ABSTRACT Background Missed nursing care (MNC) is prevalent in ICU settings and may negatively impact patient outcomes while increasing the professional burden on nurses. Although many studies have explored the causes and consequences of missed care, a systematic qualitative synthesis that illuminates the critical link between them is still lacking. Specifically, the decision‐making mechanisms in ICU nurses employ under systemic pressures, and how these mechanisms lead to specific care elements being omitted. Aim This meta‐synthesis aims to synthesise qualitative evidence to systematically analyse and illuminate the determinants, processes and multifaceted impacts of missed nursing care (MNC) in the ICU. Study Design The qualitative meta‐synthesis was conducted in accordance with the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA). We searched 10 major databases (including PubMed, Web of Science, CINAHL, CNKI, etc.) from their inception to June 2025. Two reviewers independently assessed the methodological quality and extracted data. Thematic synthesis was used to integrate and analyse the findings. Findings Six studies satisfied the inclusion criteria. The meta‐synthesis identified the following six core themes: (1) nurses' divergent views of missed nursing care, (2) the convergence of multilevel systemic pressures behind missed care, (3) the decision‐making mechanism: nurses' strategic adaptations, (4) commonly missed elements of nursing care, (5) the cascading consequences of missed care and (6) nurses' perceived organisational‐level interventions. Conclusions This meta‐synthesis identified six core themes, revealing that ICU missed nursing care (MNC) is a predictable, system‐driven process. The findings demonstrate that multilevel systemic pressures compel nurses to activate strategic decision‐making mechanisms to safeguard patient safety. However, the direct product of this mechanism is the omission of low‐priority nursing measures, such as basic and psychosocial care. This omission, in turn, triggers adverse consequences for nurses, patients and the entire healthcare system. A key implication of this study is that MNC should not be attributed to personal failings but is a structural problem rooted in these systemic pressures. Therefore, managers must address this situation by implementing organisational‐level interventions that target these root causes, thereby reducing missed care, improving clinical quality and genuinely enhancing patient and nurse satisfaction. Relevance to Clinical Practice These findings provide clear directives for ICU managers. Therefore, the managerial focus must shift. Instead of ‘policing’ or punishing the rational prioritisation decisions nurses make under pressure, managers must redirect resources and energy towards solving the two root issues: (1) addressing the systemic pressures that force these decisions and (2) mitigating the emotional and moral distress that results from them. Trial Registration The protocol of this qualitative meta‐synthesis has been registered at PROSPERO with the identifier CRD420251063358
Fan et al. (Fri,) studied this question.