Commentary: Missed nursing care and complexity theory: a conceptual paper

Abstract

Having worked in strategic and operational roles that span clinical and academic environments for the last 30 years, I am in full agreement with the authors of this paper that missed nursing care (MNC) is a 'wicked problem'. The paper gives strong justification of the importance of this issue, quoting evidence that between 55-98% of nurses report regularly missing one or more aspects of care on a shift.The theoretical introduction to complexity theory has strong merits in viewing organisations as 'complex adaptive systems' and the authors present their analysis of the components of MNC as encompassing adaptation and self-organisation along with the recognition that nursing involves non-linear interactions and is inevitably shaped by history. However, my initial enthusiasm to develop my conceptual thinking via the lens of complexity theory was not without some frustration by the authors' tendency to put forward their analysis as a series of oppositional paradigms, particularly reductionism v. complexity and biomedical v. psychosocial models of care. I found myself responding to this approach as ultimately being too simplistic and found the need to somehow denigrate previous work unhelpful.My concerns were two-fold: firstly, the prevailing paradigm that all existing approaches to addressing MNC are reductionist; and secondly the strong inference that healthcare practice can be delineated as the biomedical model supressing the psychosocial model of nursing. Notwithstanding the evidence that does demonstrate that the most common 'missed' elements of nursing care are education and emotional support, my own experience would suggest that many healthcare settings integrate both models through cohesive multidisciplinary working and distributed leadership. Perhaps the suggestion that the 'doctor-nurse' game (Stein, 1967) continues to dominate hospital culture is a reflection of the authors' own experience; however, I would hope that working practices and relationships in the last 50 years have moved away from this being the norm. Indeed, Stein et al. (1990) revisited this seminal work and concluded that there had been major changes in the doctornurse relationship over the two decades since the original publication.