Missed nursing care, also termed omission of nursing care (Lima et al, 2020), unfinished nursing care (Palese et al, 2021), or even rationing of nursing care (Mantovan et al, 2020), is a global healthcare issue (Jones et al, 2015; Najafi et al, 2021). It is characterised by leaving at least one task undone by nurses in a shift (Jones et al, 2015). It is a complex often hidden problem that leads to disruption of nursing duties (Lopez-Dicastillo et al, 2020) and diminished quality of nursing care (Ghezeljeh et al, 2021). Missed nursing care has been presented as a common and frequent issue due to systemic factors (Lake et al, 2016). It care is generally thought to result from an excessive nurse workload and is an evolving measure of nursing processes that may partially elucidate the impact of workload on outcomes (Tubbs-Cooley et al, 2019). Nurses frequently relate leaving care unfinished to lower nurse-to-patient ratios (Ball et al, 2014). Omitted care also has significance for nurses such as dissatisfaction with their jobs and absenteeism (Kalisch et al, 2011a).
The issue of missed nursing care was brought to the attention of the media and public after the situation at the Mid Staffordshire NHS Foundation Trust in the UK in 2009. In this case, numerous reports were provided of substandard care provision, complaints by healthcare recipients, and unanticipated rates of death (Healthcare Commission, 2009). The main causes of these deaths were the absence of sufficient care or ‘missing care’, such as problems in medication administration and a lack of adequate documentation (Francis, 2013). Notably, the Francis report appeared to focus on nursing workforce levels as one reason for substandard care (Francis, 2013; Reeves et al, 2014).
There is considerable literature reporting research into missed nursing care. However, few studies have been carried out in the Australian healthcare context. Moreover, the focus of Australian studies in this area are on missed nursing care at a system level in several healthcare settings, rather than at the hospital or ward level. A quantitative descriptive study was conducted by Blackman et al (2018a) to explore missed nursing care and the factors associated with it in public and private hospitals in four Australian states (New South Wales, Victoria, South Australia, and Tasmania). The study concluded that types of, and reasons for, missed nursing care, are influenced by the clinical settings in which nurses work (Blackman et al, 2018a).
As evident from the literature, a significant association has been noticed between missing care and nursing workload and staffing levels. Many nurses cite the problem of overwork and increased workload, thus implying that nurses do not have enough time to carry out all the necessary nursing tasks (West et al, 2005). Due to increasing concerns about a global shortage of nurses (World Health Organization, 2022) and its impacts, additional studies are needed to develop an in-depth understanding of this issue.
This case study sought to use data on the workload of nursing staff to understand how busy the ward was. Also, as missed nursing care is associated with patient outcomes, clinical incidents data that could shed light on missed nursing care episodes (Cordeiro et al, 2020), was also captured in this case study.
The authors sought to investigate the missed nursing care problem at the level of a medical ward in an acute care hospital. Every ward has a unique set of workload challenges and staffing responses to those challenges (Duffield et al, 2011). Investigation at ward level has been identified as permitting closer assessment of the predictors associated with the care context (Twigg et al, 2015). The reason for choosing a medical ward to perform the case study was due to the nature of patients in these wards, who were characterised by the presence of comorbidities and complicated conditions. Patients attending medical wards have a higher level of dependency on nurses' care than in other wards (Higgs et al, 2020). Moreover, patients in medical wards are characterised by longer lengths of stay. Thus, patients on medical wards may be better able to recognise nursing care elements such as patient communication and individualised care (Kol et al, 2018).
Method
Design
A descriptive case study (Yin, 2003) was carried out in a general medical/cardiac/telemetry ward in an acute care hospital in Brisbane, Australia. A case study was selected as suitable for the purpose of the study. A case study can be used to ask ‘what’, ‘why’ and ‘how’ in a non-controlled setting to analyse real-life conditions and their complexity (Kyburz-Graber, 2004). It is a methodological tactic that frequently uses mixed methods to perform an inquiry, circumscribed by place and time (Yin, 2003; Denzin and Lincoln, 2011). A case study performed within one specific confined time frame to investigate a particular event is called a ‘snapshot case study’ (Thomas, 2011).
This case study was performed by collecting data from several sources (hospital data and patient and nurse surveys) over a 2-week period (22 January 2018 to 4 February 2018). The analysis sought comprehensive descriptive evidence based on the Missed Nursing Care Model (Kalisch et al, 2011b) (Table 1). This examination of missed nursing care acquired information on structures and outcomes and linked these to processes in the Missed Nursing Care Model. It has been assumed that structures impact on missed nursing care processes, which, in turn, impact on outcomes. In the present study, missed nursing care as perceived by nurses and patients were identified.
Table 1. Causes and outcomes of missed nursing care
| Hospital characteristics | Unit characteristics | Staff outcomes | Patient outcomes |
|---|---|---|---|
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Key: HPPD=hours per patient day; RN=registered nurse
Study setting
The case study was performed in a 29-bed inpatient general medical/cardiology/telemetry ward in an acute care tertiary hospital. Staff in the ward comprised a total full time equivalent (FTE) cohort of 50 enrolled nurses (ENs), enrolled nurse advanced practitioners (ENAPs), registered nurses (RNs), and clinical nurses (CNs) with different professional experiences. Clinical nurses are senior registered nurses who have usually completed postgraduate study in order to take on additional roles within the healthcare setting. The nurse-to-patient ratio in the studied ward was 1:4 in the morning and afternoon shifts, and 1:7 in the night shift.
Data sources
The researchers collected both secondary and primary data for the purposes of this case study. The study sought to include data on the workload of nursing staff, along with clinical incidents data that could shed light on episodes of missed nursing care (Cordeiro et al, 2020). The secondary data were provided by the Director of Nursing in electronic format.
Data were collected on elements of the organisational structure:
- Ward profile: including average length of stay, patient turnover (number of admissions, transfers and discharges), and bed occupancy rate for the case study ward during the 2-week study period
- Patients' profile: diagnosis-related groups for the patients admitted during the 2-week study period
- Nurse rostering information.
Nurse rostering or scheduling is defined as allocating an optimal number of various grades of nurses to every shift (Asta et al, 2016) (skill mix) to ensure continuity of care and to meet fluctuations in demand.
The hospital provided nurse roster information for the study ward for the case study period. The roster information was quantified and tabulated for the case study period and enabled calculation of nursing hours per patient day (NHPPD) for the study period. NHPPD is the most frequently used nurse staffing measures (Min and Scott, 2016), particularly in healthcare quality research (Kalisch et al, 2011c). It is defined as the number of hours of nursing care required to meet each patient's care needs in a 24-hour period. NHPPD can be calculated by dividing the number of productive hours worked by all nurses in a day by the number of patients on a unit in the same day (Schreuders et al, 2017). NHPPD was calculated by dividing the number of all hours worked by the nurses by the number of patients admitted to the unit in the same day and then taking the mean for the whole period.
Data were also collected on adverse clinical incidents during the 2-week period.
Primary data collection
The primary data collected related to the nursing process in the Missed Nursing Care Model and included both patients' and nurses' perception of missed nursing care. This study involved a convenience sample of patients and nurses in the designated ward. All patients and nurses in the studied ward during the data collection period who fulfilled the following inclusion criteria were invited to participate in the research.
- Patients' inclusion criteria: adult patients (over 18 years of age) who were conscious, did not have cognitive impairment, able to read and speak English, and who had been hospitalised for at least 48 hours in the selected medical ward
- Nurses' inclusion criteria: nurses providing direct patient care in the selected medical ward regardless of sex or years of experience, who were available during the data collection period, and agreed to participate in the study.
A paper-based ‘MISSCARE survey–Patient’ was used to collect data from the patients. This survey uses a 5-point Likert scale from never to always. Permission to use the survey (Kalisch et al, 2014) was obtained from the developer.
Data collection procedures
The principal researcher (RA) visited the patients in their rooms and asked them to complete the ‘MISSCARE Survey–Patient’ after explaining the research objectives and asking them to sign the consent form. The patient survey was conducted during quiet times when there were no nurses present in the patient's room in order to preserve confidentiality and enable them to answer the questions freely. Patients surveyed in this case study were in both single rooms and open wards.
For the nurses, printed surveys were placed in the tearoom and the nurse unit manager asked the nurses to complete them and post them in a locked box.
Data analysis
This study used descriptive statistics to summarise the secondary data collected from the hospital databases. Ward and patient profiles were tabulated and reported by the principal researcher. Clinical incidents report data were also summarised and reported.
The data obtained from both patients and nurse MISSCARE surveys were inputted into SPSS v25 (Field, 2013) for analysis. In MISSCARE Survey–Patient, the Likert scale-based responses (from ‘never’ to ‘always’) were re-coded as a dichotomous (categorical) scale by grouping participants' scores of ‘never’, ‘rarely’ and ‘sometimes’ on the scale into ‘missed care’ and given code 1; and scoring ‘usually’, or ‘always’ as ‘not missed care’ and given code 2 (Kalisch et al, 2014).
Descriptive statistics performed included: proportion and frequencies for patient and nurses' demographic features as well as missed care elements as reported by both patients and nurses.
Ethical approvals
This study was approved by the Queensland Health Ethics Committee (HREC/16/QRBW/591), the hospital's site-specific approval committee (SSA/17/QPAH/704), and the Queensland University of Technology Research Ethics Committee (1700000980). Authority to release secondary data under the Public Health Act (PHA) was also obtained (RD006717).
Results
Ward profile
Ward profile information showing the average length of stay, patient turnover and the bed occupancy rate for the case study ward during the 2-week period is shown in Table 2.
Table 2. Case study ward profile during the 2-week case study period
| Metrics | Metric value |
|---|---|
| Average length of stay | 3.61 days |
| Admissions and transfers into the study ward | 141 patients |
| Number of discharges | 72 patients |
| Bed occupancy rate | 88% |
Patients' profile (clinical)
Diagnostic-related groups (DRGs) data, which is a system for classifying patients depending on their illness and thus the required resources to provide care for them (Duffield et al, 2006), were obtained for the patients involved in the case study. Of the 141 patients who were in the study ward during the case study period, the largest DRG category was cardiovascular and cardiac diseases (n=43, 30%), followed by respiratory and thoracic diseases (n=26, 18%), and renal and urologic diseases (n=13, 9%). No death was reported in the study ward during the case study period. In this context, it can be presumed that the need for nursing care is higher for patients who have more complex medical conditions.
Based on the criteria of the Australian Refined Diagnosis Related Groups (AR-DRGs) (Independent Hospital Pricing Authority, 2019), of the admitted patients, 55% (n=78) had major complex conditions (requiring the highest consumption of resources, as they had a ‘catastrophic’ complication and/or comorbidity codes). However, 7% (n=10) had intermediate complexity and 38% (n=53) had minor complexity (which required lower resources consumption as they had severe (rather than catastrophic) complication and/or comorbidity codes).
Nurse rostering information
The mean NHPPD for the ward was 7.2 hours (this value is possibly overestimated as it was not feasible to obtain only the number of productive hours (direct patient care) to perform this calculation. Based on this, the unit has been given category A according to guiding principles that classified the hospital units based on their NHPPD. A category A unit is characterised as being a high complexity unit (Twigg and Duffield, 2009).
Patient-related incidents data
Clinical incidents data for nursing-sensitive outcomes (falls, medication errors and pressure injuries) reported during the case study period were provided to the researcher by the Director of Nursing. No patient falls, medication errors or pressure injuries were reported by the nurses in the study period in the study ward.
Apart from nurse-sensitive outcomes, three patient-related incidents were reported to the hospital reporting system during the case study period. These were:
- One patient had a high blood glucose level and high ketones, which were not treated accordingly
- Nursing concerns were escalated to medical registrar in one ward call with delayed response
- One telemetry patient sent to X-ray with no nurse escort/no medical chart/no documented decision in progress notes.
Patient survey results
The number of patients who were eligible to complete the survey was 37. Seven patients declined to be involved in the survey so the number of patients who participated in the case study was 30 (response rate: 81%).
There were slightly more males in the patients' sample than females (57% male, n=17, 43% female, n=13). About one-third of the patients' sample (33% n= 10) were aged over 65 years, which may have influenced their perceptions regarding missed care in the study ward, given different priorities of nursing care for this age group.
The most frequent nursing care elements missed, as reported by the patients in this study, were: oral care (n=16, 53%), response to machine beep (n=15, 50%), and response to call light (n=14, 47%).
No patients experienced any of the problems that were listed in the last part of the MISSCARE Survey–Patient such as falls, skin breakdowns or pressure ulcers, medication administration errors, new infections, IV running dry, and IV leaking into skin. However, in the ‘other problems’ section one patient reported that one nurse ‘yelled’ at him. Another patient reported that the nurses did not respond to his request for analgesics and did not treat him well. Lack of optimal pain management represents an example of missed care.
Nurse survey results
The paper-based MISSCARE was used to examine missed care as perceived by the nurses in the case study ward. The number of nurses completing the survey in this study was 28 (response rate: 56%). There were 25 females (89%) in the study. The most common age range was 35 to 44 years (36%, n=10), followed by 25–34 years (28%, n=8). Most were RNs (78%, n=22), followed by CNs (18%, n=5) and ENs (3%, n=1).
The most frequently missed care items were assisting with ambulation (43%, n=12), followed by monitoring fluid intake/output and attendance at interdisciplinary conferences whenever held (36%, n=10), followed by mouth care (32%, n=9).
The least frequently missed nursing care elements as perceived by one nurse in each case were: handwashing (4%), patient discharge planning and teaching (4%), bedside glucose monitoring as ordered (4%), patient assessment performed each shift (4%), focused reassessment according to patients' conditions (4%), and response to call light within 5 minutes (4%). This was followed by feeding patients when the food is still warm, IV/central line site care and assessments according to hospital policy, and skin care (7%, n=2), as well as setting up meals for patients who fed themselves and patient bathing/skin care (7%, n=2).
The most frequent reasons that nurses reported as being moderate and significant reasons for missed nursing care were related to urgent patient situations (86%, n=24), an unexpected rise in the number of patients and heavy admission and discharge activity (82% for each, n=23), and inadequate numbers of staff (71%, n=20). Regarding reasons for missed nursing care, about 50% of nurses perceived an imbalance between resourcing and patient need, which may lead to an unbalanced workload.
Discussion
The aim of this case study was to examine the missed nursing care phenomenon and to shed light on the possible predictors that may impact on the occurrence of missed nursing care in the context of a medical ward in an acute care hospital. The findings revealed that 50% of the nurses perceived that they experienced unbalanced patient assignments. This finding persists despite the implementation of mandated staffing ratios and its intended impact on missed nursing care. The authors suggest that this should be investigated in further research. Several factors were found that may explain missing care in the studied context. The findings from the secondary data (hospital data) validate the findings from primary data (the survey data) in regard to reasons of missed nursing care in the study ward.
The secondary data revealed that the average length of stay in the case study ward was comparable to the average length of stay in Australian public hospitals (Australian Institute of Health and Welfare, 2016). Most admissions to the study ward during the case study period were emergency admissions. The length of stay associated with emergency admissions is considerably less than the length of stay for elective admissions (Vetrano et al, 2014), thus, further increasing nursing workload as much of work occurs in the initial period of admission. It can also be seen that the number of discharges from the case study ward (72 discharges) was less than the number of admissions and transfers onto the case study ward (141 admissions and transfers in) during the case study period. This can be explained by patients who were admitted in the previous 5 days before the case study period exceeding those who were not discharged at the end date of the case study. Also, some patients might have been transferred from the study ward to another area in the hospital due to requirements to admit a telemetry patient or a patient who needed the negative pressure isolation room (the study ward has the only one outside of the emergency department). The data reflected a high patient turnover rate in the case study ward that led to increases in the workload of the nursing staff and thus potentially to missed care.
The clinical profile for patients presenting to the case study ward informed the risk profile of the patients and thus indicated the risk factors for occurrence of adverse incidents in the patient cohort. Hence, it permitted the nursing staff to predict potential strategies and interventions that would enhance patient safety and improve patient outcomes.
It is important to note that transfers into the case study ward included patients who were transferred from the intensive care unit (ICU) or patients who were transferred from another ward. Transfers between several wards is necessary when certain diagnostic or therapeutic procedures are required. However, it undermines the continuity of care and reduces the time available to provide patient care (Blay et al, 2012). Patient transfers impose high communication requirements on the nurses (Lees, 2013).
A potential outcome of frequent patient transfers is increased nursing workload, which might have implications for patient safety (Blay, 2015). Additionally, frequent patient transfers may have a negative impact on patient safety due to unfamiliarity with the patients and their requirements/care by the nursing staff in the ward that the patient was transferred to (Lees, 2013). Thus, ineffective communication, missing essential health information, and increased rate of healthcare errors may result (Friesen et al, 2007). Also patient transfer documentation is an essential part of the process and is sometimes missed by nurses (Kulshrestha and Singh, 2016).
The transfer of a patient from ICU into a general ward represents a challenging shift of care (Kauppi et al, 2018). Such patient transfers are known as ‘medical outliers’ (Stylianou et al, 2017), ‘boarders’, ‘overflow’, ‘sleep-outs’ (Goulding et al, 2012; 2015) and ‘bed spacing’ (McAlister and Shojania, 2018). ICU patients are high acuity patients. The ICU environments are well equipped to handle such vulnerable patients. However, general wards have limited resources to deal with them (Kauppi et al, 2018). It has been identified that the assignment of patients to wards that do not have the potential to provide the care that is needed by them, may result in substandard care provision as well as endangering continuity of care (Stylianou et al, 2017). Also, patients who are admitted to the general ward from the ICU may have different requirements from other patients in the ward, such as for emotional support, medication administration and medication effectiveness assessment. Hence, the increased nursing burden necessitates additional staffing (Kauppi et al, 2018). However, patients newly transferred from ICU into a general ward should be well informed about variations in staffing levels between the ICU and the general ward. In doing so, patients could anticipate that they may not receive such prompt help as they were receiving in the ICU (Kauppi et al, 2018).
Differences in the level of care are not only related to resources, but also to the absence of specialised nursing staff based on the illness/health status of the outliers (Santamaria et al, 2014; Stylianou et al, 2017). Further examination of the relationship between medical outliers and missed nursing care in a medical ward context needs to be investigated in future research. According to an Australian observational cohort study conducted in a teaching hospital in Victoria (Santamaria et al, 2014), medical outliers were associated with a 53% increase in the number of emergency calls and, therefore, increased staff workload. Thus, suboptimal decisions might be made that have a negative impact on patient safety (Santamaria et al, 2014).
The bed-occupancy rate represents a measure for quality healthcare and reflects the hospital's capability to provide healthcare for patients in an appropriate and efficient manner (Keegan, 2010). Healthcare managers generally agree on an average 85% occupancy rate as a safe rate that avoids patient flow congestion (Scott, 2010; Stevenson et al, 2011). Average bed occupancy rates above 85% reduce the capacity of the hospital to absorb peaks in patient flow, which may exceed the available staffed beds (Sammut, 2009). Higher average occupancy rates increase the proportion of time that the system is under maximum stress. The bed occupancy rate in the 29-bed case study ward during the case study period was 88%. A high bed occupancy rate may have a negative influence on patient and staff outcomes as well as perhaps leading to missed nursing care in the study ward as staff become focused on the resource-intensive admission and discharge processes with no break to attend to patients' routine needs.
The findings from the case study revealed that oral care is one of the most frequently missed care items reported by patients. The reason for this could be related to the high prevalence of elderly patients in the study hospital and therefore the participant pool, who potentially require oral care more frequently than other age groups. It is also suggested that nurses might lack awareness of the importance of providing oral care to patients, which is in line with the findings of Blackman et al (2018b) and Jenson et al (2018).
Limitations
The findings of this case study should be interpreted in the light of several limitations. The study was limited to a single health service and thus generalisability to other sites may be limited. Also, patients who were unable to read and comprehend the patient information sheet and consent forms (eg those with severe and complicated health conditions) were excluded from the study, as well as patients who were not proficient in reading and writing in English. The exclusion of these patients could potentially impact the characteristics of the sample and fail to capture cultural differences in patient care needs. Missed nursing care is strongly contingent on the quality of communication between patients and the nursing team, and the exclusion of the above patients could affect the data obtained on missed nursing care. Additionally, these studies are reliant on the perceptions of patients and staff and do not reflect objective identification of missed care or of any evidence of impaired clinical outcomes. The connection between perceptions and actual adverse outcomes requires more detailed analysis of larger patient populations.
Conclusion
This case study identified the persistence of perceived missed nursing care by both patients and staff despite the imposition of mandated nurse-to-patient ratios. Mandated nursing ratios were introduced to respond to political and union pressure to deal with the strong perceptions of excessive workload and its impact on the quality of patient care. However, this research implies that such workforce measures alone are not sufficient to deal with the complexity of hospital nursing care and the dynamics of modern hospital systems.
Perceptions are individually generated and may relate to a range of factors beyond those able to be influenced by macro resourcing formulas. They are likely to be influenced by personal staff factors such as perceptions of the fairness of the allocation of patients, tiredness due to individual rostering influences and the impact of family and other considerations. Equally, the patient's perceptions are influenced by their expectations and other personal factors.
These unexpected events are an innate component of the uncertain and unpredictable nature of hospital and nursing practice and their relationship with an objective macro resource allocation formula may not be direct. Thus, the imposition of mandated nurse patient ratios may not have a direct impact on the events' frequency or severity. Other strategies are needed.
Staff in healthcare operate in a complex human-centric environment that is changing frequently and which is difficult to predict. Individuals need to respond to fluctuations in workload intensity and prioritise the care they provide. A more in-depth understanding of the reasons for missed care may assist nurse managers and nurses to develop better techniques to respond to the complex working environment and to thus reduce the frequency of adverse healthcare outcomes.
KEY POINTS
- Missed nursing care is a significant healthcare delivery issue that is associated with several factors
- There is increasing concern about nursing workloads and related impacts on patient outcomes as represented by perceptions of missed nursing care
- Unexpected events prevalent in the healthcare system may impact on the nurses' ability to provide nursing care in a timely manner. This unpredictability needs to be dealt with in a considerate way, so as to manage missed nursing care problems
- A more in-depth understanding of the complexity of the nursing care environment may assist with the development of both organisational and individual coping strategies that go beyond the macro formulas that system managers may apply
CPD reflective questions
- In your experience, what are the most frequently missed nursing care elements in a medical ward context as reported by nurses?
- In your experience, what are the most frequently missed nursing care elements in a medical ward context as reported by patients?
- What are the factors that may influence the occurrence of missed care in a medical ward context? How could these be overcome?