Beyond omission: Missed nursing care as prioritization under complexity in intensive care units

BACKGROUND: Missed nursing care in intensive care units (ICUs) is commonly understood as needed care that is delayed, partially completed, or omitted. However, less is known about how critical care nurses describe and negotiate these omissions during real-time prioritization under complexity of care. PURPOSE: To explore ICU nurses' perceptions of missed nursing care and the contextual factors shaping its occurrence and prioritization. METHODS: A qualitative descriptive study was conducted using five focus groups with 39 nurses from 11 adult ICUs across five hospitals in Spain. Data were analyzed inductively using thematic analysis. DISCUSSION: This study shows that missed nursing care in ICUs extends beyond complete task omission and includes care that is delayed, partially completed, or provided less frequently. Nurses described missed care across both direct care, including fundamental physical and psycho-emotional care, and indirect care, including relational care, care recording, and clinical monitoring. Less visible forms of nursing work were particularly vulnerable to displacement when physiologically urgent and technically measurable interventions were prioritized. These omissions appeared to arise from multifactorial and interrelated conditions involving organizational management, healthcare provider-related factors, patient complexity, and environmental conditions. CONCLUSION: Missed nursing care in ICUs should be understood not only as isolated task omission, but as a dynamic prioritization process shaped by complexity of care. Strategies to reduce missed care should address the system conditions that make less visible nursing work vulnerable to displacement.