UNMET NURSING CARE NEEDS ON MEDICAL AND SURGICAL WARDS: A SCOPING REVIEW OF PATIENTS’ PERSPECTIVES

Aims and objectives Review and synthesize research studies on surgical and medical inpatients’ perceptions on unmet nursing care needs.


INTRODUCTION
In the last ten years, there has been a growth of research that examines missed nursing care. This work has been prompted by numerous, high profile cases where there has been a lack of fundamental, essential nursing carein some cases resulting in national scandal as in the Mid-Staffordshire case in the UKwhere patients failed to receive the most basic levels of care (Hayter, 2013). In response to this issue, researchers have focused significant attention on investigating the impact of deficiencies in nursing care on patient outcomes. The majority of this work has been done in inpatient adult medical and surgical areasnotably the highly influential RN4CAST studies designed to investigate the quality and safety of nursing care performed in adult medical and surgical settings (Sermeus et al., 2011;Aiken et al., 2014). A key issue that emerged from this study is the phenomena of 'missed nursing care' and the detrimental effect it can have on patient care outcomes, like falls or infections (Griffiths et al., 2018b).
The amount of missed nursing care, identified by several studies, is often high; across studies that measured missed nursing care with a nurse-completed survey tool in the RN4CAST Consortium project, the estimated frequency of care omissions ranged from 75% in England , to 93% in Germany , to an overall of 88% in 12 European countries , and to 81% in South Korea (Cho et al., 2016). The nature and type of missed nursing care across the literature was quite consistent with 'comfort and talk with patients' missed by 53% of nurses from twelve European countries (Belgium, England, Finland, Germany, Greece, Ireland, The Netherlands, Norway, Poland, Spain, Sweden and Switzerland) (Ausserhofer et al., 2014), by 44% of Italian nurses , and by 65% of UK nurses . Care related to "educating patients and families" was missed by 41% (Ausserhofer et al., 2014), 45% , and 52% , respectively. The relationship between missed nursing care and mortality rates has also been extensively studied, and Ball et al. (2018) confirmed that a 10% increase in the frequency of missed nursing care is associated with a 16% increase in the odds of mortality in medical and surgical care environments. Several other studies in adult medical and surgical settings have also identified factors such as skill mix, work environment, nurse staffing and intention-to-leave that can contribute to missed care (Papastavrou, Andreou, & Efstathiou, 2014;Jones, Hamilton, & Murry, 2015;Griffiths et al., 2018b;Suhonen et al., 2018;Sasso et al., 2019). The missed care phenomenon has also led to calls for nursing to re-focus on developing a better understanding of how failing to address the fundamental aspects of nursing care effects patient experience (Kitson, 2016;Feo, Kitson & Conroy, 2018).
However, to date, the aggregated and synthesized evidence of missed care comes from research that only measures nurses' perceptions on missed care in surgical and medical settingsnot from the patient perspective (Jones et al., 2015;Griffiths et al. 2018b;Suhonen et al., 2018).
Although there is a body of literature on how patients perceive unmet care needs, there are no reviews that amalgamate or synthesis this evidence to identify the key issues on unmet care from the patient's perspective. Therefore, there is a need to complement the cumulative knowledge base regarding missed nursing care in medical and surgical settings from health professional's perspectives with that from the patient's perspective (Kalisch, McLaughlin & Dabney, 2012;Dabney & Kalisch, 2015). Furthermore, there are no papers that compare patient experiences of unmet care needs with the literature on missed care based on professionals' perspectives. Ensuring that the patient's voice is included in the missed care/unmet care needs debate is important, thus, there is a need to summarise, amalgamate and synthesise the empirical work on patient's views on missed care to contribute to our understanding of this phenomenon. This paper is designed to address this gap by conducting a scoping review to answer the following question: "which nursing care needs do medical and surgical inpatients perceive as unmet?"

AIMS
To review and synthesize research evidence on adult medical and surgical inpatients' perceptions of unmet nursing care needs and compare these with the literature on nurses' perspectives about missed care.

Design
A scoping review approach was used, according to the methodological framework proposed by Arksey and O'Malley (Arksey & O'Malley, 2005), which includes five steps to identify, select, and revise the literature: 1) research question identification; 2) identification of relevant studies; 3) study selection; 4) data collection; 5) data synthesis and summary of the findings.
Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (see Supplementary File 1).

Search strategy
The search strategy included keywords base on the Population, Exposure and Outcomes (PEO) matrix (Table 1). In September 2018, three databases were searched: MEDLINE/ PubMed, CINAHL, and SCOPUS ( Table 2). The initial database search identified 1541 abstracts, and none were identified elsewhere ( Figure 1). After removing the duplicates, another 1256 abstracts were removed due to exclusion criteria. The remaining papers were screened for full-text eligibility (n=172). Another 128 articles were excluded following full-text review because they did not meet the inclusion criteria. In the end, 44 papers were included in this study for data extraction and analysis.
At least two authors reviewed all the papers throughout the above-mentioned steps, independently. At the end of each step, the screening results were compared between the research members until agreement was reached.

Inclusion criteria
Inclusion criteria: primary studies, papers published in peer reviewed journals, in English or Italian, papers related to routine care provided in adult medical or surgical inpatient settings.
Exclusion criteria: papers on nursing education or nursing students, papers not dealing with nursing care, papers that do not consider the patients' point of views, and those published before 2009, because this was when the RN4CAST studies started (Bruyneel et al., 2009;Sermeus et al., 2011), and the concept of missed nursing care was described for the first time (Kalisch, Landstrom, & Hinshaw, 2009).

Quality appraisal
During data extraction, papers underwent a quality appraisal process. Although scoping reviews do not normally require this level of scrutiny, we decided to conduct one to give some rigour and quality context to our findings. For the qualitative studies, we used the CASP checklist for Qualitative Studies (CASP, 2018), whereas for the quantitative papers we used Kelley Survey reporting (Kelley, Clark, Brown, & Sitzia, 2003). No mixed-methods studies were found. Table   3 outlines the quality questions that were asked of each study.

Data abstraction & synthesis
Arksey and O'Malley refer to this stage as an "analytical descriptive method", which involves informing the synthesis process according to a specific format (Arksey & O'Malley, 2005). The team of reviewers jointly develops a data collection table to determine which variables to extract to answer the research question, and to conduct a descriptive analysis. The information provided in Table 4 includes: references and countries, study design and aim, participants/setting and data collection, met/unmet needs and general findings. Subsequently, a thematic analysis was performed, by two authors to identify patterns, trends, and variation in patient experience about met or unmet needs. Our starting point was the result sections of the included papers. We analysed what needs were investigated, how they were described and measured. Then we coded needs as met or unmet and continued until we defined our main themes. This analysis allowed us to describe the voice of patients about how nurses take charge and satisfy their care needs. Then, this initial analysis was compared with that of the other author and then with the group who then met to agree on the final thematic analysis of the findings.

Study characteristics
Of the 44 papers included in the review, 16 were qualitative studies (most of which were descriptive), and 28 were quantitative studies (which mostly had a cross-sectional observational design). The included studies were conducted in different geographical areas: 18 studies were conducted in various European countries; 8 studies were conducted in the United States, 8 in the Middle East, 5 in East Asia, and one in Canada. A summary of the studies and the types of missed care are shown in Table 4.

INSERT TABLE 4 ABOUT HERE
After conducting quality appraisal, we calculated the number of sections of each study that received a positive evaluation. In general, the quality of quantitative studies was judged to be higher than that of qualitative studies: the average number of positive responses was 8/9 for the quantitative studies, and 7/9 for the qualitative studies (See Tables 5 and 6).

Thematic Analysis -Identifying the patients' perceptions about met and unmet needs by nursing care
From the thematic analysis, five themes were identified representing the patients' perspectives of their own unmet nursing care needs (see Table 7).

Communication
Communication was a key aspect of unmet needs identified by many patients across the studies.

Emotional and psychological care
Throughout the studies patients identified how they want to be treated as a 'person', an 'individual', whose dignity should be respected despite hospitalization and the situations of reduced autonomy. This often does not result to be adequately addressed in hospital settings (Alasad et al., 2015;Crispin et al., 2017;Koskienniemi et al., 2017;Malmgren et al., 2014;Papastavrou et al., 2012;Shoqirat, 2014;Suhonen et al., 2009;Suhonen et al., 2012). This theme includes also the need for emotional and spiritual support, which, in some included papers, is described as not always adequately met (Abu-El-Noor & Abu-El-Noor, 2014; Crispin et al., 2017;Goh et al., 2016;Koskienniemi et al., 2017;Mukasa et al., 2015;Palese et al., 2011;Papastavrou et al., 2012;Portillo & Cowley, 2011). Receiving good care in the emotional and psychological sphere allows the patient to develop a sense of safety and confidence towards the nursing staff and the care environment. When this sense of protection is lacking, it generates a psycho-physical malaise that is then reflected in the patient's well-being (Crispin et al. 2017;Dorigan & De Brito Guirardello 2010;Gellerstedt et al. 2014;Laird et al. 2014;Suhonen et al. 2009;Twibell et al. 2015).

The personal sphere
A cross-cutting theme of nursing care involved aspects related to what can be labelled 'personal sphere'. Respect for privacy and care that recognised the importance of privacy in terms of maintaining dignity was an area of missed care identified by patients. This was a particular issue in medical and surgical settings where men and women share the same bed bays, and patients may experience embarrassment when they are seen by health workers of the opposite gender (Ebrahimi et al., 2012;Mbuzi et al., 2017;Yiu et al., 2011). The privacy of information was also an unmet care need for many patients who felt that their confidentiality was not always respected during their conversations with nurses (Abdel et al., 2012;Alasad et al., 2015;Crispin et al., 2017;Ebrahimi et al., 2012;Gellerstedt et al., 2014;Goh et al., 2016;Lin et al., 2011;Rasmussen & Delmar, 2018;Ringdal et al., 2017). Many patients felt that their need for a care environment that ensured the quietness and rest they needed was missed by nurses (Gellerstedt et al., 2014;Ringdal et al., 2017). Some patients also identified that not being able to have family members at their bedsides was also an unmet needoften as a result of ward rules on visiting hours (Alhusban, & Abualrub, 2009;Bruss et al., 2011;Ebrahimi et al., 2012;Mbuzi et al., 2017;Sayin & Aksoy, 2012). There was also some evidence that patients' culturally related care needs are often not met (Mbuzi et al., 2017;Yiu et al., 2011).

DISCUSSION
Nursing is fundamentally about meeting the full care needs of patients to ensure their psychophysical wellbeing (Feo et al., 2018). This scoping review highlights how many patients in medical and surgical inpatient settings identify numerous areas where their nursing care needs are not met. The results highlight how nurses run the risk of missing some aspects of care, which affect several care domains including the communicative, emotional and psychological, and relational spheres. The results of the review, and in particular the themes regarding the 'personal sphere' and 'emotional and psychological care', underline how patients feel the need for nurses to pay more attention to their cultural background, and to consider the person as a whole, moving towards the provision of holistic nursing and respecting the dignity of the patient. It is important for patients to feel that they are being cared for in their entirety as persons, and not seen as an item on the 'to do' list (Crispin et al., 2017), or merely as a clinical condition to be dealt with (Lin et al., 2011). All this also involves the patient's need to feeling safe and protected throughout their stay in hospital (Crispin et al., 2017;Dorigan, & De Brito Guirardello, 2010;Gellerstedt et al., 2014;Laird et al., 2014;Suhonen et al., 2009;Twibell et al., 2015), although hospitalization on the contrary has often been described as a place that generates feelings of unsafety due to uncertainty and lack of knowledge about hospital dynamics (Gellerstedt et al., 2014). With regard to the 'personal sphere', the first aspect to take into consideration is the language, which constitutes a barrier between the expression of a need, and it being met, especially in immigrants and ethnic minorities (Mbuzi et al., 2017). Attention to culture is a need that can negatively affect the patient's experience during hospitalization (Ebrahimi et al., 2012;Mbuzi et al., 2017;Yiu et al., 2011). However, previous studies on the phenomenon of missed nursing care from the perspective of nurses do not reveal this as an issue. Although the definition of missed nursing care describes these as necessary activities for the patient , and the fundamental care framework takes into account these needs (Feo et al., 2018), none of the instruments found in the literature (Kalisch, & Williams, 2009;Schubert et al., 2007;Squires et al., 2012) allow for the evaluation of care activities that enable culturally congruent care.
The other three themes that emerged from our review of patients' perspectives of missed care were mostly congruent with those identified by nurses in other studies. 'Communication' appears to be an aspect of nursing that can be improved: quantitative studies about missed nursing care phenomenon have found that nurses are conscious about the omission of this important aspect of nursing care (Ausserhofer et al., 2014;Ball et al., 2014;Lake, Germack, & Viscardi, 2016;. Patients interpret the need of communication not only as a need for a closer interaction and the building a relationship of trust with nurses, but also in terms of a greater participation in decisions that concern their care (Bruus et al., 2012;Crispin et al., 2017;Goh et al., 2016;Laird et al., 2014;Mahjoub & Rutledge, 2011;Palese et al., 2011;Rasmussen & Delmar, 2014;Ringdal et al., 2017). It is often noted that nurses attribute unmet care needs related to communication to a lack of time (Ringdal et al., 2017) however, from a patient perspective simply by spending time getting to know and talking with patients, professionals can earn the trust of their patients and are thereby more likely to involve them as partners in their care (Lin et al., 2011). A review (2013) on nursing communication behaviours in the acute care setting has previously highlighted how nurses' habits and attitudes might affect patient safety.
During handover, fundamental parts of care, such as emotional or social support were often excluded. Moreover, the exclusion of the patient from the communication did not allow active participation of the patient in their care process of carewith the use of jargon and medical terms compounding this exclusion (Kitson, Muntlin Athlin, Elliott & Cant, 2013).
Communication is therefore urgent, and this is demonstrated by the fact that all the actors involved in the care process are aware of this. It is necessary to look for solutions that allow, on the one hand, making handover more effective and safer; on the other hand, to find solutions that allow the patient to feel listened to, involved and be an active part of the care process.
Hospital settings can be very disempowering and the literature included in this review reinforces that this is a common feeling amongst patients and that there are unmet nursing care needs that would have helped address these anxieties (Alhusban, & Abualrub, 2009;Bruss et al., 2011;Portillo & Cowley, 2011;Shoqirat, 2014;Suhonen et al., 2012). For example, the need to ensure patients feel as autonomous as possible was a care need that was often missed and was linked to patient's desires to 'being able to manage one's own life' (Yiu et al., 2011;Shoqirat, 2014).
Moreover, the need for autonomy is also linked to having the ability to manage situations that will arise after they leave the safety of the hospital environment and return home (Portillo & Cowley, 2011). This also links to the area of discharge planning and communication identified in several of the included studies as being a substantial unmet need.
Through this review we found that several of the unmet care needs identified within the patient perspective literature mapped closely with those identified by nurses, which is the source of some comfort for practitioners working in medical and surgical settings. Despite this, there were also other needs described by patients as unmet that did not intersect with the ones identified by nurses. On the other hand, there were some aspects of missed care identified by the nurses, but not by the patients. However, these were primarily about documentation, such as updating nursing care plans and completion of nursing charts (Ausserhofer et al., 2014;Aiken et al., 2018) and it is therefore understandable that patients would not highlight this as they would not be aware of such missed care. Looking at the literature on both nurse and patient perspectives of care, some aspects are identified by both groups, whereas others sit outside the mutually reported areas (see Figure 2) This reinforces the need for a joint agenda to be developed in addressing these gaps in nursing care recognising that nursing is a partnership that relies on both parties understanding each other and being able to communicate effectively to ensure that both care and care needs are holistic and complete . The results of this review underline the importance of taking the patient's point of view into account throughout the health care delivery process and, although research into missed care from the professional perspective is valuable, we must also ensure we check that against the experiences of patients too. Furthermore, this reflection should also involve the leaders and stakeholders of the profession, at all levels. When basic needs such as hygiene, nutrition, mobilization, communication are not recognized, the patient feels humiliated, ignored; missed care creeps into the patient-nurse relationship and undermines confidence, esteem, and the sense of security. Because of the complex interaction of basic nursing care, every time nurses interact with a patient, they perform a "complex intervention" within a complex system such as healthcare. Often this complexity remains invisible to the eyes of the nurses themselves and consequently remains invisible even for all the others, due to the lack of systematic traceability of nursing activities. The traceability of the provision of nursing interventions could allow an objective quantification of the economic resources necessary to guarantee quality care . Models that take into account the complexity of patients' needs, such as the Fundamentals of Care Framework, could help to get assistance more effectively, also intervening on many activities (Needleman, 2016), which, like this revision highlighted, are omitted. Many of the recent health care scandals, particularly in the United Kingdom, have been related to the neglect of fundamental patient care (Hayter 2013).
Our review highlights that patients often report unmet needs and highlights how nursing needs to constantly strive to develop models of working that reduce this type of care deficit.

Limitations
Although this scoping review was conducted in line with the methodology proposed by Arksey and O'Malley (Arksey & O'Malley, 2005), it has some limitations. First of all, we searched only mainstream research databases and did include other data sources (e.g. reference lists or the grey literature). Moreover, a consolidated practice in scoping reviews is the involvement of the stakeholders to obtain an in-depth discussion of the results, which can lead to the integration of further elements of reflection. However, this was not done due to lack of time and resources.
Finally, although our review was designed to complement the missed care work in medicine and surgery, our findings cannot be generalized to other healthcare settings.

CONCLUSION
In today's modern healthcare world, the scope of nursing is expanding, with the risk of moving away from the provision of care that is fundamental to meet the patients' needs. Activities such as communication, helping patients during mealtimes, during mobilization and personal hygiene, maintaining their dignity, the provision of culturally congruent care, education in view of discharge to improve self-management, and emotional support, are the foundations for nursing care today and for the future.
If we continue to talk about missed nursing care only from the perspective of the professionals, without paying attention to the person as a whole, we run the risk of turning nursing care into a mere set of technical activities that are not centred on the real needs of the patient. Future research should aim at improving the essential component of nursing care, focusing namely on the patient, by adapting health services, hospital policies and procedures, so that they may support nurses in their mission to achieve the main goal of their profession: the psychophysical well-being of the patient.

RELEVANCE TO CLINICAL PRACTICE
This review enabled to highlight the importance of taking into account patients' perspectives throughout the healthcare process, because patients are the principal end users of the services that health organizations provide. The scientific literature of the last decade on the omission of nursing care, has demonstrated nurses' desire to improve the quality of care delivered, based on the awareness of the erosion that nursing care is undergoing, due to several reasons (e.g. the shortage of nurses). The intention to compare the results of studies that investigated the omission of activities from nurses' perceptions, with the results of studies that investigated patients' perceptions about unmet needs, is well-founded on the need to find a new gateway to the point of care in clinical practice. The actual healthcare landscape sees, on one side, patients increasingly competent related to their rights and health, on the other side, nurses increasingly conscious about their accountability for patient and healthcare outcomes. Knowing patients' point of view about their needs could help professionals to improve the quality and safety of care delivered, by responding more efficiently to patients' requests. Finally, although nurses often recognise in the same way as patients do, however patients may also identify unmet needs that are not perceived as such by nurses. Therefore, it could be useful to analyse available tools to measure missed care at the nurse level to align the data collection with the complexity of the patients' needs, as well outlined in the Fundamentals of Care Framework.

Conflict of Interest statement
The authors declare that they have no conflict of interest.

Figure 1 PRISMA 2009 Flow Diagram
Records identified through database searching (n=1541)