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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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BackgroundGermack, H. D., Griffiths, P., Sloane, D. M., Rafferty, A. M., Ball, J., & Aiken, L. H. (2015) · BMJ Open · doi:10.1136/bmjopen-2015-009483 · Cited by 19
“care after discharge, activities that might be particularly salient to patients and influence their perceptions of their overall hospital experience.(32) Large hospitals and those in London are particularly likely to employ larger proportions of non-UK educated nurses.”
BackgroundRecio‐Saucedo, A., Maruotti, A., Griffiths, P., Smith, G. B., Meredith, P., Westwood, G., Fogg, C., & Schmidt, P. E. (2018) · Nursing Open · doi:10.1002/nop2.179 · Cited by 18
Bir üniversite hastanesinde karşılanmayan hemşirelik bakım gereksinimi miktarı ve nedenleri
İLASLAN, N., & Yıldırım, N. (2019) · Çukurova medical journal (Online)/Çukurova medical journal · doi:10.17826/cumj.509488 · Cited by 20
How do intensive work environments affect nurses' absenteeism and turnover intent?
Heistad, A. L., Goldsworthy, S., Reilly, S., & Perez, G. (2022) · Applied Nursing Research · doi:10.1016/j.apnr.2022.151608 · Cited by 18
Missed nursing care in emergency departments: a cross-sectional descriptive study
Rooddehghan, Z., Karimi, H. R., Mohammadnejad, E., Sayadi, L., Haghani, S., & Karimi, R. (2024) · BMC Emergency Medicine · doi:10.1186/s12873-024-00936-9 · Cited by 18
“%) did not perform one or more aspects of care in their previous shift due to lack of time [7].”
BackgroundCauses of missed nursing care: qualitative responses to a survey of Australian nurses
Henderson, J., Willis, E., Blackman, I. R., Toffoli, L., & Verrall, C. (2016) · Labour & Industry a journal of the social and economic relations of work · doi:10.1080/10301763.2016.1257755 · Cited by 18
“Ball et al. (2013), in contrast, found that while staff:patient ratios directly impact the volume of missed care that the ratio of unlicensed care providers (Healthcare Support Workers) was not related to the volume of missed care reported by RNs or to the omission of any care item.”
BackgroundAssessment of the nursing care product (APROCENF): a reliability and construct validity study
Cucolo, D. F., & Perroca, M. G. (2017) · Revista Latino-Americana de Enfermagem · doi:10.1590/1518-8345.1495.2860 · Cited by 18
“and/or unattended needs and the occurrence of adverse events(10)and the nurses working at these institutions prioritize patient care management, mitigating these risks(21),also evidenced in this study.”
BackgroundForsberg, A., & Engström, Å. H. (2018) · Journal of Vascular Nursing · doi:10.1016/j.jvn.2018.02.002 · Cited by 18
Missed nursing care and related factors: a cross-sectional study
Khajoei, R., Balvardi, M., Eghbali, T., Yousefi, M. S., & Forouzi, M. A. (2025) · BMC Nursing · doi:10.1186/s12912-025-02984-3 · Cited by 17
“A study conducted in a UK hospital revealed that 86% of nurses reported omitting at least one of 13 nursing care tasks due to time constraints during their work shifts [13].”
Déry, J., Clarke, S. P., D’Amour, D., & Blais, R. (2016) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0000000000000341 · Cited by 17
Developing policies and actions in response to missed nursing care: A consensus process
Palese, A., Bassi, E., Tommasini, C., Vesca, R., Falco, A. D., Lucia, P. D., Mulloni, G., Paoletti, F., Rissolo, R., Sist, L., et al. (2019) · Journal of Nursing Management · doi:10.1111/jonm.12835 · Cited by 17
“However, the validity of the consensus development process undertaken, as well as of the findings that emerged for other concepts, such as that of ‘Failure to Maintain’ (Bail & Grealish, 2016), and ‘Care left undone’ (Ball et al., 2014; Jones et al., 2015) should be verified.”
The qualitative dimension of Nursing workload: a measurement proposal
Cucolo, D. F., & Perroca, M. G. (2019) · Revista Latino-Americana de Enfermagem · doi:10.1590/1518-8345.3274.3238 · Cited by 17
“This management model would enable the identification of risks, such as missing care, based on early warning such as the high number of patients per nurse, among other inadequacies in the practice context(8).”
BackgroundYoo, M. S., Jeong, M. R., Kim, K. J., & Lee, Y. (2019) · Journal of Korean Academy of Nursing Administration · doi:10.11111/jkana.2019.25.5.489 · Cited by 17
Saville, C. E., Dall’Ora, C., & Griffiths, P. (2020) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2020.103721 · Cited by 17
Jones, T., Drach‐Zahavy, A., Sermeus, W., Willis, E., & Zeleníková, R. (2021) · Springer eBooks · doi:10.1007/978-3-030-71073-6_2 · Cited by 17
The Impact of Sociodemographic Factors on the Rationing of Nursing Care in Urology Wards
Jarosz, K., & Młynarska, A. (2023) · Nursing Reports · doi:10.3390/nursrep13010051 · Cited by 17
“showed that there were 12–24 patients per nurse on duty [44], compared to 6–11 patients in the UK [45].”
BackgroundIs Spending More Time Associated With Less Missed Care?
McNair, N. D., Baird, J. D., Grogan, T., Walsh, C. M., Liang, L.-J. F., Worobel-Luk, P., Needleman, J., & Nuckols, T. K. (2016) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0000000000000371 · Cited by 17
Louch, G., O'Hara, J. K., & Mohammed, M. A. (2017) · Health Expectations · doi:10.1111/hex.12560 · Cited by 17
“With health care organizations globally functioning with strained resources, 11-13 and in the UK the National Health Service (NHS) under ever increasing pressure, 14 paid ward staff have little or no spare capacity to undertake this role.”
Riklikienė, O., Blackman, I. R., Bendinskaitė, I., Henderson, J., & Willis, E. (2019) · Journal of Nursing Management · doi:10.1111/jonm.12918 · Cited by 18
Damme, N. V., Hecke, A. V., Himpens, A., Verhaeghe, S. T. L., & Beeckman, D. (2018) · International Wound Journal · doi:10.1111/iwj.13062 · Cited by 21
“immediate result, such as treatment procedures and pain management.(4,7) The proportion of nurses who reported that”
BackgroundJomaa, C., Dubois, C., Caron, I., & Prud’homme, A. (2021) · Journal of Advanced Nursing · doi:10.1111/jan.15112 · Cited by 16
Zárate-Grajales, R. A., Benítez-Chavira, L. A., Servan-Mori, E. E., Hernández‐Corral, S., Cadena-Estrada, J. C., & Nigenda, G. (2021) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2021.104140 · Cited by 21
Sarpong, A. A., Arabiat, D. H., Gent, L., Afrifa‐Yamoah, E., & Towell‐Barnard, A. (2023) · Collegian Journal of the Royal College of Nursing Australia · doi:10.1016/j.colegn.2023.05.005 · Cited by 16
“When insufficient staffing occurs, it directly impacts the results of nursing care because nurses are forced to miss, delay or leave patient care unfinished (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014; Twigg, Gelder, & Myers, 2015).”
BackgroundThompson, E., Senek, M., & Ryan, T. (2023) · International Journal of Mental Health Nursing · doi:10.1111/inm.13216 · Cited by 16
Higgs, M., Fernandez, R. S., Polis, S., & Manning, V. (2016) · Journal of Patient Safety · doi:10.1097/pts.0000000000000295 · Cited by 16
“01) than did nurses looking after 11 or more patients, with an exponential trend in the frequency of missed care as the patientto-nurse ratio increased.(24) In another large-scale, multisite study carried out in Europe, similar findings were ascertained with nurse-reported missed care being significantly less in hospi…”
ResultProviding high-quality fundamental care for patients with acute abdominal pain
Feo, R., Donnelly, F., Athlin, Å. M., & Jangland, E. (2018) · Journal of Health Organization and Management · doi:10.1108/jhom-02-2018-0037 · Cited by 16
Missed or rationed nursing care: Where to now for the nurse manager?
Kirwan, M., & Schubert, M. (2020) · Journal of Nursing Management · doi:10.1111/jonm.13078 · Cited by 16
Amiri, A. (2020) · Applied Nursing Research · doi:10.1016/j.apnr.2020.151343 · Cited by 16
Registered nurses views of caring in coronary care--a deductive and inductive content analysis.
Andersson, E., Sjostrom-Strand, A., Willman, A., & Borglin, G. (2015) · Journal of Clinical Nursing · doi:10.1111/jocn.12975 · Cited by 14
Transscleral freezing of the retina: an experimental study.
Archambeau, P. L., & Henderson, J. W. (1965) · PubMed · Cited by 16
Leary, A., Mason, I., & Punshon, G. (2018) · Journal of Crohn s and Colitis · doi:10.1093/ecco-jcc/jjy106 · Cited by 15
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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