Development of an emergency department missed nursing care scale using the Delphi method

Missed nursing care is a common and critical issue in emergency departments, where high patient acuity, time pressure, and frequent interruptions compromise patient safety and care quality, yet no validated emergency-specific missed nursing care scale currently exists in domestic emergency care settings.

The aim of this study was to develop a valid and reliable emergency department-specific scale, based on universal and existing specialized scales, to assess missed nursing care in emergency settings.

A modified Delphi method was used. A total of 21 experts were invited. The process consisted of two rounds. Preliminary scale items were developed through a literature review, qualitative interviews, and research team discussion based on the missed nursing care theoretical model and Maslow's hierarchy of needs theory. From November 2025 to January 2026, 21 experts in emergency medicine, nursing, and nursing management from various healthcare institutions were invited to participate in two rounds of online Delphi studies. The first round involved rating the initial items' importance, proposing viewpoints and suggestions for improvement and identifying of redundant and/or missing items. The second round re-evaluated and provided feedback on the revised items from the first round.

Two Delphi rounds were completed: 21 of 24 invited experts responded in Round 1, and 17 of 21 responded in Round 2. Among 91 statements evaluated in Round 2, 88 (96.7%) achieved consensus (importance score ≥ 4 and CV ≤ 0.25). The ultimately formed Emergency Department Missed Nursing Care Assessment Scale comprises three sections: The Emergency Missed Nursing Care Items include five dimensions: Safety-Related Care, Physiological Needs-Related Care, Affection-Related Care, Respect-Related Care, and Cognitive Needs-Related Care, totaling 43 items. The Emergency Missed Nursing Care Causes dimension comprises seven categories: human resource factors, material resource factors, communication factors, nursing team factors, patient family factors, organizational management factors, and work environment factors, totaling 30 items; The Emergency Missed Nursing Care Outcomes dimension encompasses three categories: patient level, nurse level, and hospital level, totaling 15 items, The overall content validity index (S-CVI) of the scale is 0.87.

The Missed Nursing Care Scale, developed using the Delphi method, demonstrates strong content validity, which provides a solid foundation for its scientific rigor. Its reliability is intended to be further verified through large-scale surveys, thereby offering a targeted evaluation tool for investigating missed nursing care in emergency departments.

Patient participation is a crucial component in the initial development of this scale. We conducted semi-structured interviews with five patients who had received treatment in the emergency department. These interviews aimed to explore their experiences of missed nursing care during their emergency visits, understand the impacts of such shortcomings, and solicit their suggestions for improving care services. Their insights directly influenced the content and relevance of the preliminary scale items. Additionally, this study included perspectives from healthcare professionals by conducting semi-structured interviews with fourteen emergency department nurses. These interviews examined the issue of missed nursing care from a frontline clinical perspective, focusing on its occurrence in daily practice, influencing factors, and perceived consequences. The feedback from nurses played a crucial role in forming the initial item pool, ensuring the scale's contextual appropriateness and its clinical practicality.