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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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Gathara, D., Serem, G., Murphy, G. A. V., Obengo, A., Tallam, E., Jackson, D. W., Brownie, S. M., & English, M. (2019) · BMJ Quality & Safety · doi:10.1136/bmjqs-2019-009363 · Cited by 8
Factors affecting missed nursing care in hospitals: A scoping review
Amrolahi-Mishavan, F., Sigaroudi, A. E., Jafaraghaee, F., Shahsavari, H., & Maroufizadeh, S. (2022) · Health Sciences Review · doi:10.1016/j.hsr.2022.100053 · Cited by 8
Negash, B. T., & Alelgn, Y. (2022) · BMC Women s Health · doi:10.1186/s12905-022-02117-x · Cited by 8
A Bibliometric Analysis of Missed Nursing Care Research: Current Themes and Way Forward
Sarpong, A. A., Arabiat, D. H., Gent, L., & Towell‐Barnard, A. (2023) · Nursing Forum · doi:10.1155/2023/8334252 · Cited by 8
“Te most cited paper was the study published by Ball and colleagues, recording total citations of 337 (33.7 citations per year) in BMJ Quality and Safety [33].”
BackgroundInfluentialAyuso-Fernandez, M. A., Gómez-Rosado, J.-C., Barrientos‐Trigo, S., Rodríguez‐Gómez, S., & Pórcel‐Gálvez, A. M. (2021) · Enfermería Clínica · doi:10.1016/j.enfcli.2020.11.005 · Cited by 8
Surveys conducted pre‐ and post‐implementation of a synergy tool: Giving voice to emergency teams
Wagner, J. I. J., MacPhee, M., Udod, S. A., Berry, L., Perchie, G., & Conway, A. (2021) · Journal of Nursing Management · doi:10.1111/jonm.13317 · Cited by 8
Zhang, Q., Zhang, K., Wang, Y., Jia, Y., Gu, J., Li, X., & Li, M. (2021) · Journal of Tissue Viability · doi:10.1016/j.jtv.2021.03.006 · Cited by 8
Staff perceptions of patient safety in the NHS ambulance services: an exploratory qualitative study
Shepard, K., Spencer, S., Kelly, C. A., & Wankhade, P. (2022) · British Paramedic Journal · doi:10.29045/14784726.2022.03.6.4.18 · Cited by 8
“…as evidenced by the events at Mid Staffordshire NHS Foundation Trust, where an estimated 400 to 1200 patients died due to a combination of staffing shortages, financial pressures and a poor organisational culture which led to the tolerance of inferior practice (Ball et al., 2013; Francis, 2013).”
BackgroundInfluentialHemşirelik Bakımında Önemli Bir Kavram: Karşılanamayan Hemşirelik Bakımı ve Nedenleri
Güleşen, G. (2022) · Türkiye Sağlık Bilimleri ve Araştırmaları Dergisi · doi:10.51536/tusbad.1042757 · Cited by 8
LIFE: International Journal of Health and Life-Sciences
Ghedadba, N., Hambaba, L., Fercha, N., Bousselsela, H., Abdessemed, S., Mokhtar, S. M. O., & Unité de Biodiversité et Valorisation des Ressources Végétales (BVRV) – Faculté des Sciences et Techniques (FST)- Université des Sciences, D. T. E. D. M. (. N. (2016) · LIFE International Journal of Health and Life-Sciences · doi:10.20319/lijhls.2016.s21.253258 · Cited by 8
Commentary on the Past, Present, and Future of Nursing Workload Research
MacPhee, M., Havaei, F., Bookey‐Bassett, S., Neumann, P., Qureshi, S. M., Greig, M. A., & Keselman, D. (2024) · Nursing Research and Reviews · doi:10.2147/nrr.s442571 · Cited by 8
Ji, Y., Min, A., Kang, M., & Park, C. G. (2024) · Journal of Advanced Nursing · doi:10.1111/jan.16483 · Cited by 7
Özmen, S., & Yürümezoğlu, H. A. (2024) · Journal of Pediatric Nursing · doi:10.1016/j.pedn.2024.10.019 · Cited by 7
Provost, J., Gosselin, É., & Rochefort, C. M. (2025) · Journal of Advanced Nursing · doi:10.1111/jan.17017 · Cited by 7
“For nurses, the persistent occurrence of ONC contributes to job dissatisfaction, burnout, and moral distress, resulting in higher turnover rates (Ball et al. 2014; Stemmer et al. 2022).”
Nymark, C., Falk, A., von Vogelsang, A., & Göransson, K. E. (2023) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.13175 · Cited by 7
Mehrabian, F., Javadi‐Pashaki, N., Ashouri, A., & Mousavi, A. F. (2023) · Journal of Nursing and Midwifery Sciences · doi:10.5812/jnms-134379 · Cited by 7
Sheahan, K. L., Speizer, I. S., Orgill‐Meyer, J., Curtis, S., Weinberger, M., Paul, J. E., & Bennett, A. V. (2021) · BMC Public Health · doi:10.1186/s12889-021-11436-x · Cited by 7
“This finding reinforces studies highlighting that heavier workloads challenge integration efforts and result in poorer quality of care [45].”
ResultAyuso-Fernandez, M. A., Gómez-Rosado, J.-C., Barrientos‐Trigo, S., Rodríguez‐Gómez, S., & Pórcel‐Gálvez, A. M. (2021) · Enfermería Clínica (English Edition) · doi:10.1016/j.enfcle.2020.11.003 · Cited by 7
The experience of nurses to reduce implicit rationing of nursing care: a phenomenological study
Li, H. Q., Xie, P., Huang, X., & Luo, S. X. (2023) · BMC Nursing · doi:10.1186/s12912-023-01334-5 · Cited by 7
Oral Health Care Guidelines, Training, and Resources among Stroke Care Providers
Malik, N. A., Yatim, S. M., Lam, O., Jin, L., & McGrath, C. P. J. (2017) · JDR Clinical & Translational Research · doi:10.1177/2380084417693784 · Cited by 7
“2015), limited time for individual patients (Ball et al. 2014; Gibney et al. 2015), and lack of adequate knowledge on the importance of oral health care (Chan and Hui-Ling Ng 2012).”
BackgroundInfluentialFawkes, K., & Moore, J. (2019) · Journal of research in nursing · doi:10.1177/1744987119869770 · Cited by 7
“Time constraints and heavy workloads can frustrate attempts to educate patients (Ball et al., 2014; Jones et al., 2015), as can concerns among some staff for appearing critical or judgemental, thereby adversely affecting the nurse–patient relationship (Svavarsdóttir et al.”
BackgroundPunshon, G., Sopala, J., Hannan, G., Roberts, M., Vernon, K., Pearce, A., & Leary, A. (2020) · International Journal of MS Care · doi:10.7224/1537-2073.2019-058 · Cited by 7
Planning and Evaluating Evidence‐Based Perinatal Nurse Staffing
Bingham, D., & Ruhl, C. (2015) · Journal of Obstetric, Gynecologic & Neonatal Nursing · doi:10.1111/1552-6909.12544 · Cited by 9
Nursing in the 21st century: is there a place for nursing philosophy?
Holt, J. (2013) · Nursing Philosophy · doi:10.1111/nup.12042 · Cited by 7
Gammon, J., Hunt, J., Holland, P. J., Tham, T. L., & Williams, S. (2024) · British Journal of Healthcare Management · doi:10.12968/bjhc.2023.0026 · Cited by 6
Identification of a Theory-Practice Gap in the Education of Biomedical Scientists
Dudley, K., & Matheson, D. (2024) · British Journal of Biomedical Science · doi:10.3389/bjbs.2024.12629 · Cited by 6
“In nursing, workload pressures are also recognised as detracting from high quality care and are known to impact patient safety [53, 54].”
Background
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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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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