What impact does nursing care left undone have on patient outcomes? Review of the literature

Abstract

Aims and objectivesSystematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes.BackgroundA considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear.DesignSystematic review.MethodsWe searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses’ aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review.ResultsFourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged.ConclusionsThe review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self‐reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required.Relevance to clinical practiceAlthough nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses’ reports of missed care and consider routine monitoring as a quality and safety indicator.

Nurse staffing, nurses prioritization, missed care, quality of nursing care, and nurse outcomes

“…Our findings enrich the empirical evidence that nurse staffing and missed care impact patient safety, quality of care, and patient and nurse outcomes (Ball et al, 2014;Ball et al, 2017;Cho et al, 2016;Jones et al, 2015;Lake et al, 2016;Recio-Saucedo et al, 2017;Tschannen et al, 2010). The finding that perceived staffing adequacy had significant relationships with all dependent variables, unlike the patient-to-RN ratio, indicates that perceived staffing adequacy may be more sensitive to the overall workload than the staffing ratio, because it reflects the effect of additional factors other than the staffing ratio.…”

“…Missed care occurs when nurses are required to perform multiple activities at the same time and cannot engage in some nursing activities under conditions of time scarcity. Empirical evidence has suggested that poorer nurse staffing was associated with an increase in nurse-reported missed care, and increased missed care was associated with nurse-reported quality of nursing care and patient safety, adverse events, mortality, and patient satisfaction Jones et al, 2015;Lake, Germack, & Viscardi, 2016;Recio-Saucedo et al, 2017). Empirical evidence has suggested that poorer nurse staffing was associated with an increase in nurse-reported missed care, and increased missed care was associated with nurse-reported quality of nursing care and patient safety, adverse events, mortality, and patient satisfaction Jones et al, 2015;Lake, Germack, & Viscardi, 2016;Recio-Saucedo et al, 2017).…”

The association between nurse staffing and omissions in nursing care: A systematic review

“…Broad measures of missed care make no distinction between the relative importance of the care that is missed. Not all missed care is of equal significance and impact on patient outcomes will vary (Recio‐Saucedo et al., ). While there is some evidence that missed care mediates the relationship between staffing levels and measures of patient satisfaction (Bruyneel, et al., ) and falls (Kalisch et al., ), direct evidence of omitted clinical care mediating the relationship between staffing and mortality is absent (Jones et al., ).…”

“…Although nurse reports of missed care are associated with adverse patient outcomes (Recio‐Saucedo, et al. ), it remains unclear to what extent these reports correlate with actual omissions of care. While studies that failed to show significant associations were typically smaller and had a higher risk of bias, those which used patient reports did not clearly confirm the results of studies which used nurse reports.…”

Design and psychometric testing of the attitude towards the prevention of incontinence‐associated dermatitis instrument (APrIAD)

“…The proportion of nurses who reported that skin care was missed during their most recent shift varied between 20.5% and 39.5% . Inadequate skin care is associated with complications, such as pressure ulcers and incontinence‐associated dermatitis (IAD) …”