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

Aims and objectives Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes. Background 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, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear. Design Systematic review. Methods We 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. Results Fourteen 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. Conclusions The 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 practice Although 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.


| BACKGROUND
The 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 , while in others, the focus is on unmet patient need (Lucero, Lake, & Aiken, 2009). Most evidence of missed care comes from selfreported nursing or patient questionnaires .
The 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, 2011Papastavrou, 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).
Studies 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 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.
Resource 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 . 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).
In 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.

| AIM
To conduct a systematic review of the impact of missed nursing care on outcomes in adults on acute hospital wards and in nursing homes.
What does this article contribute to the wider global clinical community?
• Nursing 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.

| Search strategy
The 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 , we included the following terms: "missed nursing care," "care rationing," "care left undone" and "unfinished care." Search 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.

| Search results
The 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: • absence of reports of associations between missed care and patient outcomes; n = 2 • reports of associations of missed care and staff outcomes instead of patient outcomes; n = 2 • unclear definition and assessment of missed care; n = 1 • duplication 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 • Missed care from other health professionals (i.e., not nursing staff); n = 1 • Medication errors studied as a missed care process and not as outcomes; n = 23 A total of 14 papers were analysed fully (Figure 1).

| Quality appraisal
To 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.
Quality 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.

| RESULTS
The 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.
Most studies measured missed care with nurse or patient surveys that have been widely used in the missed care literature,  (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).

| Patient satisfaction
Four studies in hospital settings found missed care significantly decreased patient satisfaction. These findings are summarised in Table 3. 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"  (Ausserhofer et al., 2013).
Overall, 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.

| Quality of care delivered
Three studies identified from the literature search found a significant association between measures of quality of care and tasks left undone (Table 3)

| Clinical outcomes
Six 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 Three of the identified patient outcomes (nosocomial infections, pressure ulcers, and patient satisfaction) were sensitive to rationing, showing negative consequences at average BERNCA rationing scores of .5 or above (never, rarely or sometimes). Results also showed increases in negative outcomes at rationing average ratings of 1 (rarely) Thompson ( While 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.

| Missed care, readmissions and mortality
Overall four studies explored the association between missed care, readmissions and mortality. They are summarised in Table 5  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 30days patient mortality (OR = 0.99; 0.89-1.10).
Overall, 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.

| DISCUSSION
In summary, the evidence we reviewed indicates an association between missed care and patient outcomes, albeit tenuous in some 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.
As 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).
Despite 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. However, the introduction of a new system that demands time from an already overstretched workforce needs careful planning.
Increasingly, 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).
Our 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.

| CONCLUSION S
This 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. Were CIs wide or were they sufficiently precise to aid decision-making? If precision is lacking, is this because the study is under-powered? If correlations between observations and workload how precise is the prediction?
Overall score □ 5.3 Are the study results internally valid (i.e., unbiased)?
How well did the study minimise sources of bias (i.e., adjusting for potential confounders)?
Were there significant flaws in the study design?
5.4 Are the findings generalizable to the source population (i.e., externally valid)? □ Are there sufficient details given about the study to determine if the findings are generalizable to the source population?
Consider: participants, interventions and comparisons, outcomes, resource and policy implications RECIO-SAUCEDO ET AL.