‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care

Abstract

BackgroundThere 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’.AimTo 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.MethodsCross-sectional survey of 2917 registered nurses working in 401 general medical/surgical wards in 46 general acute National Health Service hospitals in England.ResultsMost 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).ConclusionsNurses 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.

The Impact of Heavy Perceived Nurse Workloads on Patient and Nurse Outcomes

“…The notion of leading and lagging indicators was recently discussed in a paper by Ball et al that urged employers and regulators to focus on leading nurse indicators that have the potential to proactively address quality and safety deficiencies [5]. Our study goal, therefore, was to focus on nurse-perceived workload factors that are assessable and actionable.…”

“…[14] (p. 24). Some moderating/mediating mechanisms that have been explored to date include missed care [5] and care left undone [15].…”

“…Ball et al postulated that when care is not done or "missed", the quality and safety of patient care may be compromised [5]. Based on the RN4CAST protocol, Ball et al surveyed National Health Service England nurses about job-level care left undone on their most recent shift worked for 13 essential, nursing care activities.…”

A Daily Diary Approach to the Examination of Chronic Stress, Daily Hassles and Safety Perceptions in Hospital Nursing

“…The workload and demands placed on nurses are ever increasing [3,4] and healthcare organisations are under rising pressure [5,6]. High workloads and inadequate staffing are challenges for hospital nursing workforces internationally [7][8][9], with these issues recognised as important job related stressors within hospital nursing [10][11][12].…”

A Staffing Tool to Improve Efficiency at a Nursing Department

“…Akinci and Krolikowski [8] conclude on the negative effect of nurse understaffing levels on the quality of care. As in [8], Ball et al [9] report a fact fro m Eng lish hospitals where nurses fail to assure care due to time pressure-"missed care". In the same topic, Kalisch et al [10] analy ze whether missed nursing care can be projected by actual nurse staffing.…”