Care quality and safety in long‐term aged care settings: A systematic review and narrative analysis of missed care measurements

Abstract

Aim

To critically evaluate missed care measurement approaches and their application in long‐term aged care (LTAC) settings.

Design

Systematic review using Tawfik's guideline.

Data Sources

PubMed, Scopus, Web of Science, CINAHL and ProQuest were searched. Supplemental searching was from reference lists of retrieved records, first authors' ORCID homepages and Google advanced search for grey literature. Search limitations were English language, published between 1 January 2001 and 31 December 2022.

Review Method

COVIDENCE was utilized for screening, data extraction and quality appraisal. JBI Critical Appraisal Tools and COSMIN Risk of Bias Tool were used for quality appraisal. Data were summarized and synthesized using narrative analysis.

Results

Twenty‐four publications across 11 regions were included, with two principal methods of missed care measurement: modified standard scales and tailored specific approaches. They were applied inconsistently and generated diverse measurement outcomes. There were challenges even with the most commonly used tool, the BERNCA‐NH, including absence of high‐quality verification through comparative analysis against an established ‘gold standard’, reliance on self‐administration, incomplete assessment of constructs and inadequate exploration of psychometric properties.

Conclusion

Globally, there are deficiencies in the effectiveness and comprehensiveness of the instruments measuring missed care in LTAC settings. Further research on theoretical and practical perspectives is required.

Implications

Findings highlighted a critical need to establish a standardized, validated approach to measure missed care in LTAC settings. This review calls for collaborative efforts by researchers, clinical staff and policymakers to develop and implement evidence‐based practices as a way of safeguarding the well‐being of older clients living in LTAC settings.

Impact

Measurements of missed care in LTAC settings rely on adapting acute care tools. There is a critical gap in measuring missed care in LTAC settings. Developing a new tool could improve care quality and safety in LTAC settings globally.

Reporting Method

Adhered to PRISMA guideline.

Patient or Public Contribution

No patient or public contribution.

What does this paper contribute to the wider global clinical community?

Awareness of shortfalls in current models of missed care monitoring and a call for development of a more effective measure in long‐term aged care settings.

1. INTRODUCTION

Ensuring the provision of safe, high‐quality care to consumers is the overarching responsibility of all healthcare practitioners, organizations and systems (World Health Organization, 2021). However, the care quality and safety of aged care remain a concern, especially for highly dependent older people living in long‐term aged care (LTAC) settings (Kalideen et al., 2022). Among multifaceted factors contributing to poor care quality, missed care stands out as a persistently existing quality hazard in global LTAC settings (Sworn & Booth, 2020). Missed care arises from conflicts between the demands and supply of aged care resources and capabilities. It negatively impacted subjective and objective assessments of care quality, causing numerous detrimental outcomes for care recipients, providers and even regulatory bodies (Sworn & Booth, 2020). Despite this recognition, the absence of robust approaches to measure and concretize missed care in LTAC settings still exists, impeding progress in accurately assessing its extent and effectively addressing its impact on relevant stakeholders.

In response to this gap, this study presented a systematic review of missed care measurements in LTAC settings. By comprehensively examining the strengths and weaknesses of existing measurement approaches and their implementations in current literature, this review aims to provide insights and recommendations for future research and practice in missed care management under these settings, catering to elevate the standard of care provided to older people living in LTAC settings.

2. BACKGROUND

Missed care, a broad phenomenon encompassing partial or total omissions in care delivery (Jones et al., 2021), was initially described by Aiken et al. (2001) as ‘tasks left undone’ in hospital settings. Over time, several concepts were used to explain missed nursing care in hospital contexts, such as ‘implicit rationing of nursing care’ (Schubert et al., 2007), ‘missed nursing care’ (Kalisch et al., 2009) and ‘unfinished care’ (Jones et al., 2015). Researchers create these different terms to reflect their linguistic interpretation of the same or similar concepts and their distinct understanding of missed care, such as whether and how ‘delayed care’ should be included within a missed care framework, and how to differentiate between ‘missed care’ that leads to tangible adverse events compared to those without clear negative consequences (Jones et al., 2015).

The core concern for missed care should transcend definition nuances and, instead, focus on its increasing incidence and the potential of missed care to cause adverse events (PSNet, 2019). In a systematic review of 42 studies in acute care, 98% of nurses reported the omission of at least one ‘required care’ task during their previous shift (Jones et al., 2015). Missed care is linked with an increased risk of medical errors, falls, hospital‐acquired infections, pressure injuries, and mortality (Chaboyer et al., 2021). Missed care can also induce psychological stress on nurses who experience remorse and distress over providing substandard care (Sworn & Booth, 2020). In a recent hospital study, labour shortages and material resources were the most commonly cited cause of missed care by nurses (Chiappinotto et al., 2022). Other micro‐ to macro‐factors include individual care providers' knowledge and work experience, team dynamics, and organizational operational models (Chaboyer et al., 2021).

With the global shift in demographics towards an ageing population, the gap between demand and supply of aged care resources is progressively widening. This is resulting in an emergence of missed care as a pressing issue in the aged care industry, particularly in LTAC settings (Henderson et al., 2017). As life expectancy increases, more of the population face extended periods of physical and cognitive decline brought on by illness associated with ageing (Hu et al., 2023). With the growing ageing population, there is a higher prevalence of dependency and older people with increasingly complex and multifaceted care needs. This requires a response from LTAC settings to provide services that respond effectively to these changing population needs. However, because of limited resources, LTAC settings struggle to meet the needs of older clients, in particular, staffing shortfalls (Hodgkin et al., 2017), with the projected workforce gap to rise from 14.5 million by 2030 to 26.8 million by 2050 (Gibson, 2022). These problems in the aged care industry are due to low monetary compensation, high job stress, limited advancement opportunities and the prevailing negative perceptions of the industry. Recruiting and retaining qualified aged care workforce is extraordinarily challenging (Hodgkin et al., 2017).

Consequently, it is not surprising that missed care has become inevitable and will persist because there is a conflict between the surging care needs of older clients alongside strains in the workforce in LTAC settings. A scoping review (Andersson, Bååth, et al., 2022) indicated that 48% of nurses in LTAC settings reported missing at least one essential care task during their previous shift. Given the vulnerable nature of older people living in LTAC settings, and the difficulty in mitigating negative outcomes from frequent care omissions, an increasing number of studies suggest using ‘the incidence of missed care’ as a sensitive process indicator of care quality and safety in these settings (Hessels et al., 2019).

Despite the significance of this issue, there is no consensus on approaches to monitoring and measuring the occurrence of missed care in LTAC settings, preventing the generation of an evidence‐based to manage and mitigate care omissions (Sworn & Booth, 2020). There are varying approaches to missed care assessment focusing on specific interests, involving quantitative scales and questionnaires (Norman & Sjetne, 2019), or qualitative interviews (White et al., 2021) or field observations (Simmons et al., 2013), but the LTAC industry and regulatory authorities want more inclusive approaches to better understand missed care in real‐world practice. Although Palese et al. (2021) provided a valuable summary and evaluation of tools for measuring ‘unfinished nursing care’ without limiting their application contexts, the unique service content of LTAC settings is crucial for the person‐centred overall well‐being of older people (Powell et al., 2024). This distinctiveness necessitates tailored considerations for measuring missed care. Therefore, the approach to measuring missed care in LTAC settings should differ from that in other healthcare contexts. Furthermore, a scoping search found there is no evidence about how missed care should be measured within LTAC settings. This demonstrated the need to systematically examine missed care measurement in LTAC settings and provide insights into criteria for measuring quality care for older people in LTAC settings.

3. AIM AND RESEARCH QUESTIONS

This review aims to provide a comprehensive view of existing evidence of missed care measurement in LTAC settings. By identifying the advantages and exploring the shortcomings of current missed care measurement approaches and their implementations, the review seeks to provide insightful recommendations for improving missed care measurement in LTAC settings. This review addresses the following two questions:

1. What are the characteristics of reports containing the measurement of missed care?

2. What are the characteristics of approaches used to measure missed care?

4. METHOD

The methodology proposed by Tawfik et al. (2019) was utilized to guide the construction of this systematic review, offering a step‐by‐step guide to review development. This included: raising questions, clarifying objectives, preliminary searching and idea validation, identifying eligibility criteria and search strategy, writing protocol and registration, independent screening, data extraction and checking, quality appraisal, data analysis and manuscript drafting. Additionally, this systematic review adhered to the Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) guidelines (Page et al., 2021) and subsequent reporting adhered to the PRISMA 2020 checklist (Appendix S1). The review protocol was registered on the PROSPERO platform (ID: CRD42023438716).

4.1. Information resources and search strategy

Five digital databases, MEDLINE, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus, and ProQuest, were searched for relevant reports. Additionally, a comprehensive search of grey literature was conducted using Google.

The two‐step search strategy was constricted by a predefined filter: all reports be published between 1 January 2001 and 31 December 2022, be written in English and provide full‐text access: The first, the amalgamation of search terms to locate reports within the information resources; and the second, a manual search of reference lists and author publications via their ORCID homepages, carried out during the screening process.

The initial database search employed a skilled librarian (R.L.) from the University of Wollongong, assisting in formulating search terms by synthesizing medical subject indexing and free‐text terms. Search terms were developed around four aspects of measuring missed care: the context of application, assessed content, evaluation format and the approach's function. Addressing varied terminology used to describe missed care in previous reports, terms commonly employed were included in the search terms related to evaluated content in Table 1.

TABLE 1.

Search terms.

Aspects	Search terms
Applied contexts	“Residential aged care” OR “residential facility*” OR “residential care” OR “residential care facility*” OR “long‐term care” OR “long term care” OR “old age home” OR “old‐age home” OR “care home”
Evaluated contents	“Missed care” OR “missed nursing care” OR “care left undone” OR “nursing care left undone” OR “nursing task* left undone” OR “rationing of nursing care” OR “implicit rationing of nursing care” OR “rationed care” OR “unfinished care” OR “omission of care” OR “omitted care” OR “delayed care” OR “error* of omission” OR “task* incomplete” OR “task* left undone” OR “task* undone” OR “care poverty”
Format	“Questionnaire*” OR “survey*” OR “interview*” OR “scale*” OR “test*” OR “equipment*” OR “checklist*” OR “tool*” OR “instrument*” OR “approach*”
Function	“Assess*” OR “measure*” OR “determin*” OR “evaluat*” OR “analyz*” OR “analys*” OR “estimate*” OR “observ*”

4.2. Eligible criteria

This review included reports focused on the development, implementation and comparison of methods to detect missed care in LTAC settings. Reports were excluded when they were not focused on the approach and the findings were not related to missed care assessment.

In addition to the search filter restrictions, the reports needed to include LTAC settings as a focus. According to the World Health Organization (2023)'s definition of LTAC for older people, these settings were required to offer continuous and integrated services, emphasizing the core principle of person‐centredness. These services encompass medical and health services for managing and promoting health conditions and preventing harm, as well as assistive services that included aid in daily tasks and social support. Although LTAC settings tend to be called differently across the world (Powell et al., 2024), studies shall be included in this review if conducted in settings such as nursing homes (NHs), residential aged care facilities, assisted living facilities, homes for the older people and other similar settings aligned with the WHO's definition. Day‐care centres and respite care were excluded from consideration. It is noteworthy that the definitions of older people could vary in included studies, due to differences in religious beliefs, cultural contexts and economic development.

To enhance the probability of retrieving pertinent publications, no restrictions were placed on the type of missed care reported. This could include omissions in personal care, medical and nursing care, advance care planning and end‐of‐life care. To reduce bias in the reports reviewed, peer‐reviewed journal publications and grey literature such as conference reports, letters to editors, government documents and reports were included. Books and Master's and Doctoral dissertations were excluded. The research design of included publications had no limits and thus, quantitative and qualitative studies, experimental and non‐experimental studies were deemed fit for inclusion. All types of review were excluded. A summary of the inclusion criteria is provided in Table 2.

TABLE 2.

Eligible criteria.

Category	Inclusion criteria	Exclusion criteria
Reports' contents	Development, implementation and comparison of approaches to detect the presence of missed care No restrictions on the types of missed care being evaluated	Not report‐specific approach to measure missed care Not report findings related to the occurrence of missed care
Research design	Primary studies with qualitative and quantitative designs Solely conduct or include residential LTC facilities for older adults aged 65 years and above as research settings No restrictions on the geographical locations, identities of participants and types of measurement approaches	Any type of review Do not include long‐term aged care facilities as research settings
Reports' format	Peer‐reviewed journal articles Grey literatures including conference papers, letters to editors, government documents, reports and comments	Grey literatures including books, master's and Doctoral dissertations

4.3. Study selection

Study selection and screening process is illustrated in Figure 1. In the initial search, a total of 519 records were identified, comprising 238 from MEDLINE, 163 from CINHAL, 35 from Web of Science, 72 from Scopus and 11 from ProQuest. All records were imported into COVIDENCE for scrutiny. Three reviewers were involved in the screening process, with each record being examined by two independent reviewers. In cases of non‐consensus within the reviewing pairs, a third reviewer intervened to resolve the discrepancy. After eliminating duplicates, 116 automatically and one manually, an additional 174 and 192 records were removed due to non‐alignment of titles and abstracts with the research questions and inclusion criteria, respectively. Upon full‐text screening, 12 records were excluded and one study found through manual searching was added (Senek et al., 2020). Through Google Advanced Search, 36 records were identified, but since none met the eligibility criteria, they were excluded from the review. Consequently, 24 publications, consisting of 23 journal publications and one letter to the editor, were included in this review with the mean of inter‐rater reliability (Cohen's Kappa) of 0.70 (95% CI: 0.43–0.97).

FIGURE 1.

The PRISMA flowchart of screening process.

4.4. Data extraction and synthesis

Data extraction was performed to capture the characteristics of the included publications and specific approaches used to measure missed care in LTAC settings. Extracted information included name of the first author, publication year, geographical location(s), study objectives, research design, settings, sampling methods and participants, response rate, data collection and analysis approaches, and main findings. In addition, the characteristics of missed care assessment approaches, data such as the approach name (if applicable), supporting concepts, administrative methods, recall period, included items, options, scoring and psychometric properties were extracted. This information was systematically arranged in Excel spreadsheets. The first author of this review conducted a double verification of the extracted data, and the fourth author performed a random check of half the records for additional accuracy assurance.

A narrative synthesis approach was employed to summarize and interpret the findings across multiple studies. Included publications were categorized according to their study design, and approaches used to measure missed care were categorized based on their format for further synthesis. The synthesis process recognized the interconnectedness of selecting an appropriate measurement approach with the method itself and the rationale for its selection and proper implementation (Allen et al., 2022). This involved considering measurement approaches, intrinsic properties and attributes, as well as their rational and effectiveness in practical implications revealed by research design and measurement outcomes reported in individual studies. This strategy not only facilitated the summarizing and evaluation of different study types involving the development and/or implementation of the research design but also enabled the examination of various measurement approaches. In this review, these approaches were inclusive of quantitative scales, interviews, focus group discussions, non‐participatory observations and digital healthcare management system. By examining missed care measurement approaches, the synthesis aimed to provide comprehensive insights into their effectiveness and applicability in real‐world LTAC settings.

4.5. Quality appraisal

The Joanna Briggs Institute's (JBI) Critical Appraisal Tools (Munn et al., 2023) and the Risk of Bias (RoBs) Checklist from the COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN) (Mokkink, De Vet, et al., 2018; Mokkink, Prinsen, et al., 2018) were utilized to appraise the quality of the included publications. Four reviewers performed quality appraisals on 23 journal publications, and every publication was thoroughly reviewed by two independent reviewers. When there was a lack of consensus among the reviewing pairs, a third reviewer reconciled the differences in opinions.

The JBI Critical Appraisal Checklist for Prevalence Studies, Analytical Cross‐Sectional Studies, Cohort Studies and Qualitative Research offer a robust ability to assess quality and methodological rigour of corresponding research, evaluating the risk of bias and the overall credibility of included studies. Applying this checklist, researchers can critically appraise the methodological quality of the two research designs, identify potential bias sources and determine the overall trustworthiness and reliability of the evidence (Munn et al., 2023). For each study, the number of criteria met (indicated by a ‘yes’ response) was counted to quantify the quality of each study.

The COSMIN initiative is an internationally recognized organization and aims to improve the selection and evaluation of health measurement instruments. Its ‘RoBs’ checklist is instrumental in helping evaluate bias risk in studies that assess health instruments' measurement properties. This checklist enables researchers to systematically evaluate the methodological quality of studies. This included identifying sources of bias and making informed judgements about the overall quality and reliability of the reported measurement properties of instruments from responsiveness, reliability, validity and interpretability four aspects. The checklist contains 10 boxes, each consisting of a 5‐point rating scale: ‘Very good’, ‘Adequate’, ‘Doubtful’, ‘Inadequate’ and ‘Not applicable’. The final score for the instrument development study is determined by the lowest score among the 10 boxes, following a ‘worst score counts’ strategy.

5. RESULTS

This review analysed a total of 24 publications (Table 3) across 11 regions and 9 years. Studies from Switzerland accounted for approximately one‐third of all included publications and more than half of all the studies were published within the last 5 years (2018–2022).

TABLE 3.

Characteristics of included reports (n = 24).

References and region	Aims/hypothesis	Study design	Settings	Participants	Data collection	Main results
Andersson, Bååth, et al. (2022), Andersson, Eklund, et al. (2022), Sweden	To describe prevalence, type and causes of missed nursing care	Cross‐sectional prevalence study	Home care and NHs	624 direct‐care workers with 359 of them working at NHs which included 19RNs, 308 ENs and 31 NAs. Response rate was 20.4%	BERNCA‐NH (20 items) complemented with additional 15 study‐specific items, one open‐ended question and demographic questions	15 care activities were missed half the time in NHs, with “schedule group activity” (22.8%) and “schedule single activity” (19.7%) being most frequently missed Compared with home care context, “monitor care recipient”, “monitor confused/cognitive impaired”, “schedule group/single activity” and “assistance while food hot” were more often missed in NHs Reasons for missed care in home care and NHs are similar, including lack of preparedness/unexpected situation, obstacles in work environment, unsatisfactory planning and individual shortcomings
Ausserhofer et al. (2021), Switzerland	To investigate the opinions of care workers on the usefulness of electronic health record (HER) systems and adequacy of computer availability To examine the relationship between information technology infrastructure and the implicit rationing of documentation care	Cross‐sectional analytical study	107 NHs including 88 in German‐speaking region and 19 NHs in French‐speaking region	1975 care workers including 944 (47.8%) RNs and 1031 (52.2%) LPNs	“Documentation” subscale of BERNCA‐NH (3 items) Self‐designed questionnaires of HER systems usefulness (5 items) and computer sufficiency (1 item) Subscales of PES‐NWI: “Nurse manager ability, leadership and support of care workers” (5 items) and “Staffing and resources adequacy” (3 items) “Teamwork and safety climate” subscale (10 items) of SAQ	Up to 78.3% of care workers believed ENR systems were useful, while only 46.6% of care workers reported enough computers for timely documentation About half of care workers reported that they sometimes or often had to ration documentation‐related care activities Positive perceptions of EHR system usefulness and computer sufficiency were linked to lower levels of implicit rationing. Meanwhile, care worker‐perceived staffing and resource adequacy, higher ratings of leadership and safety teamwork climate were associated with lower levels of rationing. Educational backgrounds were also associated with rationing, with LPNs reporting lower levels of rationing than RNs
Bail et al. (2021), Australia	To evaluate the implementation of a new digital care management system	Qualitative design	A 156‐bed private RACF	128 participants including 48 residents or their visitors and 65 staff	Multiple methods of data collection: Online survey with open‐ended questions, Hallway interviews with residents and staff, focus groups with system developers, managers, staff, and residents	The system was acceptable to both residents and staff due to perceptions of time‐saving and improved quality of care. Increased efficiency was perceived through timeliness as well as reduced time spent retrieving and documenting information Quality of care was improved through care scheduling individualized to resident needs, with reminders to avoid missed care The co‐design implementation process was successful through commitment to quality from leadership teams and prioritizing the focus on the holistic needs of the residents
Blackman et al. (2019), Australia	To estimate and model the correlating relationships between missed care and maximizing residents' life potential, relieving distress and maintaining their health status	Cross‐sectional analytical study	Online survey	2467 aged care workers of RACFs, including 888 RNs, 898 AINs and 41 NPs	MISSCARE survey (26 items in Part A and 27 items in Part B) complemented with demographic questions	Staffing levels, staff training, communication between staff and residents, resident‐centred care, restorative care, health promotion, pain management and emotional support have direct predictor effects on missed care Missed care related to maintaining residents' health is impacted by staff's role and nursing time allocation to undertake extra shifts. Missed care associated with maximizing the residents' life potential was influenced by the size and ownership type of residence, with smaller and publicly operated facilities showed significant deficits. Missed care related to minimizing the residents' distress is influenced by workers' beliefs of teamwork ability, adequacy of staffing and securing extra staff, extra shifts, and the size and the type of the residential facilities
Braun et al. (2018), Switzerland	To explore how care workers' and residents' working experiences affected by implicit rationing of care	Qualitative study	A 100‐bed Swiss NH	Nine care workers, 11 residents	Two focus groups interview with care workers and 11 semi‐structured individual interviews with residents	1. Results from focus groups interviews with care workers: (1) Care tasks typically rationed are social activities, special care (nail, hair) and tasks that are disliked by either care workers or residents (2) Factors increasing rationing included a poor skill and grade mix, unmotivated co‐workers, absences due to illness, or care workers' unfamiliarity with residents, residents' case mixes and care demands (3) Rationing effects: care workers felt dissatisfied and irritated at their inability to fulfil residents' needs, and even became impatient and less 2. Results from individual interviews with residents: (1) need for “acknowledgement as individuals”; (2) dependence on institutional structures; (3) their sensitivity to impersonality in care routines
Campagna et al. (2021), Italy	To describe the prevalence, causes and perceived severity of missed nursing care	Cross‐sectional prevalence study	50 NHs including 33 privately operated and 17 publicly operated	266 nurses and 1000 patients they cared for	Study‐specific approach of missed care measurement: Participating nurses reported missed nursing care in the 1000 NH residents: the type, the causes, management (time of delay/resolution), recurrence (in the previous week) and severity of possible consequences	101 reported 223 missed nursing care among 175 residents, with the most frequent missed nursing care related to drug administration (n = 71, 34.5%) 19.9% of missed care (n = 41) were categorized as severe because of discomfort caused to the patient, clinical impact, or the repetitiveness of the situation. 21 of 75 recurrent missed care (36.4%) were considered to be of high severity 100 missed care (48.5%) was ascribed to inadequate staffing and the causes of missed care at night did not differ from causes during the day shift
Campagna et al. (2022), Italy	To examine the relationships between individual and environment factors and missed care	Cross‐sectional analytical study	43 NHs including 33 privately operated and 10 publicly operated	217 RNs and 860 most dependent residents they cared for	Study‐specific approach of missed care measurement (Campagna et al., 2021) Individual factors: gender, age, work experience and educational backgrounds Work‐related factors: working shifts, employment status, weekly working hours, work environment, workload, staffing and skill mix	88 out of 217 (40.5%) reported at least one episode of missed nursing care Younger RNs with permanent contracts working in publicly owned NHs reported more episodes of missed nursing care Public ownership of NHs, more residents with severe clinical conditions, a lower skill mix and perceived lack of time were associated with more missed nursing care
Dhaini et al. (2017), Switzerland	To assess the prevalence of implicit rationing of care, particularly rationing of ADLs and of caring, rehabilitation and monitoring 2. To explore the relationship between care workers' health and presenteeism regarding implicit rationing of care	Cross‐sectional analytical study	162 NHs, including 60 owned by state, 43 subsidized by private and 59 owned by private	3259 care workers provide direct care, including 910 RNs, 799 LPNs and 1550 NAs Response rate was 76.6%	Care worker and facility profile questionnaire Two subscales of BERNCA‐NH: “implicit rationing of ADLs” (5 items) and “implicit rationing of caring, rehabilitation and monitoring” (8 items) Swiss Health Survey: 3 items for self‐reported physical health problems including back pain, joint pain and headache and 2 items for self‐reported tiredness and sleeplessness MBI for work‐related exhaustion Single‐item presenteeism question 6. Two subscales in PES‐NWI: “Nurses manager ability, leadership, and support of care workers” and “staffing and resource adequacy”	Care workers reported physical health complaints including back pain (72.6%) and joint pain (50.8%). For mental health conditions, 66.2% reported tiredness, 47.7% reported sleeplessness, 45.3% reported headache, 37.7% reported emotional exhaustion from work and 26.3% reporting presenteeism. The work environment quality was rated high for leadership and slightly below “rather agree” for staffing adequacy Rationing of care was rare among participants in the study, with most (66.0%) reporting never or rarely rationing ADLs, assisting in food intake, drinking, bathing and oral hygiene Joint pain, tiredness, headache, emotional exhaustion and presenteeism were positively associated with rationing of ADLs. Joint pain, tiredness, headache and emotional exhaustion were positively related to rationing of caring, rehabilitation and monitoring activities
Henderson et al. (2017), Australia	To explore the frequency and causes of missed care	Cross‐sectional prevalence study	Online survey	922 care workers of RACFs including RNs, ENs and PCWs	MISSCARE Survey (22 items in Part A and 17 items in Part B) complemented with demographic and workplace factors	All tasks were perceived to be missed at least part of the time. The most frequently missed activities were responding to call bells, toileting residents within 5 min of a request and ambulating with residents Lack of staff was the most identified reason for missed care in residential aged care. An overwhelming focus was that insufficient staffing levels, reduced skill mix by replacing RNs with PCWs, insufficient knowledge of carers and increasing resident acuity impacted negatively upon capacity to deliver care
Henderson et al. (2018), Australia	To compare the frequency and causes of missed care as reported by nurses and PCWs in RACFs with different ownership	Cross‐sectional analytical study	Online survey	3206 care workers including 1119 RNs, 939 ENs, 1092 PCWs and 56 NPs	MISSCARE Survey (27 items in Part A and 27 items in Part B) complemented with demographic and workplace factors	The tasks most likely to be identified as being missed across all facilities were responding to call bells within 5 min and assisting residents with toileting needs within 5 min of request. The tasks that were reported as least likely to be missed related to complex healthcare needs In all cases, nurses in the public sector were less likely to report that these tasks were missed with nurses in the for‐profit sector most likely to identify missed care Too few staff, resident complexity, inadequate skill mix and unbalanced resident allocation were identified by nurses working in all three settings as the most important reasons for missed care. The responses were dominated by concerns that facilities were prioritizing “profit over performance” and “profits before people” compromising care
Hogh et al. (2018), Denmark	To investigate the impact of bullying on missed nursing care and QOC before and after a 2‐year period	Cohort study	Eldercare sector in 10 Danish municipalities, including nursing home, home care and combined care settings	4000 healthcare providers participate in both T1 (2016) and T2 (2018). T1: 308 exposed to bullying, including 10.1% RNs, 21.9% social and healthcare assistants, 45.4% social and healthcare helpers and 22.6% other care staff; 3692 not exposed to bullying including 13.1% RNs, 17.2% social and healthcare assistants, 46.6% social and healthcare helpers, and 22.7% other care staff	Single item, self‐labelling question on the presence and frequencies of bullying within the past 12 month Self‐developed 2‐item scale for missed nursing care Self‐developed six‐item scale for QOC COPSOQ‐II for measuring affective organizational commitment	Respondents reporting being bullied at T1 were more likely to work in NHs and reported higher levels of missed nursing care and lower level of affective commitment No significant association was found between bullying (T1) and affective organizational commitment (T2) and QOC (T2). Affective organizational commitment (T1) was not significantly associated with missed nursing care (T2) 3. There is a significant association between bullying and missed nursing care
Knopp‐Sihota et al. (2015), Canada	To assess the association of rushed and missed care with characteristics of care aids and workplace at the unit level	Cross‐sectional analytical study	36 NHs including 30 in urban region and 6 in rural region	583 care aids	Questionnaires for demographic variables of care aides and work‐related structural variables A single‐item scale for job satisfaction and vocational satisfaction SF‐8 Health Survey for mental and physical health status MBI for burnout ACT for organizational context Self‐developed scale for exploring rushed (7 items) and missed care (10 items)	86% of care aides feel rushed, with 75% leaving at least one care task missed due to lack of time during previous shift. Healthcare aides report feeling rushed in talking with residents, dressing, toileting and feeding residents Healthcare aides most frequently miss talking with residents and assisting with mobility, followed by nail care, mouth care, toileting, hair care and bathing Healthcare aides working on units with higher organizational context scores are less likely to report rushed and missed care Healthcare aides are more likely to feel rushed and miss care activities when they work on day shift, in small rural nursing homes, reported higher levels of exhaustion and cynicism, had lower efficacy and worse self‐reported physical and mental health, less satisfied with their job and work on a unit with lower organizational context with younger age
Nelson and Flynn (2015), US	To determine the relationship between missed care and the incidence of UTI	Cross‐sectional analytical study with secondary data analysis	63 Medicare‐ and Medicaid‐certified NHs in New Jersey	340 direct‐care RNs	NH‐level indicators, RNs' characteristics and prevalence of UTI were collected from existing data sets Self‐developed 12‐item questionnaire for measuring missed care The Individual Workload Perception Survey	48.2% of nurses reported that they had missed at least one necessary care activity by leaving it undone during their last shift worked. The most common missed care activities by type included comforting/talking with patients, developing or updating nursing care plans, teaching patients and families, documenting nursing care, and patient surveillance Seven of 12 types of missed care were significantly associated with UTI Among the missed care activities correlated with UTI, the failure to administer medications on time and the failure to provide adequate patient surveillance had the strongest association with missed care
Norman and Sjetne (2019), Norway	To modify and psychometric test the BERNCA‐NH Norwegian version	Mixed‐method instrument development study including adaptation, modification and validation stages	66 NHs representing 162 units (psychometric testing stage only)	Modification stage enrolled 14 participants including 9 PNs, 2 NAs and 3 RNs Validation stage enrolled 931 respondents, including 47 NAs, 490 PNs and 394 RNs with response rate being 37.1%	Adaptation and Modification stages: qualitative approaches including cognitive interviews with a mixture of think‐loud and verbal probing Validation stage: BERNCA‐NH Norwegian version (20 items)	All subscales demonstrated good internal consistency. The confirmatory factor analysis supported the four‐factor structure with fit statistics indicating a robust model. Three items, which were not relevant for all care workers, including “Change/apply wound dressings”, “Set up update patients' care plans” and “Administer prescribed medication”, were not included in the subscales and treated as single items “Activity that she/he wanted”, “studying care plans at the beginning of shift” and “set up or update patients' care plans” were the top three care tasks being missed. “Leave a patient in urine/stool longer than 30 min” and “Providing food other than regular meals” were the least care tasks being missed
Renner et al. (2022), Switzerland	To describe changes in levels and patterns of implicit rationing of nursing care in Swiss NHs over time To explore relationships between key explanatory factors and implicit care rationing	Cross‐sectional analytical study	47 NHs included in both the 2013 and 2018 SHURP from Switzerland's German‐ and French‐speaking regions	1580 care workers in 2013, including 29.9% RNs, 26.3% LPNs, 16.5% certified assistant nurse, 27.9% NAs 1689 in 2018, including 26.8% RNs, 33.2% LPNs, 16.8% certified assistant nurses and 23.2% NAs Response rates were 69% in 2013 and 78% in 2018	Facility‐ and unit‐level questionnaires including objective staffing levels, turnover and skill mix levels, as well as facility characteristics of language region, ownership status and nursing home size Subscales of PES‐NWI: “Nurse manager ability, leadership and support of care workers” (5 items) and “Staffing and resources adequacy” (3 items) Individual factors questionnaires: care workers characteristics (age, usual shift and educational background) and residents characteristics on facility level (care loads, age and length of stay) BERNCA‐NH for implicit care rationing (19 items)	Significant differences were found in the frequencies of each single rationing of nursing care activities between 2013 and 2018, except “necessary conversation with resident or their family” and “toileting/continence training.” “Respond promptly to resident calls”, “set up or update resident's care plans”, “documentation of care”, “scheduled single activity with a resident” and “scheduled group activity with several residents” were more likely to be rationed in 2018. In both 2013 and 2018, “set up or update residents' care plan” and “leave a resident in urine /stool longer than 30 min” were the most and least rationed care tasks The increases in rationing of nursing care accompanied a deterioration of nursing homes' work environment, including perceived staffing adequacy, FTE/100 beds, staff turnover rates and skill mix levels, while the residents' care loads remained similar Overall increase in rationing of nursing care across all four subscales (ADLs, social care, caring and documentation) from 2013 to 2018. Organizational factors, work environment factors and individual characteristics could be explanatory factors for ADLs and social care
Senek et al. (2020), UK	To demonstrate the prevalence of care left undone and its relationships to RNs' staffing levels	Cross‐sectional analytical study	Primary and community care settings including care homes	3009 RNs including 1742 RNs from community and primary care and 1267 RNs from care homes	Staffing level ratio: the actual number of RNs/planned number of RNs on last shift Self‐developed single‐item scale for measuring care left undone	A higher proportion of day shifts were understaffed compared to night shifts 32.6% of care tasks were left undone in care homes. On day shifts, there was a higher proportion of “care left undone” when understaffed; Night shifts had a lower level of care left undone than day shifts Significant relationship was found between understaffed on day shift and higher level of care left undone
Simmons et al. (2013), USA	To examine whether resident characteristics and behaviours influenced morning care provision	Cross‐sectional analytical study	4 community for‐profit LTC facilities	169 long‐stay residents with 44.2% repose rate	MMSE for cognitive status G‐GPM for probable chronic pain NPI‐NH for delusions, hallucinations, agitation/aggression, depression, apathy, euphoria and irritability A close‐ended question of structured interview for morning care preference A standard observational protocol for morning care provision	In 38%–41% of occasions no care or communication observed Occasions of no care and communication observed in both transfer out of bed and dressing occurred more frequent in 4‐star facility, while absence of incontinence care occurred more in 2‐star facility Two persons assist, MDS‐ADL dependency and length of stay were each significantly associated with not receiving care for transfer out of bed and dressing. Neither depression nor chronic pain was associated with remaining in bed Most participants (ranging from 75% to 87%) expressed a stable preference for care to remain the same in each care area
Song et al. (2020), Canada	To assess the association of work environment with missed and rushed care	Cross‐sectional analytical study	93 urban NHs including 312 care units	4016 care aides with 74.2% response rate	ACT for analysing organizational context at the unit level Knopp‐Sihota's scales for missed care (10 items) and rushed care (7 items) 9‐item short form MBI SF‐8 Health Survey Demographic and work characteristics of care aides (age, sex, education, first language, shift worked most often, experience on current unit, responsive behaviours from residents, job satisfaction), unit and facility characteristics (type, staffing level, care aides staffing/total unit staffing, owner‐operator model, size and health region)	Missing and rushing care tasks were common in NHs, with 57.4% of care aides reporting missing at least 1 care task and 65.4% of care aides reporting rushing at least 1 care task. The most frequently missed care tasks were taking residents for a walk, and the most frequently rushed care task was talking with residents Participants working in more favourable organizational context were 59% less likely to miss any care task and 66% less likely to rush any care task Missed care was associated with 4 organizational context elements: culture, organizational slack use of staffing or use of time and social capital. With a 1‐unit increase in culture, nurse aides were more likely to miss any care tasks by 62%. While with 1 unit increase in organizational slack use of staffing and organizational slack use of time, 65% and 103% less likely to miss any care, separately. With 1‐unit increase in social capital, 49% fewer care tasks tend to be missed
Tou et al. (2020), Taiwan	To clarify the correlation between missed care and the characteristics of nursing aides and facilities	Cross‐sectional analytical study	10 NHs, including 5 hospital affiliated NHs, 4 NPO's NHs and 1 private facility	274 responses, including 184 NAs, 80 nurses and 10 from managers, with 92.3% response rate	Demographic information: facility characteristics (facility type, staff ratio and NS turnover rates) and personal characteristics (sex, age, educational level, job qualifications, work shifts, hours of overtime work, intention to leave, opinions on labour sufficiency and total hours of in‐service training) MISSSCARE survey (25 items in Part A and 16 items in Part B)	Assistance with body cleaning was the most frequently missed care item, with 30.4% of respondents reporting its occurrence from occasionally to always, followed by reminding of or assistance with hand cleaning and assistance with rehabilitation activities Poor communication was the most cited reason for missed care, followed by staff shortage and material resource insufficiency (64.0%). Residents' deteriorating condition was defined as the main common reason for labour or staff shortage, with missed handovers being the main cause of poor communication Missed care significantly related to and NAs' nationality and perceived manpower insufficiency Taiwanese NAs significantly reported more missed care than non‐Taiwanese, with the occurrence of missed care was higher in NAs who perceived sufficient number of staff than those who did not
White et al. (2019), USA	To examine the relationship between RN's burnout, job satisfaction and missed care	Cross‐sectional analytical study	540 Medicare‐ and Medicaid‐certified NHs	687 direct care RNs	Secondary analysis of demographic data of individual RNs and facilities The Emotional Exhaustion subscale of MBI for measuring burnout A self‐developed 4‐point scale for measuring the level of job satisfaction and specific job aspects Self‐developed 14‐item scale for evaluating care left undone	Missed care rates were significantly higher for RNs with job dissatisfaction and burnout. 83% of RNs with job dissatisfaction and 95% of RNs with burnout reported missing care The most frequently missed care was comforting/talking with patients, with 64% of RNs with job dissatisfaction and 77% of RNs with burnout reporting missing this task 42% of RNs with burnout and 34% of RNs with job dissatisfaction reported frequently being unable to complete necessary care. RNs with burnout were almost 5 times more likely to leave necessary care undone and RNs who were dissatisfied with their jobs were nearly 2.6 times more likely to leave necessary care undone
Zhang et al. (2022), China Mainland	To investigate the level of implicit care rationing and its association with training needs of caregivers	Cross‐sectional analytical study	16 publicly funded NHs	374 care workers with a response rate of 83.48%	BERNCA‐NH for implicit rationing of care (20 items) Facility characteristics and individual characteristics Training needs analysis including a criticality index for measuring the importance of activities perceived by care workers and a self‐rated skill index for measuring care workers' perception of their performance on certain activities. Training need on each activity equals the value of its criticality index minus its self‐rated skill index Two subscales from PES‐NWI for measuring nurse managers' leadership ability and adequacy of staffing and other resources SAQ for measuring teamwork and resident safety climate HPSI for measuring conflict and lack of recognition and workload	Activities that were often rationed were keeping residents who ring waiting for more than 5 min, carrying out social care and scheduling single activities, followed by activities related to documentation and activation/rehabilitation. ADL‐related activities were sufficiently provided, whereas care workers tended to neglect activities related to caring/rehabilitation/monitoring, documentation and social care Training needs, working environment and individual‐level characteristics of care workers were significantly related to implicit care rationing. The training needs of each care activity were positively related to its implicit rationing. Adequacy of staffing and other resources was found to be significantly related to ADL, activation/rehabilitation, documentation and social care. Higher‐level leadership ability was associated with less caring/rehabilitation/monitoring and social care activities. Workload was demonstrated to have negative impacts on rationing of care/rehabilitation/monitoring activities
Zúñiga et al. (2015a), Switzerland	To examine its relationship with staffing variables, work environment, work stressors, QOC and implicit rationing of nursing care	Cross‐sectional analytical study	155 NHs with 402 units	4311 direct care workers including 25.3% RNs, 21.5% LPNs, 19.9% certified assistant nurses, 30.0% NAs and 3.3% others, with 79.3% response rate	A single‐item self‐developed QOC scale Two subscales of PES‐NWI “Nurse Manager Ability, Leadership, and Support of Care Workers” and “Staffing and Resources Adequacy” 10‐item modified SAQ HPSI for measuring work stressors BERNCA‐NH for implicit rationing of nursing care (19 items) Unit characteristics: number of beds, FTE/100 beds, staff mix, turnover rate, percentage of residents with cognitive decline; as well as residents' characteristics: age, length of stay, care load	Work environment factors, work stressors and rationing of nursing care were significant related to QOC, while staffing level, staff mix and turnover were not The factor most strongly associated with QOC was teamwork and safety climate, with QOC increased more than sixfold with a one‐point increase in the rating of teamwork and safety climate and almost threefold with a better perception of staffing and resources adequacy QOC decreased with more frequent stress due to workload but increased with stress due to a lack of preparation, while no relationship between actual staffing levels and QOC For implicit rationing of care, QOC increased with less rationing of caring, rehabilitation and monitoring and less rationing of social care, with more rationing of documentation increased the odds for better QOC
Zúñiga et al. (2015b), Switzerland	To explore the relationship between staffing level, turnover, and work environment factors and implicit rationing of nursing care	Cross‐sectional analytical study	156 Swiss NHs with 402 units	4307 care workers performing direct care, including 25.3% RNs, 21.5% LPNs, 19.8% certified assistant nurses, 30.1% NAs and 3.3% others, with an average response rate 78%	BERNCA‐NH for implicit rationing of nursing care (19 items) Two subscales of PES‐NWI: “Nurse Manager Ability, Leadership, and Support of Care Workers” and “Staffing and Resources Adequacy” 10‐item modified SAQ HPSI for measuring work stressors Participants' and units' characteristics	Assistance in drinking and food intake were the least rationing tasks. The most frequently rationed activities were the studying of care plans and documentation, keeping residents who had rung waiting for more than 5 min and carrying out social care Higher staffing and resources adequacy, work stress due to workload and due to conflict and lack of recognition were associated with lower rationing in all subscales, while higher teamwork and safety climate and work stress due to lack of preparation were only related to lower rationing in the subscales ADL and care, rehabilitation and monitoring. Better teamwork and safety climate were related to higher rationing in social care. Stress due to workload and staffing and resources adequacy had the highest impact on rationing documentation with stress due to conflict social care
Zuniga et al. (2016), Switzerland	To develop and psychometric testing the BERNCA‐NH of German, French and Italian‐language versions	Mixed‐method instrument development study including adaptation, modification and validation stages	162 NHs including 123 in German‐speaking region, 30 in French‐speaking region and 9 in Italian‐speaking region (validation stage only)	For phase 3 only: 4847 care workers including 30.9% RNs, 22.4% LPNs, 17.5% NAs with 1–2‐year education, 26.4% NAs on the job training and 2.7% others. Overall response rate was 76.0%	Adaptation and Modification stages: qualitative approaches including cognitive interviews with a mixture of think‐loud and verbal probing Validation stage: BERNCA‐NH in three languages (19 items)	EFA revealed a four‐factor structure with good fit statistics, including rationing in ADLs, caring, rehabilitation and monitoring, documentation and social care. Items of the social care subscale showed lower content validity and more missing values than items of other subscales The reliability for all subscales in all language versions was in an acceptable range, showing good inter‐item consistency In both German and French versions, the most often rationed care was “studying care plans at the beginning of shift.” In Italian version, the most often rationed care was “scheduled single activity with a resident.” “Assist drinking” and “assist food intake” were the least frequent rationed care tasks in all three versions

Abbreviations: ACT, the Albert Context Tool; ADLs, activities of daily living; AIN, assistant in nursing; BERNCA‐NH, the Basel Extent of Rationing of Care for Nursing Homes instrument; COPSOQ‐II, the second version Copenhagen Psychosocial Questionnaire; EFA, Exploratory Factor Analysis; EN, enrolled nurse; FTE, full‐time equivalent; G‐GPM, the Geriatric Pain Measure; HPSI, Health Professional Stress Inventory; LPN, Licensed practice nurse; LTC, long‐term care; MBI, the Maslach Burnout Inventory; MDS, Minimum Data Set; MISSCARE survey, Missed Care survey; MMSE, the Mini‐Mental Examination scale; NA, nursing assistant; NH, nursing home; NP, nursing practitioner; NPI‐NH, the Neuropsychiatric Inventory for Nursing Home; NPO, non‐for‐profit organization; PCW, personal care worker; PES‐NWI, the Practice Environment Scale–Nursing Work Index; PN, practical nurse; QOC, quality of care; RACF, residential aged care facility; RN, registered nurse; SAQ, Safety Attitudes Questionnaire; SHURP, Swiss Nursing Homes Human Resources Project; UTI, urinary tract infection.

5.1. Characteristics of included reports

Among the analysed publications, 19 were cross‐sectional studies, two were adaptations of standard missed care measurement scales for application in LTAC settings, two were qualitative studies and the remaining one was a cohort study.

5.1.1. Cross‐sectional and cohort reports

Three (Andersson, Bååth, et al., 2022; Andersson, Eklund, et al., 2022; Campagna et al., 2021; Henderson et al., 2017) out of 19 cross‐sectional studies were prevalence studies solely identifying the types, incidence and causes of missed care. Building upon the prevalence survey of missed care, the remaining 16 studies employed analytical cross‐sectional design, investigating the correlated factors of missed care using inferential statistical techniques.

The 19 cross‐sectional studies reported the occurrence of missed care in a total of 1482 LTAC settings. Among these, 14 studies exclusively focused on a single type of LTAC setting. Nine out of 14 studies included a sample size of less than 100 LTAC settings, with the smallest study including only four LTAC settings (Simmons et al., 2013). The largest study in this category included 540 LTAC settings (White et al., 2019). The remaining five studies (Andersson, Bååth, et al., 2022; Andersson, Eklund, et al., 2022; Blackman et al., 2020; Henderson et al., 2017, 2018; Senek et al., 2020) did not report the actual number of LTAC setting but did provide details about the workplace of the participants.

The 19 cross‐sectional studies included a total of 30,961 staff and 2029 clients. 16 out of the 19 studies solely used staff as participants, one study exclusively focused on older clients (Simmons et al., 2013), and the remaining two studies included nurses and patients as their samples (Campagna et al., 2021, 2022). The whole workforce sample, except two that did not report details on their samples (Henderson et al., 2017; Zhang et al., 2022), ranged from 169 (Simmons et al., 2013) to 4311 (Zuniga et al., 2015a) participants. The roles in the workforce sample consisted of 97 nurse practitioners, 9543 registered nurses (RNs), 6056 licensed practical nurses (LPNs) and enrolled nurses (ENs), 2600 certified assistant nurses (CANs), 10,739 nursing assistants (NAs) and care aides, 10 managers, 346 unclassified nursing roles and 284 others. Two studies only included care aides (Knopp‐Sihota et al., 2015; Song et al., 2020), while three studies only included RNs (Nelson & Flynn, 2015; Senek et al., 2020; White et al., 2019). A total of 14 studies had a mixed sample of care workers, including two or more staff roles within a single study. Among the 19 cross‐sectional studies, 11 provided information on the response rate, which ranged from 20.4% to 92.3%, including seven studies with a response rate below 80%.

Significant correlated factors of missed care reported by 16 analytical cross‐sectional studies can be categorized into three domain levels: individual, unit, and organizational. At the individual level, instances of missed care were associated with the characteristics of older people living in LTAC settings and the workforce skill mix. At the unit level, the instances of missed care were associated with shift types (Blackman et al., 2020; Senek et al., 2020), level of skill mix (Campagna et al., 2022; Henderson et al., 2018; Renner et al., 2022), teamwork and leadership (Andersson, Bååth, et al., 2022; Andersson, Eklund, et al., 2022; Blackman et al., 2020; Zhang et al., 2022; Zuniga et al., 2015b) and culture (Song et al., 2020) At the organizational level, the instances of missed care were associated with size and operational models (Blackman et al., 2020; Campagna et al., 2022; Henderson et al., 2018; Knopp‐Sihota et al., 2015). Detailed relationships between missed care and its correlated factors are reported in Table S1.

Workplace culture also impacts missed care. A large‐scale cohort design study including 515 RNs, 702 social and healthcare assistants, 1860 social and healthcare helpers and 3985 other staff in LTAC settings in 10 Danish municipalities (Hogh et al., 2018) found that bullying was more common in LTAC settings and a positive correlation between bullying and missed care.

5.1.2. Instrument adjustment studies

Only two out of the 24 included publications focused on adjusting existing measurement tools for application in LTAC settings. One study in Switzerland aimed to adapt the initial version of the Basel Extent of Rationing of Nursing Care (BERNCA) scale, originally developed for hospitals, into the NH version (BERNCA‐NH) within the same cultural context (Zuniga et al., 2016). The other study adapted the BERNCA‐NH for the Norwegian context (Norman & Sjetne, 2019). Both studies involved content adaptation, modifications and psychometric property testing of the adjusted scales through a mixed‐method design.

The BERNCA‐NH developed in Switzerland has three language versions: German, French and Italian. The field test for psychometric assessment included 4847 care providers (German = 3876, French = 735, Italian = 236) from 162 LTAC settings in Switzerland, with an overall response rate of 76%. The three language versions provided almost identical four‐factor structures, with the Cronbach's α for all subscales in all language versions falling within an acceptable range of 0.77–0.89, indicating a good inter‐item consistency. Items of the social care subscale showed lower content validity and more missing values than items of other subscales.

Psychometric testing of the scale developed in Norway was conducted with a total of 931 Norwegian care providers from 66 LTAC settings, with a response rate of 37.1%. The Norwegian version, BERNCA‐NH, also exhibited a robust four‐factor structure, with the Cronbach's α values for its subscales ranging between 0.67 and 0.85. However, three items, including ‘Set up or update patients’ care plans', ‘Administer prescribed medication’ and ‘Change/apply wound dressings’, are not relevant for all care worker occupations and were kept as single items.

5.1.3. Qualitative studies

One qualitative study (Braun et al., 2018) conducted in Switzerland, explored the experiences of care workers and older clients impacted by implicit rationing of nursing care in a 100‐bed LTAC setting. This research, presented as a letter to the editor, utilized data from two focus group interviews involving nine care workers, and 11 semi‐structured individual interviews with older clients. Thematic analysis was employed to interpret the data. Not only assessing the nature, contributing factors, and consequences of care rationing through interviews, but it also identified unique characteristics of clients experiencing implicit care rationing in LTAC settings. These characteristics included a reliance on institutional structures, a need for individual recognition and sensitivity to impersonality in care workers' daily interactions.

Bail et al. (2023) reported on qualitative findings from their 2‐year, three‐stage participatory action research study evaluating the implementation of a digital care system in an Australian residential aged care home with 156 beds. The study's objective was to appraise the system and its implementation using a multifaceted qualitative data collection approach encompassing: an online staff survey featuring open‐ended questions, impromptu hallway interviews with older clients and staff, and focus groups with system developers, managers, staff and older clients (n = 128, 48 older clients and their visitors, and 65 staff)., The analysis generated four central themes: ‘acceptability’, ‘efficiency’, ‘quality’ and ‘implementation process’. Notably, the digital system enhanced care quality by reducing the perception of missed care, primarily through its reminder functions in workflow scheduling, which made omissions and delays more visible and easier to address.

5.2. Result of quality appraisal

A thorough quality appraisal, evaluating the study design of 23 journal publications and one letter to the editor was undertaken. Of these publications, 11 were deemed to be free of bias. The remaining publications exhibited a range of quality issues, attributable to various methodological shortcomings (Table S2.).

Among the 16 analytical cross‐sectional studies evaluated, nine demonstrated no potential biases, but several methodological shortcomings were noted in the remaining studies, scoring between three and seven out of eight. Specifically, two studies (Blackman et al., 2020; Henderson et al., 2018) failed to clearly define their eligibility criteria for sampling. Three studies (Henderson et al., 2018; Senek et al., 2020; Tou et al., 2020) lacked detailed descriptions of study subjects and settings. Furthermore, six studies (Henderson et al., 2018; Knopp‐Sihota et al., 2015; Senek et al., 2020; Tou et al., 2020; Zhang et al., 2022; Zuniga et al., 2015a) did not adequately identify and address confounding factors. One study (Senek et al., 2020) employed a nonstandard method for calculating the staff level ratio. This method involved asking participants to recall the planned number of RNs for a shift compared to the actual number present, an approach inconsistent with standard practices in LTAC settings. Additionally, this study (Senek et al., 2020) utilized a single‐item scale to assess the occurrence of care left undone, without providing either a supporting reference or evidence of psychometric properties. This was identified as a significant limitation, undermining the validity and reliability of the outcome measurement.

Of the three prevalence studies, Campagna et al. (2021) exhibited no potential bias. However, Andersson, Bååth, et al. (2022) and Andersson, Eklund, et al. (2022) and Henderson et al. (2017) displayed similar shortcomings, each receiving a score of five out of nine. Both studies failed to adequately report their sampling strategy, leaving the appropriateness of the sample frame for addressing the target population unclear. Additionally, they provided insufficient detail regarding the study subjects and settings, only mentioning participants' workplaces. Moreover, Andersson, Bååth, et al. (2022) and Andersson, Eklund, et al. (2022) reported a notably low response rate of 20.4% and did not take any measures to address this issue effectively. The Henderson et al. (2017) study meanwhile failed to report its response rate at all, which is a significant oversight in evaluating the representativeness of the study's findings.

Quality assessment of the two publications reporting on instrument adjustment (Norman & Sjetne, 2019; Zuniga et al., 2016) deemed them ‘Inadequate’ though they differed in the scores of their respective subcategories. A key issue in both was the questionable content validity; neither study clarified whether they employed trained group moderators or interviewers nor did they confirm if all meetings and interviews were transcribed verbatim and analysed appropriately. Additionally, Norman and Sjetne (2019) did not provide an analysis of subgroup differences among participants with distinct responsibilities, resulting in an ‘Inadequate’ rating for cross‐cultural validity testing. Comparatively, Zuniga et al. (2016), despite facing a similar issue, did report separately on the psychometric properties across three language versions, which was classified as ‘Doubtful’ in this box. Consequently, the limitations in subgroup comparisons in both studies led to identical scores in the evaluation of construct validity. Both studies applied a ‘last 7 working days’ recall period, raising doubts about the accuracy in identifying incidents of rationed nursing care and potentially introducing specific measurement errors. Lastly, the absence of comparisons with other missed care measurement methods or gold standards in both studies resulted in an ‘Inadequate’ rating regarding their responsiveness, reliability and validity, thus questioning their overall credibility.

The qualitative study (Bail et al., 2023) was assigned a score of 8 out of 10. This reflects the absence of a statement to position the researchers culturally or theoretically, and a lack of information concerning the influence of the researcher on the research, and vice versa. These omissions result in biased interpretations and diminished credibility, failing to recognize the potential impact of the researcher's background and biases on the study's findings and analysis. Conversely, the cohort study (Hogh et al., 2018) was evaluated as being free from bias.

5.3. Approaches of missed care measurement in LTAC settings

In the 24 publications reviewed, two primary methods were employed to measure missed care in LTAC settings: modified standard scales and study‐specific approaches (Table 4). More than half of the included publications adopted adjusted versions of the BERNCA‐NH scale and the MISSCARE survey. The remainder of the studies employed self‐designed scales, observational protocols, qualitative interviews and digital health management systems.

TABLE 4.

Characteristics of approaches for missed care measurement.

Attribute	Adjusted standard scales (n = 13)		Study‐specific approaches (n = 11)
	BERNCA‐NH (n = 9)	MISSCARE survey (n = 4)	Questionnaires or scales (n = 8)	Observation (n = 1)	Interview (n = 1)	Digital care management system (n = 1)
Definition of “missed care”	Implicit rationing of nursing care: Necessary and usual care activities not performed due to lack of time or high workload	Missed care: Required patient care that is omitted (in part or in whole) or delayed, due to multiple demands and inadequate resources	Terms included “missed care”, “missed nursing care”, “care left undone” and “task left undone”, with specific definitions varying by study	The phenomenon of “no care or communication observed” except when residents performed task independently	Implicit rationing of nursing care: Necessary and usual care activities not performed due to lack of time or high workload	The phenomenon of care omission and delay
Administration	Self‐report by caregivers	Self‐report by caregivers	Self‐report by caregivers	Objective observation protocol	In‐person and/or focus group interview	Self‐report by caregivers
Recall period	Last 7 days	Last shift	Last shift	NA	NA	Timely inspection of task lists as planned
Structure and Items	Focus on types of missed care in four subscales: ADLs, Caring, Rehabilitation and Monitoring, Documentation, and Social Care with 19–35 items	Part A: Unidimensional scale on types of missed nursing care with 22–27 items Part B: Causes of missed care with three subscales: Labour, Communication, Equipment/Resources with 16–27 items	Unidimensional structure with a limited number of items (1–14) based on research interests	Incidence of “No care or communication observed”, except when residents perform tasks independently	Open‐ended questions about incidence, patterns and causes of missed care	Automatically flagging up the overdue tasks and raising the hierarchy and visibility in system to attract the attention of care providers
Options	Likert scale	Likert scale	Likert scale, open‐ended or close‐ended questions	NA	Open‐ended questions	NA
Psychometric Properties	EFA applied, Cronbach's α ranges from 0.64 to 0.93	Rasch analysis applied yet no specific outcomes reported	Only Hogh et al. (2018) reported Pearson's correlation was 0.70 in T1 and 0.69 in T2	Observers' interrater reliability ranging from 0.94 to 1.0	NA	NA

Abbreviations: ADLs, activities of daily living; EFA, exploratory factor analysis; NA, not applicable.

5.3.1. The BERNCA‐NH scale

The BERNCA‐NH scale was employed in nine studies conducted across four regions, with six studies in Switzerland (Ausserhofer et al., 2021; Braun et al., 2018; Dhaini et al., 2017; Renner et al., 2022; Zuniga et al., 2015a, 2015b), one in Sweden (Andersson, Bååth, et al., 2022; Andersson, Eklund, et al., 2022), one in Norway (Norman & Sjetne, 2019) and one in Mainland China (Zhang et al., 2022). In this review, the BERNCA‐NH scale was used in various language versions, including German, French, Italian, Swedish, Norwegian and Simplified Chinese. Zuniga et al. (2016) modified the original BERNCA scale to its NH version and used it in two additional studies (Zuniga et al., 2015a, 2015b). The scales used in the remaining six studies were adjusted versions based on the BERNCA‐NH developed by Zuniga et al. (2016), tailored to the specific application scenarios.

The BERNCA‐NH scale, grounded in the concept of implicit rationing of nursing care (Schubert et al., 2007), addresses conditions where necessary and customary care activities are omitted due to constraints of time or high workload. Designed for self‐reporting, it aims to identify the type and prevalence of missed care. The BERNCA‐NH scale developed by Zuniga et al. (2016) comprises 19 items across four subscales: ‘Activities of Daily Living’, ‘Caring, Rehabilitation, and Monitoring’, ‘Documentation’ and ‘Social Care’, based on care delivery from the past seven working days. The scale is, however, adaptable to specific study contexts, enabling modifications in item content and themes. The Swedish version (Andersson, Bååth, et al., 2022; Andersson, Eklund, et al., 2022) incorporated 15 additional study‐specific items and an open‐ended question to explore the causes of missed care. Similarly, Chinese researchers (Zhang et al., 2022) included an open‐ended question to understand the reasons behind care omissions.

The response options ranged from ‘never’ to ‘always’ on a Likert scale, with two additional options: ‘activities were not necessary’ and ‘not within my field of responsibilities’. The prevalence of missed care was calculated by determining the mean and standard deviation of each subscale or by analysing the frequency of ‘often’ and ‘always’ responses for each item. Psychometric properties of the scale were evaluated using confirmatory factor analysis and exploratory factor analysis, and the reported measures included Cronbach's α and content validity index. In the studies employing the BERNCA‐NH scale, the most frequently reported missed care tasks were items in the ‘Documentation’ and ‘Caring, Rehabilitation, and Monitoring’ subscales. In contrast, care tasks listed in the ‘Activities of Daily Living’ subscale, particularly ‘assisting with food intake’ and ‘assisting with drinking’, were the least frequently missed care tasks.

5.3.2. The MISSCARE survey

The modified Missed Care (MISSCARE) survey was employed in four studies across two regions, including three in Australia (Blackman et al., 2020; Henderson et al., 2017, 2018) and one in Taiwan (Tou et al., 2020). In this review, the modified MISSCARE survey was available in English and Chinese versions. Modified MISSCARE survey utilized in each study was directly tailored from the original hospital version to fit the specific LTAC settings being studied, with variations in the number and content of items.

The modified MISSCARE survey is supported by the conceptual framework of ‘missed nursing care’ proposed by Kalisch et al. (2009), referring to the omission or delay of required care due to multiple demands and inadequate resources. This survey differs from the BERNCA‐NH scale in that it not only identifies the type and prevalence of missed care but also reasons for these omissions through self‐reporting. In Part A of the scale, caregivers report incidence of missed personal and nursing care (22–25 items) based on their most recent shift. Part B, comprising 16–27 items, aims to identify the causes of missed care. While Henderson et al. (2018) subdivided Part A into three subscales, other studies retained its unidimensional structure, in line with the original version (Kalisch & Williams, 2009).

Response options in Part A range from ‘never missed’ to ‘always missed’, and Part B employs a Likert scale from ‘not important’ to ‘very important’. Prevalence of missed care is calculated using methods akin to the BERNCA‐NH scale. Psychometric properties of the scale were evaluated using factor analysis (Tou et al., 2020) and Rasch Scaling (Blackman et al., 2020), yet two studies did not report the results of psychometric testing. In the Australian studies (Blackman et al., 2020; Henderson et al., 2017, 2018), the most frequently missed care tasks were ‘responding to call bells’, ‘toileting residents within 5 minutes’ and ‘ambulating with residents’. The most cited causes of missed care were ‘lack of staff’, ‘complexity of residents’ and ‘inadequate skill mix’. In the Taiwanese survey (Tou et al., 2020), the most frequently cited care omissions were ‘assistance with body and hand cleaning’ and ‘rehabilitation activities’, with the most common reasons for missed care being ‘staff and material shortage’ and ‘poor communication’.

5.3.3. Study‐specific approaches

The remaining 11 studies used study‐specific approaches to measure missed care, with one in Australia (Bail et al., 2023), two in Canada (Knopp‐Sihota et al., 2015; Song et al., 2020), one in Denmark (Hogh et al., 2018), two in Italy (Campagna et al., 2021, 2022), one in Switzerland (Braun et al., 2018), one in the United Kingdom (Senek et al., 2020) and three in the United States (Nelson & Flynn, 2015; Simmons et al., 2013; White et al., 2019). Among these, Simmons et al. (2013) utilized an observational protocol to detect omissions in morning care provision, another (Braun et al., 2018) employed qualitative interviews to explore the types, correlated factors and effects of implicit care rationing, with Bail et al. (2023) identifying missed care using digital healthcare management technology. The remaining studies used self‐designed scales or questionnaires to measure missed care. Due to considerable differences in self‐designed tool content, there was significant variation in the types and prevalence of missed care identified by these approaches.

The self‐designed scales or questionnaires used in these studies were underpinned by the concepts of ‘missed nursing care’ (Kalisch et al., 2009) and ‘care left undone’ (Aiken et al., 2001). These instruments were adept at measuring the incidence of missed care, either overall or for specific care tasks, and generally contained fewer items than the modified standardized scales. Notably, one instrument utilized in two studies (Campagna et al., 2021, 2022) also possessed the capacity to investigate causes, severity and recurrence of missed nursing care. Item counts in these self‐designed instruments varied from a single item to 14 items. Items focused on tailoring to specific aspects of care delivery, aligning with the research interests of each study. Instruments gathered data on the types and frequency of care omissions through self‐reporting. Response formats for each item varied among instruments, with some employing Likert scales, while others, a binary ‘yes’ or ‘no’ format. Despite all eight studies asserting excellent psychometric properties for their self‐designed tools, seven did not present specific data to substantiate these claims.

The observational method was the only wholly objective approach utilized to ascertain the occurrence of missed care. This involved researchers observing three specific morning care activities requiring staff assistance: assisting older clients out of bed, aiding with toilet use or changing undergarments, and helping with dressing (Simmons et al., 2013). Missed care during these activities was identified when the targeted care or communication was absent. The researchers reported exceptional inter‐rater reliability, with scores ranging from 0.94 to 1.00, indicating a high level of consistency and accuracy in their observations. Between 38% and 41% of morning care occasions were omitted, with clients' high dependency being identified as a significant correlated factor of omission.

In the study undertaking focus groups to understand perceptions about implicit rationed care (Braun et al., 2018), care workers identified that rationing typically occurred in social activities care, special care such as nail and hair care, and tasks unpopular with either staff or older clients. High‐priority tasks such as wound care or therapies were occasionally delayed, but crucial tasks, medication administration, acute care, pain management and food intake support were prioritized. Factors causing increased rationing included poor staff skill mix, lack of motivation among co‐workers, staff illness and unfamiliarity with older clients, alongside fluctuating care demands. The impact of rationing was mixed: Some older clients showed understanding, while others reacted with anger, anxiety or increased demands. Care workers expressed frustration and reduced empathy related to their inability to meet older clients' needs, with some viewing rationing as an ‘inevitable aspect of the job’. Regardless of these challenges, there was a common desire among care workers to allocate more time to care for older people living in LTAC settings.

The digital care management system applied and evaluated by Bail et al. (2023) effectively highlighted required tasks through a ‘flagging’ feature that made delays or omissions more conspicuous to staff. This system provided a follow‐up mechanism for care tasks, enabling reminders to care providers of any delays or omissions via technology‐supported documentation, performance review and time management. Additionally, the system's reminder function was reported by participants to notably reduce the perception of missed care by presenting it in a clearer and more visible format. This feature also helped lessen the cognitive burden on the staff, contributing to the reduction of missed care.

6. DISCUSSION

This review systematically analysed missed care measurement in LTAC settings through comprehensively summarizing and comparing research design and measurement approaches of 24 included publications. The review noted an increasing number of publications over the past two decades, reflecting increasing research interest in the investigation of missed care within LTAC settings. Among various measurement approaches identified, the BERNCA‐NH emerged as the most commonly used instrument in LTAC settings, in contrast to the MISSCARE survey, which is more prevalent in hospital contexts (Palese et al., 2021). However, the diversity of approaches, along with variations in their development and application, resulted in a range of measured outcomes which are challenging to synthesize and compare. When critically appraising the quality of these publications and evaluating the approaches taken to missed care, it was evident that the current evidence is insufficient to conclusively determine the most efficient, comprehensive and accurate measurement instrument for real‐world evidence‐based application in LTAC settings. This gap highlighted the deficiencies in research dedicated to the development, application and validation of missed care measurement in LTAC settings at theoretical and practical levels.

6.1. Challenges in standardizing missed care measurement in LTAC settings

This review discovered that all included publications included only a single instrument to measure missed care in LTAC settings, and thus no comparisons made between different assessment methods to ascertain which approach to measuring missed care were most robust. This omission primarily stems from their being a lack of an established ‘gold standard’ for the accurate and reliable measurement of missed care. Specifically, there is ambiguity around the crucial aspects of measurement such as what should be measured, when measurements should occur and how these measurements should be conducted within LTAC settings. Ongoing debate and the absence of a consensus about how to define ‘missed care’ further hinder the development of a ‘gold standard’ measurement (Jones et al., 2015). As a result, there are a range of measurement approaches, each based on different rationales, and this poses challenges for effectively comparing measurement instruments. Researchers resort to simply adapting existing instruments to fit LTAC settings or creating new methods of measurements tailored to their research interests. This results in inconsistencies in research designs when selecting missed care measurement instruments and difficulties in integrating and comparing research findings. This is compounded by a lack of unified quality appraisal for the research methods adopted for instrument development. As the ageing population is growing and the provision of safe and high‐quality aged care is in doubt, globally, there is an urgent need for theoretical research to establish benchmarks for measuring missed care in LTAC settings. Such benchmarks would enable robust comparisons between different approaches to measurement and a determination about which instruments can be effectively applied in LTAC settings.

The study designs of most of the publications reviewed did not provide a comprehensive understanding of missed care in LTAC settings. Missed care, as a critical quality issue, extends beyond the scope of individual care providers' responsibilities and is linked to broader social profiles of institutions in which they operate (Chaboyer et al., 2021). The implementation of cross‐sectional surveys with robust research designs is crucial for providing a transparent and holistic view of missed care that benefits consumers and government departments. More than half of the studies in this review had methodological shortcomings, including non‐probability sampling methods, not reporting response rates or having low response rates and missing participant and setting characteristics. These flaws significantly weakened the outcomes of the quality appraisal and the validity of reported missed care prevalence rates in LTAC settings. The applicability of the findings about missed care in LTAC settings was constrained by limitations in the study designs of included publications.

6.2. Limitations in current approaches to measuring missed care

In addition to a lack of high‐quality evidence for implementing missed care measuring approaches in LTAC settings, there are disadvantages to the approaches summarized in this review of measuring missed care, including administration methods, content and inadequate examination of psychometric properties. These factors impede the recommendation of reliable approaches for measuring missed care based on the available evidence.

First, this review identified two types of administration methods: subjective report and objective observation. Subjective report instruments are susceptible to providing misinformation about missed care, as caregivers might consciously or unconsciously underreport care omissions (Kalisch & Williams, 2009). Pressure from their employment institution, particularly the fear of punishment, can result in nursing staff to intentionally understate care omissions (Kalisch et al., 2009). Additionally, certain omissions might be normalized within work experience and unit cultures, particularly when not causing immediate adverse outcomes (PSNet, 2019). While the observational approach can offer greater accuracy in identifying missed care, it is more time‐consuming to evaluate the comprehensive condition of in‐care provision and challenging to detect partial care omissions (Simmons et al., 2013). Moreover, the Hawthorne effect (Cohen, 2023) further complicates this method, as care workers' behaviour could improve under observation. Consequently, a combined approach of subjective and objective techniques is suggested as the most effective strategy for identifying missed care (Jones et al., 2021). This dual method can mitigate biases such as response, social desirability and memory biases in self‐report instruments, while augmenting the comprehensiveness and precision of objective observations (Guliyeva, 2022).

Second, there could be elements of bias in the assessment outcomes of missed care using the included approaches and incompleteness due to differences in the content of the measurement instruments. Comparing the BERNCA‐NH scale and the modified MISSCARE survey, the former provides a more detailed breakdown with more items for omissions in care documentation and social activities, whereas the latter includes more items to detect omissions in nursing care, causing the commonly reported missed care services in LTAC settings (Jones et al., 2015). Additionally, scale length can influence measurement outcomes. Among the scales reviewed, the shortest comprised only one item. While a single‐item scale could offer flexibility and accommodate various responses from caregivers (Senek et al., 2020), it tends to overlook some care omissions due to the limited representation of missed care listed in the scale (Allen et al., 2022). Conversely, lengthy scales with numerous items can burden aged care providers with practical utilization. Participants could become disengaged or less motivated to provide accurate and thoughtful answers, potentially compromising the data quality (Gibson & Bowling, 2020). Moreover, longer scales can result in lower response rates or increased attrition, limiting the representativeness of the sample and potentially introducing response bias (Eisele et al., 2022). Further research is encouraged to strike a balance between comprehensiveness and effectiveness in the measurement approach of missed care, with proper scale length and content.

Third, incomplete examination and reporting of the psychometric properties further compromises the quality appraisal of measurement approaches. In this review, content validity and reliability were fully tested and reported in only two instrument development studies, with only half of the remaining cross‐sectional studies reporting Cronbach's α and scale‐level or item‐level content validity index. Utilizing measurement approaches with incomplete examination of psychometric properties can result in measurement inaccuracy, reduced confidence in the results and unreliable findings (Mokkink et al., 2020). Collecting data via a single instrument from respondents with diverse backgrounds could further compromise the accuracy of psychometric testing (Boateng et al., 2018). To mitigate missing data, researchers included options such as ‘activities were not necessary’ and ‘not within my field of responsibilities’ to accommodate respondents with varying degrees of skill, knowledge and responsibilities. However, these responses were considered invalid when conducting psychometric testing and calculating the occurrence of missed care, causing inaccurate outcomes. Therefore, it is essential to conduct more rigorous and comprehensive testing of psychometric properties focused on subgroup and cross‐cultural analysis, starting from instrument development studies to pre‐implementation examination, to guarantee the quality of the instruments and the research.

6.3. Limitations and future improvements

This review offered an extensive examination and analysis of approaches used for measuring missed care in LTAC settings globally, and the limitations identified are used to demonstrate what should be addressed in future research.

First, the identification and inclusion of publications in this review were challenged by inconsistencies in the terminology used to describe missed care. Without the guidance of an expert health librarian on search term selection, variations in the terminology used to describe missed care would have led to omissions. For instance, the Final Report on Aged Care Quality and Safety in Australia (Pagone & Briggs, 2021) used the term ‘substandard care’ to denote LTAC settings not meeting or violating regulations, aligning with the concept of missed care in this review. However, as this report did not specifically address substandard care evaluation methods, it was excluded from this review. The concept of ‘unmet care needs’, though closely related to missed care, was also excluded as it represents a broader range of unfulfilled healthcare services (Rahman et al., 2022). Missed care, being more practical in nature, can be seen as a potential precursor to unmet care needs (Kalánková et al., 2021). Despite their exclusion, such publications are valuable for informing this review and future research.

Second, this review was unable to adhere to the COSMIN guidelines for systematic reviews of outcome measurement instruments (Prinsen et al., 2018). This deviation was due to the limited information provided in the 24 included publications, which constrained the quality appraisal of missed care measurement instruments. The COSMIN guidelines offer a robust framework for evaluating the methodological quality of studies on the development, validation and responsiveness of health measurement instruments (Mokkink, Prinsen, et al., 2018). Ideally, these guidelines enable a thorough appraisal and comparison of different tools, aiding in the selection of the most appropriate instruments for specific research contexts (Prinsen et al., 2018). However, in this review, only two instrument adjustment studies provided relatively complete psychometric properties, and both were rated as ‘inadequate’ in study design according to the COSMIN RoBs checklist, while others provided limited or no psychometric data. This limitation hampered the quality assessment of the measurement instruments, affecting judgements about their suitability and undermining the reproducibility and interpretability of the review's findings (Elsman et al., 2022). Nonetheless, the review was registered on the PROSPERO platform and followed critical methodology and PRISMA guidelines by experienced researchers, ensuring the integrity, sufficiency and transparency of the review process and outcome.

7. CONCLUSION

Missed care is a significant concern in the care quality and safety management in LTAC settings for older clients, necessitating an effective measurement to accurately assess its incidence for all stakeholders. To the best of our knowledge, this could be the first systematic review particularly focusing on available evidence of missed care measurement in LTAC settings. This review identified 24 publications capturing two main categories of approaches to measuring missed care with a focus on LTAC settings. However, based on the characteristics of the included publications and measurement approaches, this review was unable to provide recommendations on the most effective approach for measuring the prevalence of missed care in real‐world practice in LTAC settings due to there being inadequate evidence in the included studies. The deficiencies observed in the study designs and the way they were applied to measuring missed care underscore the need for more comprehensive research in this field, spanning theoretical to practical approaches. As research evidence accumulates regarding measurement of missed care, further reviews following the COSMIN guidelines are necessary to inform evidence‐based practices for selecting the most suitable approach to measuring missed care.

AUTHOR CONTRIBUTIONS

X.W., N.B., J.RT., V.T.: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. X.W., J.RT., K.B., V.T.: Involved in drafting the manuscript or revising it critically for important intellectual content. J.RT., V.T.: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. X.W., J.RT., V.T.: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest related to this article.

PEER REVIEW

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16358.

Supporting information

Appendix S1.

Table S1.

Table S2.

Wang, X. , Rihari‐Thomas, J. , Bail, K. , Bala, N. , & Traynor, V. (2025). Care quality and safety in long‐term aged care settings: A systematic review and narrative analysis of missed care measurements. Journal of Advanced Nursing, 81, 5264–5290. 10.1111/jan.16358

DATA AVAILABILITY STATEMENT

Data available on request from the authors.