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

1Nursing staff and patients indicate instances where care delivered or received is incomplete and suboptimal when staffing levels are inadequate.The negative impact on patient outcomes resulting from missed care highlights the significance of exploring further the factors that affect the completion of nursing activities.

2Nursing staff and patients indicate instances where care delivered or received is incomplete and suboptimal when staffing levels are inadequate.The negative impact on patient outcomes resulting from missed care highlights the significance of exploring further the factors that affect the completion of nursing activities.

3Nursing staff and patients indicate instances where care delivered or received is incomplete and suboptimal when staffing levels are inadequate.

4The negative impact on patient outcomes resulting from missed care highlights the significance of exploring further the factors that affect the completion of nursing activities.

5The association between inadequate quality of nursing care and patient harm has been highlighted as an issue in numerous reports into failings in National Health Service (NHS) hospitals in England (Keogh, 2013). Indeed, failure to ensure adequate nurse staffing levels has frequently been cited as a contributing factor (Luettel, Beaumont, & Healey, 2007; Smith, 2010). Delayed or unfinished care, more broadly identified as missed care, encompasses all aspects of clinical, emotional or administrative nursing care that have only been partially completed, were delayed or were not completed at all. The terminology used to refer to missed care varies slightly with the instruments used in the studies of the field. In some instances, missed care is viewed as a form of care rationing (Jones, Hamilton, & Murry, 2015), or care left undone (Ausserhofer et al., 2014), while in others, the focus is on unmet patient need (Lucero, Lake, & Aiken, 2009). Most evidence of missed care comes from self‐reported nursing or patient questionnaires (Jones et al., 2015).

6The current literature on missed care provides mounting evidence of the pervasive nature of the problem and, more importantly, the threat it poses to patient safety. Patient outcomes reported in the missed care literature, which have been associated with quality of care delivered, include hospital‐acquired infections, discharge planning, mortality, falls, patient mobilisation, feeding, psychological and emotional support (Cho, Kim, Yeon, You, & Lee, 2015; Kalisch, 2006; Kalisch, Tschannen, & Lee, 2011, 2012; Papastavrou, Andreou, & Efstathiou, 2014; Schubert, Clarke, Aiken, & de Geest, 2012). Likely factors that influence care prioritisation and completion include the time that is required to complete a care task and the immediate effect that delaying or missing this task might have on patients (Kalisch, 2006).

7Studies exploring missed care under the implicit rationing approach have found that nursing activities related to surveillance are among the top five most frequently left undone (Jones et al., 2015; Rochefort & Clarke, 2010; Schubert et al., 2012). These findings resonate with analysis by Smith (2010) about the acute problem regarding frequency of physiological observations. Smith proposes that the problem might lie in the levels of trained staff, suggesting that more nursing staff on duty might provide better surveillance, resulting in reduced deterioration, cardiac arrest and failure‐to‐rescue.

8Resource adequacy and nurse staffing have been reported as key environment factors influencing the incidence and prevalence of missed care. A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards (Griffiths et al., 2016; Needleman et al., 2011) and the risk of many aspects of care being either delayed or left undone (Ausserhofer et al., 2014). Guidelines on safe staffing published by the National Institute for Care and Health Excellence (NICE) highlighted the need for more evidence and indicators to determine safe nurse staffing levels, and studies to determine the extent to which they are achieved in practice. Furthermore, NICE proposed that missed care could be used as a “red flag” to warn of inadequate staffing levels and, as a result, be a potential useful indicator of the quality of nursing services (National Institute for Health and Care Excellence (NICE), 2014).

9In this systematic review, we searched for quantitative studies reporting associations between missed care and patient outcomes in acute hospital and nursing homes, where care is delivered by nursing staff. We then assessed the evidence of the short‐ and long‐term effects that missed care has on patients.

10To conduct a systematic review of the impact of missed nursing care on outcomes in adults on acute hospital wards and in nursing homes.

11Medline (via Ovid), CINAHL (EBSCOhost) and Scopus were searched for studies examining the association of missed nursing care and at least one patient outcome. We included primary research where missed care was not treated as the outcome measure. Studies regarding care delivered by registered nurses, healthcare assistants/support workers/nurses’ aides were retained. We included studies conducted in acute hospitals or nursing homes; only adult settings were considered. Only studies with quantitative evidence were retained. Consequently, qualitative studies, editorials, letters and commentaries were excluded. Papers were not excluded on the basis of replicability or generalisability of findings. This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).

12The search strategy was built using free‐text keywords and medical subject headings, and related to missed nursing care and patient outcomes. Because of the different conceptualisations of missed care in the literature (Jones et al., 2015), we included the following terms: “missed nursing care,” “care rationing,” “care left undone” and “unfinished care.”

13Search terms for patient outcomes were as follows: pressure ulcers; falls; catheter‐related and urinary tract infections; venous thromboembolism; patient and/or carer experience (including satisfaction ratings and/or complaints concerning care received); mortality; hospital‐acquired infections; hospital readmissions; medication system errors (i.e., drug administration delayed or missed); quality of health care; and patient safety.

14The search produced 2,430 records. An initial screen of titles was carried out to exclude irrelevant papers, resulting in the retention of 155 titles abstract screened. Following abstract screening, 44 studies were retained for full review, during which 30 studies were excluded due to the following:

15absence of reports of associations between missed care and patient outcomes; n = 2reports of associations of missed care and staff outcomes instead of patient outcomes; n = 2unclear definition and assessment of missed care; n = 1duplication of study as reported in two sources (i.e., doctoral thesis and journal article). The content of the study in a more extended version (i.e., doctoral thesis) was retained; n = 1Missed care from other health professionals (i.e., not nursing staff); n = 1Medication errors studied as a missed care process and not as outcomes; n = 23

16absence of reports of associations between missed care and patient outcomes; n = 2

17reports of associations of missed care and staff outcomes instead of patient outcomes; n = 2

18unclear definition and assessment of missed care; n = 1

19duplication of study as reported in two sources (i.e., doctoral thesis and journal article). The content of the study in a more extended version (i.e., doctoral thesis) was retained; n = 1

20Missed care from other health professionals (i.e., not nursing staff); n = 1

21Medication errors studied as a missed care process and not as outcomes; n = 23

22A total of 14 papers were analysed fully (Figure 1).

23To assess the quality of the studies, we adapted the National Institute for Health and Care Excellence (NICE) quality appraisal checklist for quantitative studies (National Institute for Health and Care Excellence (NICE), 2014). The quality assessment was expressed in terms of internal and external validity. Internal validity included information on reliability and completeness of the measurements, and ability of the study to control for potential confounding factors. External validity was assessed by appropriate sample size and statistical power. The complete appraisal checklist is available in Appendix.

24Quality assessments were performed separately by two reviewers (AR‐S and CDO), and disagreements were resolved by discussion. Most studies were rated as having significant limitations in internal and/or external validity. One study was weak in both aspects of validity, and no study was rated as strong in both. Quality ratings for each study can be found in Table 1.

25The 14 studies reported a range of outcomes of interest: medication errors; bloodstream infections; pneumonia; urinary tract infections (UTIs); nosocomial infections; patient falls; pressure ulcers; patient and/or carer experience and satisfaction ratings; patient safety; quality of nurse delivered care; critical incidents; adverse events; mortality and 30‐day hospital readmissions.

26Most studies measured missed care with nurse or patient surveys that have been widely used in the missed care literature, namely survey from the International Hospital Outcomes Consortium [IHOC]/RN4CAST (Sermeus et al., 2011); MISSCARE (Kalisch, 2006) and the Basel Extent of Rationing of Nursing Care: BERNCA (Schubert, Glass, Clarke, Schaffert‐Witvliet, & De Geest, 2007). Three studies were secondary analyses of the large RN4CAST study conducted across 15 European countries (Ausserhofer et al., 2013; Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014; Bruyneel et al., 2015), where authors analysed and reported data from individual countries. The majority of the studies used nurse or patient reports to capture outcomes, with some studies using administrative data (Table 2).

27Four studies in hospital settings found missed care significantly decreased patient satisfaction. These findings are summarised in Table 3.

28Bruyneel et al. analysed survey data from 217 hospitals across eight European countries enrolled in the RN4CAST study. Using factor analysis, the authors classified care left undone into two domains—clinical nursing activities and planning/communication activities—and examined the relationships with patient satisfaction. The authors reported a significant association between clinical care left undone (omission of at least one of: adequate patient surveillance, skincare, oral hygiene, pain management, treatments and procedures, timely medication administration, frequently changing the patient's position) and patients recommending the hospital to family and friends (Bruyneel et al., 2015). A study of five hospitals in Cyprus (Papastavrou, Andreou, Tsangari, et al., 2014) used the BERNCA survey, which included 20 questions on activities related to care and support, rehabilitation, monitoring and safety. Responses to the survey indicated the extent to which nurses felt able to perform the activities in the past 7 days. Responses were collected on a four‐point Likert‐type scale, and a “rationing score” was derived from the average sum of all items. A high degree of rationing was negatively associated with all five dimensions of patient satisfaction (Papastavrou, Andreou, Tsangari, et al., 2014). Schubert et al. applied the same BERNCA survey within 118 acute hospital units in Switzerland and demonstrated a 37% reduction in the odds of patients reporting satisfaction with the care they received (p =.08) with each 0.5 increase in the rationing score (Schubert et al., 2008). A smaller study (Ausserhofer et al., 2013) of 35 Swiss hospitals used the BERNCA‐R survey (which extends the original BERNCA instrument from 20–32 items and adds the statement Not required to the responses options) to capture rationing of care. Nurses reported how frequently they were unable to perform 32 basic nursing activities in the past seven working days due to inadequate time, nurse staffing and/or skill mix. Respondents rated each item on a 5‐point Likert‐type scale (task was not required = 0—often = 4). Results indicated that when patients experienced higher levels of nursing care rationing, they were less likely to recommend the hospital to a family member or a friend (OR = 0.27; 95% CI = 0.11–0.67) (Ausserhofer et al., 2013).

29Overall, the evidence shows a consistent detrimental effect of rationing care on patient satisfaction. However, studies used different instruments to capture patient satisfaction, which affects direct comparability of the findings.

30Three studies identified from the literature search found a significant association between measures of quality of care and tasks left undone (Table 3). Ball et al. used the RN4CAST survey to examine care left undone in 46 English NHS hospitals. Nurses were asked to report how frequently they were unable to perform any of 13 nursing activities on their last shift due to time constraints. Two measures of “missed care” were derived. The first measure quantified the prevalence of any care being left undone, based on one or more of the activities having been ticked (binary measure). A second score indicated the volume of care left undone, by summing the number of activities ticked per person. The authors showed a significant correlation between the number of items of missed care and nurses perception of quality of care (polyserial correlation = −0.037, p <.001) and nurse overall grading of patient safety on their unit/ward (polyserial correlation = −0.40, p <.001) (Ausserhofer et al., 2014). Sochalski's study in US acute hospitals used a survey based on a list of seven care activities, and nurses had to indicate which was left undone during their last shift due to lack of time. The results indicated an association between a poor rating of quality of care and the number of tasks left undone (β = −0.20; p <.001; Sochalski, 2004). Similar results were reported by Zúñiga et al. in a study of 155 Swiss nursing homes. The authors used BERNCA‐NH (Adapted for Nursing Homes) 19‐item scale. Care workers were asked how often in the last 7 days they could not conduct necessary care activities due to lack of time or high workload. Items were rated on a 5‐point Likert‐type scale, and the mean score per subscale was calculated. The study found that nurses reported a better quality of care when the amount of implicit rationing of care, rehabilitation and monitoring (i.e., a subscale of the BERNCA instrument) was lower (OR 0.34; 95% CI 0.24–0.49), and when less instances of rationing social care were perceived to have occurred (OR 0.80; 95% CI 0.69–0.92) (Zúñiga et al., 2015).

31Six studies reported associations between missed care, and one or more clinical outcomes, mainly medication errors; bloodstream infections; pneumonia; UTIs; nosocomial infections; patient falls; pressure ulcers; critical incidents and quality of care; and patient safety. Five of the studies found that missed care was associated with adverse outcomes, but in regard to pressure ulcers, two studies (Ausserhofer et al., 2013; Thompson, 2014) found no significant associations between missed care and the incidence or prevalence of hospital‐acquired pressure ulcers. Results are summarised in Table 4.

32The study by Ausserhofer et al. reported an association between rationing of nursing care and higher nurse‐reported levels of bloodstream infections (OR = 3.01; 95% CI = 1.42–6.34), pneumonia (OR = 2.67; 95% CI = 1.11–6.39) and medication administration errors (OR = 2.51; 95% CI = 1.18–5.65). However, there were no significant effects of rationing care on the incidence of pressure ulcers and urinary tract infections (Ausserhofer et al., 2013). Similarly, a study across 1,291 hospitals in the USA conducted by Thompson found no significant associations of missed care with the prevalence rates of hospital‐acquired pressure ulcers. The author used the National Database of Nurse Quality Indicators survey in 741 US hospitals. This survey reported five activities due on the last shift with a yes/no/not applicable answer. Items were aggregated to the unit level to represent the percentage of nurses on the unit who endorsed each item. Missed care had no significant direct effects for the pressure ulcer prevalence rates either in 2011 or in 2012 (Thompson, 2014).

33Results on further clinical outcomes were reported in a study conducted in the USA by Lucero et al. in 168 acute care hospitals. The authors used a survey asking nurses to select from a list of seven care activities that were necessary, but left undone, due to the lack of time during their last shift worked. They concluded that unmet nursing care needs were associated with nosocomial infection (p <.001) and patient falls with injuries (p <.001) (Lucero, Lake, & Aiken, 2010). The study by Nelson and Flynn in 63 US nursing homes drew on the Multi‐State Nursing Care and Patient Safety Survey, with 12 items asking nurses to indicate which necessary activities were left undone due to the lack of time during their last shift. The authors found a number of missed nursing care tasks associated with a higher likelihood of residents experiencing UTIs. The tasks reported were administering medications on time (p =.000); adequate patients surveillance (p =.001); performing necessary treatments and procedures (p =.007); comforting/talking with patients (p =.008); teaching patients and/or families (p =.018); documenting nursing care (p =.04); coordinating patient care (p =.36) (Nelson & Flynn, 2015). A study in eight hospitals in Switzerland found care rationing to be associated with medication errors (OR = 1.68; p <.005); falls (OR = 2.81; p <.001); nosocomial infections (OR = 1.61; p <.04); critical incidents (OR = 1.10; p <.002); and pressure ulcers (OR = 1.15; p <.0010) (Schubert et al., 2008). A subsequent analysis of the sample from the previous study (1,338 nurses and 779 patients) sought to define a clinically meaningful rationing threshold level and found consistent reports of nosocomial infections, pressure ulcers and patient satisfaction being sensitive to rationing with negative consequences (Schubert, Clarke, Glass, Schaffert‐Witvliet, & De Geest, 2009).

34While the evidence originating from nurse reports largely indicates significant associations between missed care and adverse clinical outcomes (e.g., pressure ulcers, medication errors, nosocomial infections), evidence relying on objective clinical data is more mixed, with one study indicating an association between several activities left undone and urinary tract infection. Yet, another study concluded that there was no association between missed care and pressure ulcers. However, these studies derived from diverse contexts, and missed care was captured with different surveys, and as seen in Table 1, their validity was assessed as moderate or weak.

35Overall four studies explored the association between missed care, readmissions and mortality. They are summarised in Table 5. A large study of 419 hospitals in the USA by Carthon et al. relying on the Multi‐State Nursing Care and Patient Safety Survey showed that a 10% increase in missed treatments and procedures was associated with patients more likely to experience readmissions within 30 days of hospital discharge (OR = 1.12; 95% CI = 1.06–1.18). When the analysis was adjusted for the quality of the work environment, the effect of missing essential nursing was no longer a significant predictor of readmission, except for missing treatments and procedures, which still showed high odds for patients being readmitted to hospital within 30 days of discharge (OR = 1.07; 95% CI = 1.01–1.13) (Carthon, Lasater, Sloane, & Kutney‐Lee, 2015).

36Three studies reported associations between missed care and patient mortality. In their study comparing two groups of acute hospitals in Switzerland (n = 8 sample; n = 71 comparator), Schubert et al. reported that patients admitted to hospitals with the highest level of care rationing (i.e., BERNCA score 1.11–1.40) had a 51% increase in the odds of death compared to those patients hospitalised in the comparison group consisting of 71 out of 352 acute hospitals and specialised clinics in Switzerland (i.e., BERNCA score 0.51–0.80) (OR = 1.51; 95% CI = 1.34–1.70) (Schubert et al., 2012). However, overall levels of inpatient mortality (2.7% vs. 2.8%) and emergency admissions (45.7% vs. 47.4%) were similar for both groups of hospitals. Ambrosi et al. conducted a secondary analysis of data collected in 12 Italian hospitals with the aim of identifying factors associated with in‐hospital mortality of patients >65 years old. They used the MISSCARE survey, where nurses and nurse aides reported the frequency of missing 24 nursing interventions during their last shift on a 5‐point Likert‐type scale (1 = never—5 = always). The analysis showed a statistically significant difference between the groups of patients who died or survived (average missed care score = 51.5% in deceased patients and 52.6% in surviving patients, p =.04); however, when stepwise logistic regression analysis was performed, no associations were observed between missed nursing care and inpatient mortality (Ambrosi et al., 2016). Lucero et al., 2010 after adjusting for patient and ward environment characteristics, found no evidence of an association between unmet nursing care needs and 30‐days patient mortality (OR = 0.99; 0.89–1.10).

37Overall, these studies provide insufficient evidence to support an effect of missed care on patient mortality. However, the study that considered a larger and more diverse sample seemed to support the notion of the association between missed care and in‐hospital mortality.

38In summary, the evidence we reviewed indicates an association between missed care and patient outcomes, albeit tenuous in some instances. A number of studies provide evidence in two major categories of patient outcomes negatively affected by omissions of care: patient satisfaction and clinical outcomes. Patient satisfaction was negatively associated with missed care in four studies. Clinical outcomes affected by missed care, as reported in nine studies, included pressure ulcers, medication errors, nosocomial infections, patient falls, critical incidents, 30‐day hospital readmission and mortality. Although most studies controlled for patient case mix, and hospital and nurse characteristics, differences in the context in which the studies took place (e.g., hospital vs. nursing home) or units included in the studies (e.g., medical, surgical and gynaecology) create potential limitations to the generalisability of the findings.

39As with hospital studies, research conducted in nursing homes reports that omission of nursing care activities affects the probability of residents experiencing UTIs and the nurses’ ability to perform certain tasks (i.e., administer medication on time, adequately monitor patients, or perform necessary treatments and procedures).

40Despite it being essential to patient safety, surveillance has been reported along with other nursing activities (i.e., ambulation, oral hygiene) that are frequently missed in hospital settings (Osborne et al., 2015). While we found mixed evidence about the relationship between nurse‐reported measures of missed care and mortality, the potential of such negative outcome calls for an in‐depth look of the issues surrounding missed care in the form of inadequate patient surveillance and its consequences. Early identification of physiological deterioration has been recognised as one of the factors associated with preventable hospital deaths (Luettel et al., 2007; Smith, 2010) which relies on timely and adequate patient monitoring. Technological solutions in the form of patient surveillance systems that enable healthcare professionals to efficiently monitor patients and identify those who require the most urgent attention may be a solution to surveillance issues. While automated continuous monitoring has not been shown to be associated with reductions in mortality, innovations in intermittent monitoring, including electronic recording with calculation of a risk based early warning score, have been shown to reduce inpatient deaths (Cardona‐Morrell, Prgomet, Turner, Nicholson, & Hillman, 2016; Schmidt et al., 2015). Such automated clinical risk prediction models could support healthcare providers to deploy resources where they are needed most, resulting in improved outcomes and costs (Imison, Castle‐Clarke, Watson, & Edwards, 2016). However, the introduction of a new system that demands time from an already overstretched workforce needs careful planning.

41Increasingly, frequency of missed care is being considered as an indicator to assess the quality of nursing care. As reported in one study in our review, the amount of missed care partially mediates the effects of patient‐to‐nurse ratios and work environment on patient recommending the hospital (Bruyneel et al., 2015). However, bias in the instruments available to measure missed care, coupled with the self‐reported nature of most survey data, limits the comparability of findings from studies in the field (Jones, Gemeinhardt, Thompson, & Hamilton, 2016).

42Our findings resonate with research that highlights the associations of staffing levels of different nursing staff with patient outcomes and quality of nursing care services (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). This indicates the potential significance of missed care as a consequence of inadequate nurse staffing resources, although the relationship between missed nursing care and mortality is as yet uncertain.

43This review shows a modest evidence base for a link between 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, more research using objective staffing and outcome measures is required. Nursing staff and patients indicate instances where care delivered or received is suboptimal when staffing levels are inadequate. The negative effects on patients in hospital of missing care tasks have, highlight the significance of exploring further the factors that affect the completion of nursing activities. Limiting the occurrence of omissions of care could potentially increase patient satisfaction and decrease the frequency of negative adverse events.

44Study design: AR‐S, CDO, JB, PG; data collection and analysis: AR‐S, CDO, AM, CK, PG; and manuscript preparation AR‐S, CDO, JB, AM, PM, JB, OR, CK, DP, GS, PG.