Original Article

Poor Care: A Walker and Avant Concept Analysis

Introduction

Care is the fundamental fact of nursing and the goal of clinical governance is to maximize the quality of care services.^1-3 A public demand from health care providers is to provide standard care. Poor care is usually discussed in the media. Several publications report poor care, especially for vulnerable patients and the elderly.^2,3 They report a set of negligence in patient care, such as inadequate pain relief, failure to assist people with eating and drinking, providers degrading attitudes, and lack of care dignity.⁴ The methods implemented to control the quality of health services and assess customer satisfaction, and ongoing inspection and quality improvement processes in all health care delivery centers indicate that the concept of poor care is being debated around the world.^5,6

The low quality of nursing care due to the lack of resources has been one of the common concerns in previous studies.^7,8For example, in one study, nurses were concerned about life-sustaining treatments that caused moral conflicts among them. Moreover, in another study nurses unique concern was that the patient’s financial situation might have led to making a decision on the levels of treatment offered to them.⁹ The concerns that described by nurses in different countries seem to be global and these concerns are due to the possibility of poor care.¹⁰

Investigations and observations over the past few years on the state of nursing care indicate concerns about reduced quality of care. Most of these studies have been about identifying the cause of falling standards, however, these studies have not explained the main reasons for the decline in quality of care and have not provide an effective solution.⁶

Despite the widespread attention to the concepts of quality of care and poor care, an important point concerning poor care is the lack of a satisfactory and clear definition for this concept. A clear definition of this concept can lead to a common understanding of the health care providers on the concept of poor care and their uniform perception in daily interactions. A clear understanding of the concept of poor care can explain its causative factors. In this article, poor care is defined by identifying and describing its definitions, applications, antecedents, attributes, and consequences. This definition leads to clarity and a better understanding of the concept of poor care for caregivers or researchers on patient care. Accordingly, this study aimed to investigate the concept of poor care by explaining its nature and the factors affecting its occurrence. To achieve this aim, a concept analysis was conducted using Walker and Avant’s approach due to its systematic and realistic perspective.

Materials and Methods

This study aimed to analyze and clarify the concept of poor care and determine its dimensions using Walker and Avant’s concept analysis approach in 2021. In this systematic approach, a concept is analyzed to achieve a better understanding. The concept analysis process includes eight steps of selecting a concept, determining the purpose of the analysis, identifying the applications of the concept, determining the defining attributes of the concept, identifying a model case, identifying related cases, borderline cases and contrary cases, identifying the antecedents and consequences of the concept, and finally defining the empirical referents.¹¹

The literature was searched using online databases, namely SCOPUS, PubMed, ISI, and Embase, with the keywords “poor nursing care” or “poor care” in the titles and abstracts of the articles from the inception of the databases up to June 6, 2021, and then was restricted by English language (Table 1). Inclusion criteria were as follows: the full text articles published in English, and articles that discussed the attributes, antecedents, and consequences of poor care concept.

Totally, 550 retrieved articles and sources found in the initial search were reviewed to ensure the absence of duplicated publications. The references of the reviewed articles and leading articles on poor care were reviewed manually to ensure the retrieval of the most relevant articles. After removing duplicate sources, the titles and then the abstracts of the remaining articles were reviewed and finally 32 articles were reviewed. Traditionally, the Cambridge Online Dictionary and the Merriam-Webster Medical Dictionary were also used to define the concept of poor care.

Results

Concept Selection

The importance of any particular concept depends on the range of different factors in the field and its outside boundaries over time. Therefore, a concept for which there is no clear definition should be analyzed more clearly.¹¹ Since care is a basic concept in nursing, the concept of poor care was selected in this analysis due to its widespread use and increasing importance in the health care system. Being considered in the health care system and having many applications among health care providers, patients, and caregivers, this concept is sometimes used in public publications in different countries, however, there is no clear definition about it.¹² Therefore, since care is the cornerstone of nursing, and there is no single definition of the concept of poor care, which is a subset of the concept of care, it was chosen for the analysis.

Objectives of Concept Analysis

The concept analysis may aim to examine the internal structures of a complex concept and identify its components to increase the exploratory power of the concept.¹³ In addition to clarifying ambiguous and confusing concepts, concept analysis can clarify commonly-used concepts, distinguish a concept from similar ones, and provide a basis for concept development.^11,14

Despite concerns about the decline in the quality of care and the incidence of poor care in recent years, there are no acceptable main reasons for its occurrence or a realistic solution for its improvement, nor a clear and precise definition of this concept.⁶ A clear definition of this concept can lead to the health care providers’ common understanding of the concept of poor care and their uniform perception in daily interactions. A clear understanding of the concept of poor care can explain the causative factors, and this is achieved by identifying and describing its definitions, applications, antecedents, attributes, and consequences.

Some Applications of the Concept of Poor Care

Step 3 of the Walker and Avant’s method involves the applications of concept analysis.¹¹ One of the most widely used concepts of poor care is its use in assessing the quality of care. The quality of nursing care is a multidimensional concept that is affected by many factors, and the nurse and patient’s perception of the quality of care is formed based on these factors.¹⁵ Brooke et al assessed the quality of care and poor care in several levels, from the care provided by health care professionals (e.g., nurses or physicians) to that provided by a health care program.¹⁶ In some studies, the level of patient satisfaction has been used as an indicator of the quality of care, suggesting that the lower the level of patient satisfaction, the lower the quality of care.¹⁷

The Merriam-Webster Medical Dictionary defines the word care as being responsible for or paying attention to the health, well-being, and safety of individuals, and negligence occurs when a person responsible for caring for someone fails to care for them. In this dictionary, the word “poor” has been meant as less than sufficient.¹⁸ The Cambridge Online Dictionary defines poor as having a small amount of a substance with a specified quality or having a very low standard or quality or quantity.¹⁹ Alternative terms for poor (in relation to care) include non-optimal, just good enough, bad, wrong, unsatisfactory, substandard, inefficient, unmet, inappropriate, unacceptable, incomplete, defective, inadequate, and neglected. Ion et al believe that there is no agreed definition of poor care. However, they defined poor care as actions with negligence, abuse, or incompetence that occur for any reason other than error, and distinguished it from errors that are unintended consequences of actual errors.⁸ Therefore, a nurse who makes a mistake when using medication does not necessarily provide poor care, and there is a possibility of error for any human being; however, actions with abuse, neglect, or incompetence can lead to poor care. Therefore, if a nurse commits a medication error and reports it according to the hospital policy, this is not poor care, and the nurse has done the best task, i.e. reporting the error. However, if the nurse recognizes the error and makes a deliberate decision to ignore it, it is considered an act of negligence, and possibly abuse, and the committed error becomes a state of poor care. In this example, deciding not to report and disclose an error, can result in poor care.²⁰

Defining Attributes

Defining attributes are those that best explain the intended concept. According to Walker and Avant, these attributes are repeated over and again in one concept and play a key role in differentiating different concepts. Each concept contains more than one defining attribute, however, it is necessary to determine which attribute is more appropriate to describe the concept.¹¹ Based on a review of the literature, the repeated defining attributes of poor care can be summarized in three categories, some of which overlap: poor evaluation, inadequate or inappropriate patient management, and delay in diagnosis, treatment, or referral.

Delay in diagnosis, treatment, or referral includes such cases as misdiagnosis, lack of understanding of urgency, inadequate or delayed contact, understanding the inadequacy and unreliability of information provided by nurses to physicians, inadequate treatment, failure to report the poor condition of the patient to the physician by nurses, failure to inform patient status by junior physicians to senior ones, inadequate examination or inadequate treatment of respiratory failure, inadequate stabilization of patient condition before transfer to other wards, delay in evaluation and treatment, and incorrect diagnoses.^15,16,20-22

Poor evaluation includes failure to diagnose the severity of the disease, delay to report worsening of the patient’s condition by the nurse, physician’s delay in responding to nurses’ requests to attend wards, insufficient response or failure to respond to abnormal laboratory findings of the patient, lack of counseling, lack of supervision, equipment failure, failure to accurately measure vital signs, lack of recognition of the importance of worsening vital signs, and delay in responding to deteriorating the patient’s vital signs.^6,7,23,24

Inadequate or inappropriate patient management also includes issues such as inadequate treatment, initial inappropriate or delayed treatment of patients, delay of senior physicians in evaluating patients, delay in referring patients to intensive care units (ICUs) despite physiological instability, and organizational negligence.^20,22,23

Model Cases

The model or sample case is a pure example of the concept under study and must have all defining attributes.¹¹ The following model case clearly demonstrates the defining attributes of the previously described poor care (delay in diagnosis, poor evaluation, and inadequate patient management).

A 60-year-old man (Patient A) with diabetes, dyspnea, and cough is admitted to the surgical ward instead of the internal ward due to special hospital conditions. In the surgical ward, the ratio of the number of nurses to the number of patients is less than the standard. Two critically ill patients are also hospitalized in this ward. At the time of admission to the ward, he has the following conditions: respiratory rate up to 35 per minute, oxygen saturation 94%, temperature 38°C, systolic blood pressure 90 mm Hg, heart rate 105, and blood sugar 80 mg/dL. Chest x-ray was taken for the patient in the emergency department (ED), however, it has not yet been reviewed. He is receiving normal saline at a rate of 100 mL/h. The nurse who is responsible for admitting the patient, reports abnormal symptoms to the doctor, however, does not report oxygen saturation and respiration rate. Two hours later, the doctor examines the patient and observes that the patient’s breathing rate is 48 breaths per minute and oxygen saturation is 90%, and the patient appears drowsy. He tries to do arterial blood gas but it is not successful. He asks the nurse to increase oxygen to 6 L/min, and visits other patients without examining the previously taken chest x-ray. Two hours later, when one of the nurses enters the room by chance, he/she notices that the patient has severe respiratory distress and cyanosis and is in a critical condition, hence vital interventions are taken for him. This case is an example of poor care.

Definition of Additional Items

Step 6 of Walker and Avant’s concept analysis involves a definition of other items, which may include borderline, related, contrary, or invented items, among which one borderline case and one Contrary case are analyzed here.

Borderline Cases

These include some but not all concept attributes. Identifying borderline cases helps to clarify the attributes that are a basic prerequisite for model cases and reduces ambiguity in the boundaries between items.¹³ The mentioned attributes can be observed in the following example.

The dressing of one of the patients in the ward should be changed at 10 pm. At 9 PM, the nurse is called from the emergency room, informing that three patients must be admitted to your ward in few minutes. Simultaneously, one of the patients in the ward suffers from chest pain and is evaluated by the nurse who takes an electrocardiogram. Then, the nurse coordinates with the doctor, the patient is visited, and immediate interventions are taken for him/her. The three mentioned patients are also admitted from the ED and receive the required basic care. The nurse then notices that it is 12:00 at midnight, however, the patient’s dressing has not been changed at 9:00 PM. This is a case of missed care. There are some but not all poor care attributes in this patient. In this situation, there are management problems and workforce shortage that are some of the poor care attributes, however, there is no poor evaluation or delay in diagnosis and treatment.

Contrary Cases

It includes none of the main attributes of the concept, and specifies what the concept is not. This difference is so obvious that is seen by most people who can state with confidence that this case is not an example of our intended concept.¹¹ The responsive nurse accurately and scientifically admits the model case patient (Patient A). Immediately after careful evaluation, the nurse informs the doctor that the patient has low blood pressure, tachycardia, tachypnea, and a low oxygen saturation level. The doctor attends immediately, examines the patient, prescribes fluid therapy, blood sugar control, oxygen therapy, and ABG, and orders hourly observations. The physician re-examines the patient half an hour later to evaluate the effectiveness of treatment. Contrary to the proposed model case, in this case there is clear evidence of accurate admission, accurate evaluation, accurate and rapid transferring information, prompt treatment, and appropriate management; in fact, it has none of the attributes of the defined model case.

Identifying Antecedents and Consequences

Antecedents include activities, situations, or events that occur before the concept and can lead to poor care.¹¹ A review of the literature shows several underlying factors of poor care, which are discussed in the following.

Vulnerability and Complexity of the Patient’s Condition

The complexity of the patient’s condition leads to increases in both the severity of the disease and the workload of nursing. Conditions such as the presence of several diseases in one patient simultaneously, care for the elderly, and the use of various technologies and equipment in care, complicate the situation.²⁵ Hospitalization in unrelated and non-specialized wards in conditions such as epidemics may result in poor care. Such situations challenge nursing staff so that they may not be familiar with the patient’s complex situation or lack the necessary care expertise.²⁰ Therefore, the special needs of patients may not be met and may even worsen their conditions.

Health Care Workforce

One of the duties of nurses is monitoring, which includes frequent evaluation of patients and identification of complications.²³ Due to the increase in workload caused by the insufficient nurse-to-patient ratio and the various tasks assigned to them, the nurses are unable to frequently monitor and use their knowledge and skills about patients.²² An insufficient nurse to patient ratio will have a negative impact on the overall quality of the patient evaluation, which may lead to poor patient care.¹⁵

Improper Interactions and Communications of Health Care Providers

Poor communication in team activities can be a factor in poor care. Poor communication in the delivery of patients to other nurses and from one ward to another, poor communication between physicians, and difficulty in seeking consulting from colleagues are some of the cases that cause poor care. However, the likelihood of poor care increases in the absence of an effective teamwork culture.^22,23

Inadequate Documentation

Inadequate documentation of actions taken for patients, such as failure to record actions, illegibility of taken actions, illegibility of physician’s instructions, and lack of consistent procedure in recording care, also leads to poor care.⁶

Education

Lack of knowledge and skills, especially in the evaluation and management of critically ill patients, leads to poor care implementation.²¹ Unrecognition of the patient’s deterioration is one of the defining attributes of poor care resulting from poor assessment skills, both in the nurse and in the medical staff.²⁶ Lack of sufficient knowledge and understanding in interpreting acute symptoms of the disease (e.g. pulse oximetry, capillary filling time, oxygen therapy, and unconscious patient management) leads to failure in understanding clinical urgency in patients.¹⁵ Most studies indicate that lack of training is an effective factor in poor care and recommend the health care providers to be trained in the key factors influencing patient management.⁶

Conditions of the Organization

As one of the antecedents of poor care, organizational factors are related to the arrangement of patient care and the availability of equipment. Bion JF et al pointed out the lack of supervision by senior physicians and reported that it was difficult to supervise senior physicians.²⁵ The organization of nursing care has also undergone changes. Financial constraints and the reality of a global shortage of nurses have led to more employment of inexperienced nurses and nursing assistants. They often do not have enough knowledge to diagnose patient problems and proper performance, which increases the likelihood of neglecting patients’ care needs and incidence of poor care.²¹

Adequate Resources/Excessive Reliance on Equipment

The availability or non-availability of equipment and their validity and reliability are also factors that may be effective in poor patient care.²⁷ Staff unfamiliarity with the equipment has been reported to be due to the number and variety of different devices in hospitals.⁶ In addition, relying on the assessment of task-oriented vital signs recorded by equipment sometimes has dangerous consequences.²⁸

Consequences are events or results that may occur after the concept or as an outcome of the concept.¹¹ The consequences of poor care are far-reaching in terms of patient outcomes. These consequences are seen in a continuum of damage rate, from no or minor damage at one end and catastrophic damage at the other end of the continuum.²⁹ Poor care reduces the trust of the population and treatment groups in nursing care, increases the economic costs of health care centers, and imposes the cost on families. Poor care can also delay and prolong treatment process and even cause death.¹⁰ In a critically ill patient, poor care can lead to preventable or avoidable death, admission to the ICUs, or cardiac arrest.³⁰

Referents of the concept reveal the range of events and situations in which the application of the phenomenon is appropriate. Empirical referents show the methods for concept measurement and the extent to which the definition can be useful in measuring and validating the concept and producing research tools.¹¹ According to the objectives of this analysis, the concept of poor care in terms of providing and receiving clinical and interpersonal attention is understandable in the structure of health care services. Despite various studies on poor care, a review of the literature by the authors reveals no universally accepted measurement tool for poor care.

One of the most widely used concepts of poor care is its use in assessing the quality of care. The quality of nursing care is a multidimensional concept whose definition or measurement is difficult, which is differently understood by nurses and patients, making it difficult to analyze. The quality of care can be assessed on several levels, from the care provided by health care professionals (e.g., nurses or physicians) to that provided by a health plan.¹⁶

The following two tools have been used to measure the quality of care and detect poor care. To measure the quality of nursing care, Brooke et al used the standard Quality Patient Care Scale (QUALPAC) questionnaire, which includes three sections of demographic-social characteristics (10 questions), psychosocial dimension (28 questions), and communication dimension (13 questions). In this tool, the total score of care obtained from the total number of questions is equal to 123, based on which the quality of care is placed in three categories: Undesirable (1-41), desirable (42-83), very desirable (84-123).¹⁶ Since 1975, this tool has been used to study the care process and quality of nursing care in the United States, the United Kingdom, and Nigeria, and has been used in Iran since 2003.

The second tool used is entitled “Interview script on nursing care for hospitalized patients” and is used to assess the quality of nursing care delivery. This tool has three levels of desirable, safe and high-quality, and poor.¹⁷

Discussion

In the review of the literature, very few studies have investigated this concept, and the findings of this study, which has provided a holistic definition of the concept of poor care, can be used as a basis for measuring poor care. As indicated by Reader and Gillespie poor care has not been defined, however, they argue that errors, abuses, and negligence in procedures and care lead to poor care. They distinguish between negligence in procedures, which refers to the failure to meet objective standards of care, and negligence in care that is associated with the mental and emotional aspects of poor care. They claim that neglect in care mostly influences patients and their families rather than employees. In their view, the definition, understanding, and expectations of care standards will undoubtedly be different in different cultures, health care systems, and individuals.²² Maclean states issues such as very poor health standards, communication problems between health care providers, caregivers, and patients, lack of manpower, poor staff morale, and a poor care environment lead to poor care.³¹ In this study, the identified antecedents, including vulnerability and complexity of patient conditions, health care workforce, poor interactions and communication of health care providers, inadequate documentation, poor training, organizational conditions, and insufficient resources/overconfidence in equipment, also confirm the results of Maclean’s study.

Considering the expectations of health care systems, the quality of health care for patients has two dimensions: access to services and its effectiveness. Access is about the availability of care needed by patients, while effectiveness is about the experience and impact of clinical and interpersonal care provided by health care providers. The satisfaction of patients, families, and caregivers can be measured using the interaction between access (structures) and effectiveness, and the absence of either of these two conditions leads to poor care.²⁰

It can be claimed that poor care will be ascertained if the components of good care are not achieved. Poor care can be regarded the counterpoint of good care. There are several definitions of good care. In a qualitative study, Burhans and Alligood described high-quality nursing care from the viewpoints of clinical nurses as providing human needs through attention, empathy, respectful interactions with the patient along with a sense of responsibility, and essential and comprehensive patient support.³² Over the past years, good care has been seen as the one that has been accompanied by up-to-date knowledge and skilled and safe clinical care; it establishes an effective and efficient relationship with the patient and leads to recovery, patient satisfaction, and reduction of health care costs.³² According to our review of the literature and considering the defining attributes, antecedents, and consequences of poor care, it can be concluded that poor care is defined as the counterpoint of good care. Poor patient care leads to patient and family dissatisfaction, an increase in treatment costs, delay in treatment, and even patient death.

Poor care is the feature of health care systems around the world. In recent years, there have been debates about the reasons for health care failure and the possible ways of its prevention. Two widespread situations have been assessed. First, poor care is a consequence of a combination of systemic problems, such as lack of budget, management orientation, insufficient staff, and cultures in which system needs are prioritized over patient needs.³³ The second reason focuses on individual factors and includes the personal characteristics and moral status of employees.^21,23,24

Other causes, such as increasing the complexity of patients’ conditions and increasing medical equipment, have increased the incidence of poor care. In such circumstances, a skilled and sufficient workforce with organizational support is required to provide timely and appropriate care.³⁴ Low clinical experience of nurses, especially in critical situations, is another cause of poor care and then increasing mortality of hospitalized patients. Also, in recent years, the number of nursing students is increasing regardless of the structures in the educational and clinical systems. This is also one of the conditions that threatens care and causes poor care.^35,36 Therefore having a proper care structure in inpatient wards prevents the occurrence of this problem.³⁷

Another noteworthy point is the care stress of nurses. The role of nurses in supporting people in vulnerable periods of their lives is another important issue in this discussion. Nurses’ activities include doing tasks that, by common standards, are unpleasant, disgusting, and anxiety-inducing; they provide ongoing care to patients round-the-clock and year-round, despite the impact of care stress.⁶ Importantly, if good care is provided for the nurses, they will also provide professional patient care properly and competently.²⁶

As with all problems that have multiple causes and multiple solutions, there is no single solution to control and eliminate poor care. The following strategies have been proposed to control and eliminate the antecedents and factors that lead to poor care. Improving positive relationships between nurses and managers,³⁸ applying transformational leadership in nursing,³⁹ creating an appropriate culture for expressing poor care,⁷ responsiveness and responsibility in the face of poor and inappropriate performance,⁷ placing nursing stations in the center of the ward and performing targeted and intermittent rounds of patients,⁶ creating more appropriate and simple tools for measuring care and diagnosing poor care (the findings of this concept analysis can be used to create care measurement tool),⁶ increasing the number of staff and modifying both the nurse-patient and the physician-patient ratios according to the defined standards,³⁹ and improving educational systems to train nurses with the ability to provide good care.⁶

The main limitation of the study was that based on our search of the literature, the concept of poor care was not directly defined in the searched articles. However, although extensive searches have been conducted to find related articles, there is concern that some data may not be entered in the article.

When performing interventions for the patient, paying attention to the meaning of poor care prevents the possibility of its occurrence. Consideration of the poor care definition in all care settings, and ongoing and planned understanding of this concept by health care providers make them sensitive to the wide scope and the potential of poor care practice. This concept analysis shows that poor care has outcomes for both patients and health care providers. Therefore, assessing the care and prevention of the outcomes of poor care are a basic need that can be done within the proposed definition. In the future researches, the findings of this concept analysis can also be used in the development of nursing care models. Researchers also suggest that future researches use the concept of poor care for researches that are related to nursing education, and nurses’ evaluation of the care they provide.

Conclusion

This study demonstrates that the concept of poor care has been widely used in recent years, however there is not clear and precise definition of this concept. Poor care is a general concept that includes undesirable and unacceptable standards for receiving or providing clinical and interpersonal health services. Poor care may include eliminating planned activities or performing unplanned activities, experienced as an undesirable and unacceptable standard by the patient, health care providers, or caregivers. In this study, the factors affecting poor care were identified and appropriate solutions were proposed based on a literature review. Poor care has been experienced in the antecedents of vulnerability and complexity of patient conditions, health care workforce, inadequate interactions and communications of health care providers, inadequate documentation, training, organizational conditions, and adequate resources/excessive reliance on equipment. Its defining attributes include delay in diagnosis, treatment or referral, poor evaluation, failure to diagnose the severity of the disease, lack of accurate measurement of vital signs, and inadequate or inappropriate patient management. These findings can underpin the development of care models and theories and building tools for evaluating nursing care. However, various and complex factors cause poor care, and more clarification is needed on its definition, the affecting factors, and its consequences.

Acknowledgments

We sincerely appreciate all the authors of the articles used in this research.

Authors’ Contribution

Conceptualization: Abbas Heydari, Hasan Khalili.

Formal analysis: Abbas Heydari, Hasan Khalili.

Methodology: Abbas Heydari, Hasan Khalili.

Supervision: Abbas Heydari

Writing–original draft: Hasan Khalili.

Writing–review & editing: Abbas Heydari, Hasan Khalili.

COI-statement

There is no conflict of interest for the authors.

Ethical Approval

None to be declared.

Funding

This research has received no financial support from any organization.

Research Highlights

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