Modeling Missed Care: Implications for
Ian Blackman, RN, MEd, EdD • Che Yee Lye, PhD • I Gusti Ngurah Darmawan, MSc,
PhD • Julie Henderson, BA, PhD • Tracey Giles, RN, PhD • Eileen Willis, MEd, PhD •
Luisa Toffoli, RN, PhD • Lily Xiao, RN, PhD • Claire Verrall, RN, MN
staff patient ratios
Background: There is a growing nursing literature that views missed care as an inevitable con-
sequence of work intensiﬁcation associated with the rationing of nursing and material resources
available to deliver care. Global studies recognize that missed care is now ubiquitous, although
studies tend to be conducted in one region, rather than nationwide. This study seeks to under-
stand the Australian context of missed care.
Aims: To explore self-reported reasons for missed care and to identify the main factors for
predicting missed care within a sample of Australian nurses and midwives working in public and
private hospitals in New South Wales, Victoria, Tasmania, and South Australia.
Methods: A nonexperimental, descriptive method using Kalisch’s (2006) MISSCARE survey was
used. Responses from 1,195 nursing and midwifery staff with differing qualiﬁcations, English
language skills, and Australian employment settings were analyzed using Rasch analysis and then
modeled using the Structural Equation Modeling.
Results: The frequency of missed care on the morning shift directly impacted on higher priority
care missed during the afternoon shift. Staff skill mix imbalances and perceived inadequacy of
staff numbers for the work demands further exacerbated all aspects of care during afternoon
shifts. Other major factors associated with missed care were the different clinical work settings
and staff to patient ratios.
Linking Evidence to Action: The incidences, types, and reasons behind missed care are a
multidimensional construct which can be predicted when known signiﬁcant factors behind missed
care are simultaneously accounted for.
There is a growing nursing literature which argues that nurses
are missing or rationing care as a result of limited human
and material resources, and that this has an impact on qual-
ity patient care (Kalisch, Tschannen, & Lee, 2011; Papastavrou,
Panayiota, Tsangari, & Merkouris, 2014; Schubert et al., 2008).
[Corrections added March 23, 2018, after online publication:
In the previous sentence “Papastavrou, Panayiota, Haritini,
& Anastasios, 2014” was changed to “Papastavrou, Panayiota,
Tsangari, & Merkouris”.] In Australia, there is an increasing
focus on quality patient care, with the Federal government
moving to penalize the various jurisdictions for hospital ac-
quired infections and other adverse events (Independent Hos-
pital Pricing Authority, 2017). For this reason, any investigation
that seeks to understand what factors impact on quality patient
care is imperative. Missed or rationed nursing care is possibly
one such factor, although teasing out the speciﬁc contributing
factors within a country is difﬁcult in health systems character-
ized by public and private provision and with varying funding
Although Australia has a universal, public health-care sys-
tem called Medicare, it also has an extensive private sector.
Medicare, the Federally funded health insurance scheme, pro-
vides free acute public hospital care to all Australians through
standardized agreements with the six states and two territo-
ries. However, public hospitals are co-funded by the Federal
government (based on outcomes using the Australian Reﬁned
Diagnosis Related Groups [DRG] case mix classiﬁcations), and
by state and territory governments, leading to variations in
stafﬁng, skills mix, rates of hospitalization, DRG, and length
of stay. Differences in stafﬁng levels and skills mix across the
country and between peer hospitals are the result of various
industrial agreements that are negotiated at state or territory
level. Similarly, within the private sector, industrial agreements
are brokered at the local level leading to variations in employ-
ment conditions across the country, even for hospitals owned
by the same company (Willis, Reynolds, & Keleher, 2015).
This study explores missed care in public and private hospi-
tals across four Australian states. In the absence of readily ac-
cessible objective data that measures nurse sensitive outcomes,
Worldviews on Evidence-Based Nursing, 2018; 15:3, 178–188.
2018 Sigma Theta Tau International