NIHR DC Discover

NIHR Signal Nurse staffing levels linked to reports of missed care in adult wards

Published on 10 July 2018

doi: 10.3310/signal-000614

Nurses are more likely to report omitting necessary care in acute inpatient wards when registered nurse staffing levels are low, even if there are additional healthcare assistants. Care categorised as planning and communication is reported as missed more often than clinical care.

NHS hospitals are responsible for ensuring that the number and skills mix of nursing staff matches patient needs. Previous reviews have shown links between lower registered nurse staffing levels and poor patient outcomes such as higher mortality. This review of 18 observational studies sought to clarify if measuring levels of reported ‘missed nursing care’ might partly explain these relationships.

The findings of this international review suggest that missed care could become a useful measure of staffing adequacy. However, we do not know whether increasing the number of registered nurses would reduce missed care.

This review is based on observational studies, identifying associations only. Other factors such as nurse education, supervision and quality of ward environments may interact so that the link with missed care may not be directly ‘causal’. This study suggests that missed care is a promising indicator which could be used with other information to assess the quality of care.

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Why was this study needed?

Around 60% of patients in the 2016 Adult Inpatient Survey said that there were always or nearly always enough nurses on duty, but a tenth said there were rarely or never enough nurses to care for them. It has been estimated that £1,400 is saved for every patient fall avoided because a nurse is available to help with mobility. Missed monitoring of vital signs and inadequate professional communication have been found to contribute to in-patient deaths.

Consequently missed nursing care has been proposed as an indicator to help detect inadequate staffing levels. This study aimed to identify which elements of nursing care were most frequently missed, and explore statistical relationships between staffing level, skill mix and missed care. If these variables are linked, missed care may be a mechanism through which staffing affects patient outcomes and therefore could become a useful metric for routine measurement.

What did this study do?

This systematic review included 18 cross-sectional studies carried out in general medical and surgical wards in Europe, the USA and Asia. This type of study is appropriate for this type of question. Specialist units, such as intensive care, were excluded. Sample sizes varied from around 200 to over 30,000 registered nurses.

The reviewers described the findings of individual studies but did not combine results due to study differences. Data on missed care was collected by a nurse or patient survey that asked questions such as “on your most recent shift, which of the following activities [13-item list] were necessary but left undone because you lacked the time to complete them?”  

Using a NICE quality appraisal tool, the highest quality 12 studies had a moderate risk of bias and controlled for confounding variables. Some were scored high for generalisability, and one was undertaken in the UK.

What did it find?

  • There were no studies based on administrative data or objective measures of missed care – all were self-reported from surveys of nurses.
  • In eight European studies, including the UK, over 75% of nurses reported missing at least one element of necessary care on their last shift.
  • Elements of necessary care most frequently missed in nurses’ reports include emotional support and education with patients and family members; patient mobility and mouth care; and assessment, documentation and interdisciplinary working.
  • Fourteen of the 18 studies reported statistically significant associations between a lower registered nurse staffing level and a higher level of missed necessary care. For example; in an English study the odds of missing care were 66% lower when nurses were caring for 6.1 patients or fewer, compared with nurses caring for 11.7 or more patients (odds ratio 0.34, 95% confidence interval 0.22 to 0.53).
  • There was no consistent evidence that including support workers in the staffing team reduces missed care (based on four studies investigating skill mix).

What does current guidance say on this issue?

A NICE guideline (2014) on safe staffing in inpatient hospital wards recommends that each ward should systematically assess nursing staff needs in each 24 hour period. No single staffing ratio can apply across varied adult wards. NICE notes an increased risk of harm when a registered nurse cares for more than eight patients during day shifts. Hospitals should systematically monitor safe nursing indicators, including red flag events.

Recent National Quality Board guidance (2016) reiterates that the right staff should be available in the right places and at the right time to provide safe, compassionate and effective care at all times. This is general guidance. In Wales, safe staffing laws were introduced in 2016 and implemented this year, and Scotland is also developing legislation. Northern Ireland guidance includes 'normative staffing ranges'.

What are the implications?

This review shows an association between lower levels of staffing and higher levels of reported missed care. These review findings are consistent with a statement in the National Quality Board’s 2018 improvement resource that local systems for sustainable, safe staffing should incorporate ward-level quality indicators. Yet it may be challenging for nurses to record all elements of missed care systematically. Surveys of missed care may be a useful indicator of nurse staffing adequacy which can be used alongside other measures of quality and safety.

Acute hospital trusts already report monthly data on care hours per patient day, but this does not separate out input from registered nurses, healthcare assistants and others.

Data from the studies included in this review do not suggest specific staffing levels for safe care. They do though point to an association between low nurse staffing levels and higher reports of missed care. But this review does not show a relationship between staffing levels and any objective measure of care. This study provides interesting evidence from observational studies which should be viewed alongside other evidence on staffing, quality and patient outcomes.

Citation and Funding

Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. The association between nurse staffing and omissions in nursing care: a systematic review. J Adv Nurs. 2018;74(4):1474-87.

This review is part of a larger project funded by the National Institute for Health Research Health Services & Delivery Research Programme (project number 13/114/17).

Bibliography

Griffiths P, Ball J, Drennan J, et al. Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud. 2016:63;213-25. 

Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509-17.

National Quality Board. Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time: safe, sustainable and productive staffing. London: NHS England; 2016.

National Quality Board. Safe, sustainable and productive staffing: an improvement resource for adult inpatient wards in acute hospitals. London: NHS England; 2018.

NICE. Safe staffing for nursing in adult inpatient wards in acute hospitals. SG1. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Around 60% of patients in the 2016 Adult Inpatient Survey said that there were always or nearly always enough nurses on duty, but a tenth said there were rarely or never enough nurses to care for them. It has been estimated that £1,400 is saved for every patient fall avoided because a nurse is available to help with mobility. Missed monitoring of vital signs and inadequate professional communication have been found to contribute to in-patient deaths.

Consequently missed nursing care has been proposed as an indicator to help detect inadequate staffing levels. This study aimed to identify which elements of nursing care were most frequently missed, and explore statistical relationships between staffing level, skill mix and missed care. If these variables are linked, missed care may be a mechanism through which staffing affects patient outcomes and therefore could become a useful metric for routine measurement.

What did this study do?

This systematic review included 18 cross-sectional studies carried out in general medical and surgical wards in Europe, the USA and Asia. This type of study is appropriate for this type of question. Specialist units, such as intensive care, were excluded. Sample sizes varied from around 200 to over 30,000 registered nurses.

The reviewers described the findings of individual studies but did not combine results due to study differences. Data on missed care was collected by a nurse or patient survey that asked questions such as “on your most recent shift, which of the following activities [13-item list] were necessary but left undone because you lacked the time to complete them?”  

Using a NICE quality appraisal tool, the highest quality 12 studies had a moderate risk of bias and controlled for confounding variables. Some were scored high for generalisability, and one was undertaken in the UK.

What did it find?

  • There were no studies based on administrative data or objective measures of missed care – all were self-reported from surveys of nurses.
  • In eight European studies, including the UK, over 75% of nurses reported missing at least one element of necessary care on their last shift.
  • Elements of necessary care most frequently missed in nurses’ reports include emotional support and education with patients and family members; patient mobility and mouth care; and assessment, documentation and interdisciplinary working.
  • Fourteen of the 18 studies reported statistically significant associations between a lower registered nurse staffing level and a higher level of missed necessary care. For example; in an English study the odds of missing care were 66% lower when nurses were caring for 6.1 patients or fewer, compared with nurses caring for 11.7 or more patients (odds ratio 0.34, 95% confidence interval 0.22 to 0.53).
  • There was no consistent evidence that including support workers in the staffing team reduces missed care (based on four studies investigating skill mix).

What does current guidance say on this issue?

A NICE guideline (2014) on safe staffing in inpatient hospital wards recommends that each ward should systematically assess nursing staff needs in each 24 hour period. No single staffing ratio can apply across varied adult wards. NICE notes an increased risk of harm when a registered nurse cares for more than eight patients during day shifts. Hospitals should systematically monitor safe nursing indicators, including red flag events.

Recent National Quality Board guidance (2016) reiterates that the right staff should be available in the right places and at the right time to provide safe, compassionate and effective care at all times. This is general guidance. In Wales, safe staffing laws were introduced in 2016 and implemented this year, and Scotland is also developing legislation. Northern Ireland guidance includes 'normative staffing ranges'.

What are the implications?

This review shows an association between lower levels of staffing and higher levels of reported missed care. These review findings are consistent with a statement in the National Quality Board’s 2018 improvement resource that local systems for sustainable, safe staffing should incorporate ward-level quality indicators. Yet it may be challenging for nurses to record all elements of missed care systematically. Surveys of missed care may be a useful indicator of nurse staffing adequacy which can be used alongside other measures of quality and safety.

Acute hospital trusts already report monthly data on care hours per patient day, but this does not separate out input from registered nurses, healthcare assistants and others.

Data from the studies included in this review do not suggest specific staffing levels for safe care. They do though point to an association between low nurse staffing levels and higher reports of missed care. But this review does not show a relationship between staffing levels and any objective measure of care. This study provides interesting evidence from observational studies which should be viewed alongside other evidence on staffing, quality and patient outcomes.

Citation and Funding

Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. The association between nurse staffing and omissions in nursing care: a systematic review. J Adv Nurs. 2018;74(4):1474-87.

This review is part of a larger project funded by the National Institute for Health Research Health Services & Delivery Research Programme (project number 13/114/17).

Bibliography

Griffiths P, Ball J, Drennan J, et al. Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development. Int J Nurs Stud. 2016:63;213-25. 

Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509-17.

National Quality Board. Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time: safe, sustainable and productive staffing. London: NHS England; 2016.

National Quality Board. Safe, sustainable and productive staffing: an improvement resource for adult inpatient wards in acute hospitals. London: NHS England; 2018.

NICE. Safe staffing for nursing in adult inpatient wards in acute hospitals. SG1. London: National Institute for Health and Care Excellence; 2014.

The association between nurse staffing and omissions in nursing care: a systematic review

Published on 23 April 2018

Griffiths P, Recio-Saucedo A, Dall’Ora C, Briggs J, Maruotti A, Meredith P, Smith GB, Ball J, On behalf of the Missed Care Study Group

Journal of Advanced Nursing , 2018

Aims To identify nursing care most frequently missed in acute adult inpatient wards and to determine evidence for the association of missed care with nurse staffing. Background Research 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. Design Systematic review. Data Sources We 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 Methods Two 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. Results Eighteen 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. Conclusions Low 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.

Missed care is necessary care that has not been fully carried out. Nursing red flags in the NICE guideline include delays in pain relief, delays or omissions in regular checks on patients, and omissions in recording patients’ vital signs. Safe nursing indicators include adequacy of meeting patients’ care needs, pain management and communication with the nursing team.

Healthcare support workers, often called healthcare assistants in the NHS, have lower levels of qualification or training than Registered Nurses. They deliver aspects of care such as patient mobility, washing and vital signs monitoring.

Expert commentary

This paper highlights the importance of considering appropriate nurse staffing levels and the links to outcomes provided by registered nurses. Care undone affects patient experience, mortality and morbidity rates. 

In Northern Ireland, the Department of Health launched a policy on nurse staffing – Delivering Care: Nurse Staffing in Northern Ireland, 2014. The framework is based on the best evidence available including a range of recognised workforce planning tools. This approach was preferred to the simple application of an absolute number or ratio.

The review of the literature suggests that measuring the reported level of missed care may be an effective, additional measure of nurse staffing needs.

Professor Charlotte McArdle, Chief Nursing Officer, Department of Health, Northern Ireland