were reviewed by inviting colleagues with different expertise and backgrounds to review the results. The moderators had previous experience with conducting focus groups. The moderators played a more passive role, using probes when needed, but allowing discussion to evolve openly. Because all of the groups had been recruited in their own classrooms, the atmosphere of the groups portrayed a sense of group membership and cohesiveness. Notably, research has shown that there is a tendency for more self-confident and articulate individuals to be more willing to agree to take part in focus groups. In two of the groups, certain members were more assertive and as a result the more silent participants had to be invited into the dialogue. Also, in groups where there were a majority of older participants, the younger tended to be less articulate. Tape recording the sessions, could have caused feelings of unease for some, and one group commented that it would have been easier to speak together without the tape recorder. However, in all groups participants were able to narrate their experiences and perceptions of what they considered was suboptimal care and the focus groups created a space which was filled with embodied dialogue. Interestingly, some of the most valuable information was discussed towards the end of the group, which could be related to the fact that the participants felt safe and were more at ease [
The environment within which professionals work, client care demands, time and staffing available to provide that care, all have an impact on patient outcomes. Based on the results of this study and other research, it is recommended that future studies explore and identify the types and reasons for care being missed in various health care settings. Future research is needed which focus on causal factors to missed care and how these factors directly influence the degree to which missing care occurs, as well as explore the specific client and nurse outcomes. Such studies could help inform quality improvement efforts in reducing regular omission of various elements of care and in securing favorable and safe patient outcomes.
Moreover, missed care also needs to be examined within a theoretical context and studied systematically in multiple cultural contexts that openly recognize it as a universal factor in client safety. Consequently, missed care is a client safety issue which would benefit from international collaborative research to enable a shared understanding of the meaning of care which is “missed.” Studies based on more objective measures which capture why clients experience delayed, inadequate or inappropriate care should be developed to more clearly to help define missed nursing care. Since the consequences of missed nursing care presents threats to patient safety, it is also recommended that studies on missed nursing care should be given consideration in state and national policy development globally.
Studies are also needed which also explore professionals own perceptions of caring so that they can evaluate their nursing practices. For example, health care professionals need to reflect upon care practices that leave clients feeling depersonalized. Studies which explore the choices that health professional face when they must deal with factors in their environment, and how they reach the decisions they do in providing care to their clients, should be given priority. Studies are also needed which focus on the identification of patient’s and relative’s perceptions of the attributes of care quality, together with other studies which focus on how client and family perceptions coincide or differ from professional perceptions. Other recommendations also include the need to test the effect of innovative programs or clinical care pathways that address difficult professional- client situations. Furthermore, studies which explore and develop valid and reliable care quality audit indicators for the assessment and evaluation of care quality and client satisfaction are of vital importance should remain paramount.
With the inflation of economic constraints on health care, demand to increase care quality and increasing demand of client’s perspectives into care, there is an increasing need to develop a clear understanding of which health professional behaviors may threaten quality care [
The author expresses appreciation to the students who willingly shared their thoughts and experiences in the focus groups. Gratitude is also expressed to Diakonova University College for research time and to the anonymous referees.
Kalfoss, M. (2017) Student’s Perception of Missed Care: Focus Group Results. Open Journal of Nursing, 7, 850-874. https://doi.org/10.4236/ojn.2017.77064