AimsTo identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing.BackgroundResearch has established associations between nurse staffing levels and adverse patient outcomes including in‐hospital mortality. However, the causal nature of this relationship is uncertain and omissions of nursing care (referred as missed care, care left undone or rationed care) have been proposed as a factor which may provide a more direct indicator of nurse staffing adequacy.DesignSystematic review.Data SourcesWe searched the Cochrane Library, CINAHL, Embase and Medline for quantitative studies of associations between staffing and missed care. We searched key journals, personal libraries and reference lists of articles.Review MethodsTwo reviewers independently selected studies. Quality appraisal was based on the National Institute for Health and Care Excellence quality appraisal checklist for studies reporting correlations and associations. Data were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative.ResultsEighteen studies gave subjective reports of missed care. Seventy‐five per cent or more nurses reported omitting some care. Fourteen studies found low nurse staffing levels were significantly associated with higher reports of missed care. There was little evidence that adding support workers to the team reduced missed care.ConclusionsLow Registered Nurse staffing is associated with reports of missed nursing care in hospitals. Missed care is a promising indicator of nurse staffing adequacy. The extent to which the relationships observed represent actual failures, is yet to be investigated.

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.

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ObjectiveTo determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality.DesignThis is a retrospective longitudinal observational study using routinely collected data. We used multilevel/hierarchical mixed-effects regression models to explore the association between patient outcomes and daily variation in RN and nursing assistant staffing, measured as hours per patient per day relative to ward mean. Analyses were controlled for ward and patient risk.Participants138 133 adult patients spending >1 days on general wards between 1 April 2012 and 31 March 2015.OutcomesIn-hospital deaths.ResultsHospital mortality was 4.1%. The hazard of death was increased by 3% for every day a patient experienced RN staffing below ward mean (adjusted HR (aHR) 1.03, 95% CI 1.01 to 1.05). Relative to ward mean, each additional hour of RN care available over the first 5 days of a patient’s stay was associated with 3% reduction in the hazard of death (aHR 0.97, 95% CI 0.94 to 1.0). Days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05, 95% CI 1.01 1.09). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality.ConclusionLower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing and do not give support to policies that encourage the use of nursing assistants to compensate for shortages of RNs.