This commentary has been inspired by the recent editorial in JAN on missed nursing care and cultures of busyness (Jackson, 2023). We do not rebut any of the content in this excellent overview of the issue of missed care – but offer here another perspective on the concept of the ‘culture of busyness’. We agree that much of missed care is caused by workload issues for nurses (rather than merely ‘forgetting’). Our position is that this workload is not a ‘cultural’ product, but instead a measurable consequence of the design of care systems. Our research, using computer simulations of care delivery processes (created and validated using real-world data), suggests that the roots of nurse workload lie in the design and operational situations nurses find themselves in where the demands on nurses far exceed their capacity to complete the required tasks within their working shifts. Nurse ‘Busyness’ is, in this case, the product of workload levels that drive the missed care problem. Thus, we argue that the way forward in managing and minimizing missed care lies in care-system design and better workload management. In this commentary, we highlight the basic modelling approach used to understand the drivers of missed care and some of the results obtained to date using this quantification approach. In the Ca-nadian context, and arguably other jurisdictions, there is currently no shift-long measure of nurse workload that would reveal the level of missed care that results from the typical patient care work assignment. As the adage goes: ‘if you can’t measure it you can’t manage it’, and right now our healthcare system is incapable of managing nurses’ workloads. This leads to a form of ‘magical thinking’ about the workload problem – somehow nurses will magically be able to complete their care tasks even as staff are reduced due to austerity politics and new technologies add hours of data entry each week to the nurses task list – a lack of attention to nurse workload in job design. The lines of effect are illustrated in Figure 1 which is based on the ‘Better Work – Better Care’ (BWBC) framework (Neumann & Purdy, 2023). While the original framework addresses care quality issues and patient outcomes more broadly – we adjust this figure here to focus on the issue at hand, namely ‘Missed Care’.
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