home residents

nursing staff

deficiency citations

administrative data

care provided

missed nursing care

care nurses

registered nurses

nurse staffing

patient satisfaction

Journal of Advanced Nursing

Aims
To identify nursing care most frequently missed in acute adult inpatient wards and 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 (2006-2016) 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. 75% 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.

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The association between nurse staffing and omissions in nursing care: A systematic review