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Systemic Pressures and Nurse Decision-Making in ICU Missed Nursing Care: A Meta-Synthesis
Ya Fan1, Mingming Zhao1, Bo Feng1
1Department of Intensive Care Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
Nursing in Critical Care
|January 30, 2026
Summary
Missed nursing care in ICUs stems from systemic pressures, not nurse failings. Addressing these pressures and their impact on nurses is key to improving patient outcomes and satisfaction.
Area of Science:
- Nursing Science
- Healthcare Management
- Patient Safety
Background:
- Missed nursing care (MNC) is common in intensive care units (ICUs), negatively impacting patient outcomes and increasing nurse workload.
- Existing research explores MNC causes and consequences, but a qualitative synthesis linking them is lacking.
- This study specifically examines ICU nurses' decision-making under systemic pressures and its role in care omission.
Purpose of the Study:
- To systematically synthesize qualitative evidence on the determinants, processes, and impacts of missed nursing care (MNC) in the ICU.
- To illuminate the critical link between systemic pressures, nurse decision-making, and the omission of nursing care elements.
- To provide a foundation for organizational interventions aimed at reducing MNC.
Main Methods:
- A qualitative meta-synthesis adhering to PRISMA guidelines.
- Searched 10 major databases from inception to June 2025.
- Thematic synthesis was employed to analyze and integrate findings from six included studies.
Main Results:
- Six core themes emerged: divergent views on MNC, multilevel systemic pressures, nurses' strategic decision-making adaptations, commonly missed care elements, cascading consequences, and perceived organizational interventions.
- Missed nursing care (MNC) is a predictable, system-driven process in ICUs.
- Systemic pressures compel nurses to omit lower-priority care (e.g., basic, psychosocial) to safeguard patients, leading to adverse outcomes.
Conclusions:
- Missed nursing care (MNC) is a structural problem resulting from systemic pressures, not individual nurse failings.
- Organizational-level interventions targeting root causes are essential to reduce MNC, improve quality, and enhance patient and nurse satisfaction.
- Managers should focus on alleviating systemic pressures and mitigating distress, rather than penalizing nurses' prioritization decisions.
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