By James X. Stobinski, Ph.D, RN, CNOR, CSSM(E), CNAMB(E)
A recent conversation with a colleague at NIFA prompted me to explore the topic of the consistency of perioperative nursing care. This nurse works as a surgical assistant and participates in a high volume of cases with a diverse selection of perioperative nurses and his opinion carries weight. This made me consider this issue from the quality improvement lens. My thoughts turned to a straightforward question – How do we assess the quality of perioperative nursing care?
One measure of the quality of care is whether all the appropriate care happened in a case. From a quality assurance perspective this is the sort of thing we measure in routine audits. Putting on my research hat, I began a quick scan of the literature and came to very recent work on the topic of missed nursing care to include perioperative nursing specific articles.
The topic of Missed Nursing Care (MNC) fits well within the framework of Avedis Donabedian’s work on healthcare quality.¹ Donabedian’s Structure-Process-Outcomes Model has held up remarkably well over time and is useful in examining this topic. From that perspective it would be easy enough to audit the process of nursing care, document the omissions and then address those aspects. I would argue that the complex reasons nursing care is missed exceeds that simplistic view. A broader, more nuanced look is needed and that will also bring us to an examination of the structure that supports nursing care.
Missed nursing care can be viewed from a large picture nursing perspective. There is an excellent, recent systematic review and meta-analysis on this topic by Gong and colleagues.¹ These researchers tell us that MNC, “… refers to any aspect of essential patient care that is omitted or delayed” and that this “…presents substantial risks to patient safety and the quality of care.”¹ In their review they state that, “The raw prevalence of missed care ranged from 6.8% to 98.1% …”¹ By any measure that is a significant portion of missed care which clearly could have a negative impact on patient outcomes. Among the reasons for missed care include unexpected increases in patient census, inadequate staffing and urgent patient care issues.¹
More relevant to my recent discussions is the MNC found in perioperative nursing. I am pleased to note the very recent work of the prolific Australian perioperative nurse researcher Dr. Brigid Gillespie. Gillespie, and her fellow researchers Harbeck and Chaboyer, report perioperative specific results using the MISSCARE Survey-Operating Room and correlated these results to self-reported rating of perioperative nursing competency as measured with the Perceived Perioperative Competence Scale-Short Form (PPCS-SF).³,4 They reported that, “participants’ age directly predicted the frequency of missed care, nurse role satisfaction, perceived perioperative competence, and reasons for missed care.” The reasons given for missed perioperative care included, “team communications and interruptions, limited resources, and … inadequate skill mix and staffing.”³ The theoretical model outlined by these authors predicted 22.6% of the frequency of missed care.
A modern operating room is a complex, technology-intensive environment with an emphasis on efficiency. Operating margins have tightened in recent years, placing even more pressure on nursing staff. Many experienced perioperative nurses left the profession in the pandemic. That lost expertise coupled with increasing time pressures and the continual onslaught of technological innovation may contribute to missed care. This research can inform further study on the how and why of missed perioperative nursing care. Future research may give us actionable items for perioperative leaders to close these shortfalls in care. Donabedian’s framework and the exemplary work of these Australian nurses outline a potential research trajectory.
– James X. Stobinski, Ph.D., RN, CNOR, CSSM(E), CNAMB(E), is the director of hospital and ASC relationships with National Institute of First Assisting (NIFA). He is also a member of the Central Michigan University faculty.
References
1.Donabedian, A. (1966). Evaluating the Quality of Medical Care. The Milbank Memorial Fund Quarterly, 44(3), 166–206. https://doi.org/10.2307/3348969
2.Gong, F., Mei, Y., Wu, M., & Tang, C. (2025). Global reasons for missed nursing care: a systematic review and meta-analysis. International Nursing Review, 72(1), e13096. https://doi.org/10.1111/inr.13096
3.Gillespie, B.M., Harbeck, E., & Chaboyer, W. (2023). The Association between Operating Room Nurses’ Characteristics, Competence, and Missed Nursing Care: A National Survey. Journal of Nursing Management.
4.Gillespie, B. M., Harbeck, E., & Chaboyer, W. (2025). The frequency and reasons for missed nursing care in Australian perioperative nurses: A national survey. Journal of Clinical Nursing, 34(3), 883–893. https://doi.org/10.1111/jocn.17082
