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. Care left undone during nursing shifts: associations with workload and perceived quality of care.
Open accessAbstract
BACKGROUND: There is strong evidence to show that lower nurse staffing levels in hospitals are associated with worse patient outcomes. One hypothesised mechanism is the omission of necessary nursing care caused by time pressure-'missed care'. AIM: To examine the nature and prevalence of care left undone by nurses in English National Health Service hospitals and to assess whether the number of missed care episodes is associated with nurse staffing levels and nurse ratings of the quality of nursing care and patient safety environment. METHODS: Cross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England. RESULTS: Most nurses (86%) reported that one or more care activity had been left undone due to lack of time on their last shift. Most frequently left undone were: comforting or talking with patients (66%), educating patients (52%) and developing/updating nursing care plans (47%). The number of patients per registered nurse was significantly associated with the incidence of 'missed care' (p<0.001). A mean of 7.8 activities per shift were left undone on wards that are rated as 'failing' on patient safety, compared with 2.4 where patient safety was rated as 'excellent' (p < 0.001). CONCLUSIONS: Nurses working in English hospitals report that care is frequently left undone. Care not being delivered may be the reason low nurse staffing levels adversely affects quality and safety. Hospitals could use a nurse-rated assessment of 'missed care' as an early warning measure to identify wards with inadequate nurse staffing.
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“This measure has been validated by associations with hospitallevel mortality, patient satisfaction, and care processes. 27”
From Nurses’ Shift Length and Overtime Working in 12 European Countries: The Association With Perceived Quality of Care and Patient Safety (2014) · cites this paper as [27]
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“Among them are missed nursing care [11], implicitly rationed care [12, 13] and nursing care left undone [14, 15].”
BackgroundInstability in patient and nurse characteristics, unit complexity and patient and system outcomes
Duffield, C. M., Roche, M. A., Dimitrelis, S., Homer, C., & Buchan, J. (2014) · Journal of Advanced Nursing · doi:10.1111/jan.12597 · Cited by 35
Yen, P., Pearl, N., Jethro, C., Cooney, E., McNeil, B., Chen, L., Lopetegui, M. A., Maddox, T. M., & Schallom, M. E. (2019) · PubMed Central · Cited by 31
Standards for Professional Registered Nurse Staffing for Perinatal Units
(2022) · Journal of Obstetric, Gynecologic & Neonatal Nursing · doi:10.1016/j.jogn.2022.02.003 · Cited by 32
Job satisfaction among small rural hospital nurses: A cross‐sectional study
Smith, S., Lapkin, S., Halcomb, E., & Sim, J. (2022) · Journal of Nursing Scholarship · doi:10.1111/jnu.12800 · Cited by 32
“…and hospital characteristics, and validated instruments that assessed the practice environment (Joyce & Crookes, 2007 ), quality of care (Ball et al., 2013), care left undone (Ball et al., 2016), career intentions (Dall'Ora et al., 2015), job satisfaction (McManus et al., 2002 ), as…”
Vincelette, C., D’Aragon, F., Stevens, L., & Rochefort, C. M. (2022) · Intensive and Critical Care Nursing · doi:10.1016/j.iccn.2022.103343 · Cited by 32
Unmet Nursing Care Linked to Rehospitalizations Among Older Black AMI Patients
Brooks-Carthon, J. M., Lasater, K. B., Rearden, J., Holland, S., & Sloane, D. M. (2016) · Medical Care · doi:10.1097/mlr.0000000000000519 · Cited by 32
Factors Leading to Missed Nursing Care among Nurses at Selected Hospitals
Diab, G. M. A. E.-H., & Ebrahim, R. M. R. (2019) · American journal of nursing research · doi:10.12691/ajnr-7-2-5 · Cited by 31
“Missed nursing care has been influenced by many complex factors such as hospital resources, the working environment of the ward, nursepatient ratios, and the number of hours a nurse works per shift has all these been associated with missed nursing care [6].”
BackgroundScheerman, K., Mesters, J. W., Borger, J. N., Meskers, C. G. M., & Maier, A. B. (2020) · Nursing Open · doi:10.1002/nop2.588 · Cited by 31
“Staff ratio and 269 workload are associated with nursing tasks being left undone which was found to be related to 270 the nurses perception of quality of nursing care (38).”
BackgroundIdentification and comparison of missed nursing care in the United States of America and South Korea
Lee, E., & Kalisch, B. J. (2021) · Journal of Clinical Nursing · doi:10.1111/jocn.15712 · Cited by 31
Hospital Magnet® Designation and Missed Nursing Care in Neonatal Intensive Care Units
Tubbs‐Cooley, H. L., Pickler, R. H., Mara, C. A., Othman, M., Kovacs, A., & Mark, B. A. (2016) · Journal of Pediatric Nursing · doi:10.1016/j.pedn.2016.12.004 · Cited by 31
Al‐ghraiybah, T., Lago, L., Fernandez, R. S., & Sim, J. (2024) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2024.104777 · Cited by 30
“Missed care includes nursing activities usually considered core components of nursing work that were required but not completed on the most recent shift (Ball et al., 2014).”
BackgroundResultInfluentialOrique, S. B., Patty, C. M., Sandidge-Renteria, A., Camarena, E., & Newsom, R. A. (2017) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0000000000000556 · Cited by 30
Contextualising missed care in two healthcare inquiries using a socio‐ecological systems approach
Phelan, A. A., & Kirwan, M. (2020) · Journal of Clinical Nursing · doi:10.1111/jocn.15391 · Cited by 34
Nurses' experiences of communicating with patients with aphasia
Hur, Y., & Kang, Y. (2021) · Nursing Open · doi:10.1002/nop2.1124 · Cited by 30
Winter, V., Dietermann, K., Schneider, U., & Schreyögg, J. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-051133 · Cited by 30
Kasaye, M. D., Beshir, M. A., Endehabtu, B. F., Tilahun, B. C., Guadie, H. A., Awol, S. M., Kalayou, M. H., & Yilma, T. M. (2022) · BMC Health Services Research · doi:10.1186/s12913-022-07809-6 · Cited by 35
“The result was consistent with a study done in Tigray [30] where the level of documentation practice was inadequate, England 47% [39], Canada 53.”
ResultInstrument to assess the nursing care product: development and content validation
Cucolo, D. F., & Perroca, M. G. (2015) · Revista Latino-Americana de Enfermagem · doi:10.1590/0104-1169.0448.2599 · Cited by 30
“Em paralelo, o movimento de segurança na atenção à saúde destaca a relação entre sobrecarga dos profissionais de enfermagem e os resultados assistenciais obtidos(8).”
Jangland, E., Nyberg, B., & Yngman‐Uhlin, P. (2016) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.12350 · Cited by 30
Straughair, C. (2019) · Nurse Education in Practice · doi:10.1016/j.nepr.2019.02.002 · Cited by 23
Determining acute nurse staffing: a hermeneutic review of an evolving science
Leary, A., & Punshon, G. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-025654 · Cited by 29
Nurses’ Perceptions of the Extent and Type of Missed Perioperative Nursing Care
Marsh, V., Kalisch, B. J., McLaughlin, M., & Nguyen, L. (2020) · AORN Journal · doi:10.1002/aorn.13146 · Cited by 33
Factors Associated With Missed Nursing Care in Nursing Homes: A Multicentre Cross-sectional Study
Campagna, S., Conti, A., Clari, M., Basso, I., Sciannameo, V., Giulio, P. D., & Dimonte, V. (2021) · International Journal of Health Policy and Management · doi:10.34172/ijhpm.2021.23 · Cited by 29
Kim, S., & Chae, S. (2022) · Child Health Nursing Research · doi:10.4094/chnr.2022.28.2.142 · Cited by 32
“Nursing care quality may in part be measured through missed nursing care [1], which refers to the commonly encountered phenomenon of nurses omitting or delaying a necessary part of their work [2].”
BackgroundFactors Related to School Nurse Workload
Jameson, B. E., Engelke, M. K., Anderson, L., Endsley, P., & Maughan, E. D. (2017) · The Journal of School Nursing · doi:10.1177/1059840517718063 · Cited by 29
Amritzer, M. A., Göransson, K. E., Berg, L. M., & Nymark, C. (2024) · Journal of Emergency Nursing · doi:10.1016/j.jen.2023.12.006 · Cited by 28
The development of nursing-sensitive indicators: A critical discussion
Gormley, E., Connolly, M., & Ryder, M. (2024) · International Journal of Nursing Studies Advances · doi:10.1016/j.ijnsa.2024.100227 · Cited by 36
“Nurses themselves have reported that due to time constraints, fundamental care, such as oral care, comforting, and educating patients and their families, is not carried out (Aiken et al ., 2014; Ball et al., 2014).”
BackgroundMoscelli, G., Mello, M., Sayli, M., & Boyle, A. A. (2024) · BMJ · doi:10.1136/bmj-2024-079987 · Cited by 28
Metadata
- Authors
- Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P.
- Affiliations
- King's College London (GB)
- University of Southampton (GB)
- Corresponding author
- Ball, Jane E
- Venue
- BMJ Quality & Safety
- Publisher
- BMJ
- Published
- 2013-07-29
- Volume
- 23
- Issue
- 2
- Pages
- 116-125
- ISSN
- 1475-3898 (ISSN-L)
- 2044-5415
- 2044-5423
- PMC
- PMC3913111
- OpenAlex
- W2147808390
- Cited by
- 666
- References
- 46
- Citations by year
- 2026: 39 · 2025: 35 · 2024: 52 · 2023: 51 · 2022: 51 · 2021: 87 · 2020: 64 · 2019: 66 · 2018: 49 · 2017: 47 · 2016: 52 · 2015: 48 · 2014: 19 · 2013: 5
- FWCI
- 121.88
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc
- Locations
- BMJ Quality & Safety (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- ePrints Soton (University of Southampton) (acceptedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- HighWire Press Open Archive (submittedVersion)
- Funders
- King's College London
- European Commission
- Menzies Centre for Australian Studies, King's College London, University of London
- Topics
- Health Sciences › Nursing › Research and Theory › Nursing education and management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Nursing › Leadership and Management › Hospital Admissions and Outcomes
- Keywords
- missed nursing care, nurse staffing, nursing workload, time pressure, nursing care quality, patient education, nursing care plan, patient comfort, early warning indicators, hospital wards
- MeSH terms
- Continuity of Patient Care, England, Humans, National Health Programs, Nurse-Patient Relations, Nursing Staff, Hospital, Patient Care Planning, Patient Education as Topic, Quality of Health Care, Work Schedule Tolerance, Workload, Medical Errors
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