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.

Most patients do not express unmet needs for supportive care after treatment. Thirty percent reported more than five moderate or severe unmet needs at both assessments. Unmet needs were predicted by hormone treatment, negative mood, and experiencing a significant event. Our results suggest that there is a proportion of survivors with unmet needs who might benefit from the targeted application of psychosocial resources.

Background and objectivesThere is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs.MethodsMixed methods pre/post ‘move’ comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms.ResultsTwo-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary increase of falls and medication errors in one ward was likely to be associated with the need to adjust work patterns rather than associated with single rooms per se. We found no evidence that single rooms reduced infection rates. Building an all single-room hospital can cost 5% more with higher housekeeping and cleaning costs but the difference is marginal over time.ConclusionsStaff needed to adapt their working practices significantly and felt unprepared for new ways of working with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms.

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Forty-four non-insulin-dependent diabetics (NIDD), all with urine negative to Albustix, were studied in 1966/67. By the end of 1980, 17 had died, all but two from cardiovascular causes. All causes of mortality and time to death were significantly related in univariate analyses to age and to the overnight urinary albumin excretion rate (AER), but not to systolic and diastolic blood pressure levels or to duration of diabetes when the latter was corrected for age. Age and duration were highly correlated with each other. In multivariate analyses age and AER were independent predictors of both mortality and time to death, with AER having the greater degree of significance. Thus subclinically elevated albumin excretion rates ('microalbuminuria') indicate a substantially increased mortality risk in non-insulin-dependent diabetes.

(2016) A cross-sectional study of 'care left undone' on nursing shifts in hospitals. Journal of Advanced Nursing 72(9), 2086-2097. doi: 10Á1111/jan.12976 Abstract Aims. To determine factors associated with variation in 'care left undone' (also referred to as 'missed care') by Registered Nurses (RNs) in acute hospital wards in Sweden. Background. 'Care left undone' has been examined as a factor mediating the relationship between nurse staffing and patient outcomes. The context has not previously been explored to determine what other factors are associated with variation in 'care left undone' by RNs. Design. Cross-sectional survey to explore the association of RN staffing and contextual factors such as time of shift, nursing role and patient acuity/dependency on 'care left undone' was examined using multi-level logistic regression. Methods. A survey of 10,174 RNs working on general medical and surgical wards in 79 acute care hospitals in Sweden (January-March 2010). Results. Seventy-four per cent of nurses reported some care was left undone on their last shift. The time of shift, patient mix, nurses' role, practice environment and staffing have a significant relationship with care left undone. The odds of care being left undone is halved on shifts where RN care for six patients or fewer compared with shifts where they care for 10 or more. Conclusion. The previously observed relationship between RN staffing and care left undone is confirmed. Reports of care left undone are influenced by RN roles. Support worker staffing has little effect. Research is needed to identify how these factors relate to one another and whether care left undone is a predictor of adverse patient outcomes.

BackgroundNew hospital design includes more single room accommodation but there is scant and ambiguous evidence relating to the impact on patient safety and staff and patient experiences.ObjectivesTo explore the impact of the move to a newly built acute hospital with all single rooms on care delivery, working practices, staff and patient experience, safety outcomes and costs.Design(1) Mixed-methods study to inform a pre-/post-‘move’ comparison within a single hospital, (2) quasi-experimental study in two control hospitals and (3) analysis of capital and operational costs associated with single rooms.SettingFour nested case study wards [postnatal, acute admissions unit (AAU), general surgery and older people’s] within a new hospital with all single rooms. Matched wards in two control hospitals formed the comparator group.Data sourcesTwenty-one stakeholder interviews; 250 hours of observation, 24 staff interviews, 32 patient interviews, staff survey (n = 55) and staff pedometer data (n = 56) in the four case study wards; routinely collected data at ward level in the control hospitals (e.g. infection rates) and costs associated with hospital design (e.g. cleaning and staffing) in the new hospital.Results(1) There was no significant change to the proportion of time spent by nursing staff on different activities. Staff perceived improvements (patient comfort and confidentiality), but thought the new accommodation worse for visibility and surveillance, teamwork, monitoring, safeguarding and remaining close to patients. Giving sufficient time and attention to each patient, locating other staff and discussing care with colleagues proved difficult. Two-thirds of patients expressed a clear preference for single rooms, with the benefits of comfort and control outweighing any disadvantages. Some patients experienced care as task-driven and functional, and interaction with other patients was absent, leading to a sense of isolation. Staff walking distances increased significantly after the move. (2) A temporary increase in falls and medication errors within the AAU was likely to be associated with the need to adjust work patterns rather than associated with single rooms, although staff perceived the loss of panoptic surveillance as the key to increases in falls. Because of the fall in infection rates nationally and the low incidence at our study site and comparator hospitals, it is difficult to conclude from our data that it is the ‘single room’ factor that prevents infection. (3) Building an all single room hospital can cost 5% more but the difference is marginal over time. Housekeeping and cleaning costs are higher.ConclusionsThe nature of tasks undertaken by nurses did not change, but staff needed to adapt their working practices significantly and felt ill prepared for the new ways of working, with potentially significant implications for the nature of teamwork in the longer term. Staff preference remained for a mix of single rooms and bays. Patients preferred single rooms. There was no strong evidence that single rooms had any impact on patient safety but housekeeping and cleaning costs are higher. In terms of future work, patient experience and preferences in hospitals with different proportions of single rooms/designs need to be explored with a larger patient sample. The long-term impact of single room working on the nature of teamwork and informal learning and on clinical/care outcomes should also be explored.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Evidence before this studyWe have searched PubMed and Scopus from 1990-2017, to identify relevant studies that contain terms for older people; all-cause mortality; glycaemic control; glycaemic variability (with synonyms). We also identified current international guidelines for older people. Overall, the data on optimal glycaemic targets for older people are scant, particularly from prospective studies. In terms of the association between glycaemic control and mortality in older populations the finding have suggested a 'J' shaped distribution in that relationship, although the point at which a significant mortality hazard is observed at the lower end of the glycaemic range has varied between studies. In terms of glycaemic variability, it has been identified that longer term variations in glycaemic control are associated with mortality risk. However, these analyses have not been graduated for magnitude or direction of variability. In addition, previous analyses have not considered the impact of low HbA1c levels, which are associated with mortality risk independent of diabetes intervention. Added value of this studyIn this large population study we are the first group to consider both glycaemic control and glycaemic variability together. We have also employed a new metric for variability which considers exposure to clinically significant changes in glycaemic control. This metric enabled us to assess the direction of change as well as the overall variability. Integrating glycaemic control and variability in our modelling enabled us to consider the importance of stability as a potential factor in understanding the mortality hazard in this population. Additional nuances to our analysis include: consideration of low HbA1c values; higher levels of granularity compared to previous studies in terms of glycaemic thresholds, with 0.5%(5.5mmol/l) HbA1c increments; consideration of gender differences; and the distinction between those who develop diabetes in midlife and those who develop it in older age. Implications of all the available evidenceOur data suggest that we may need to rethink how we consider glycaemic targets in the older diabetes population, in a number of ways: firstly, that variability expresses significant hazard in older people; secondly, that variability may be independent of diabetes therapies and may be related to other factors related to aging; thirdly, stability seems to attenuate hazard in medium to higher ranges of glycaemic control; and finally, there may be some important gender differences in relation to glycaemic control and hazard which are not considered in current guidelines. Therefore, while we recognise that observational data can often raise more questions than answers; we would advocate that we reconsider glycaemic control not simply as a target to direct therapeutic management, but as an important piece of information in relation to assessing individual risk. Perhaps in the past we have been too polarised in our view of glycaemia as purely indicative of optimal control, rather than as a p...