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Missed Nursing Care’ Effects

A 2014 cross-sectional study features 2917 nurses working in NHS hospitals in England; the nurses were surveyed to determine the association between their workload and care quality (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014). The study reveals that 86% of registered nurses have missed at least one of the care activities directly associated with care quality during their shifts. There is also a general conception among the RNs that care quality suffers due to such incidents of missed care (Ball et al., 2014).

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Among the activities that constitute care quality, one can enlist timely surveillance and documentation, emotional support, plan development, pain management, hygiene maintenance, as well as more specific activities required by each individual client. The occasions when any of these activities are omitted can be defined as “missed care” (Kalisch, Landstrom, & Hinshaw, 2009). Missed care and the quality of care are certainly correlated: when the care activities are missed, the overall quality is shattered. The correlation can be evidenced as follows.

Client satisfaction is an important factor that is generally regarded as a quality indicator. The direct association of client satisfaction – or dissatisfaction, to be more precise – and work environment and job satisfaction of the staff is evidenced by recent research in the field (Papastavrou, Andreou, Tsangari, & Merkouris, 2014). However, the overarching problem causing the omission of necessary care activities seems to be inadequate staffing (Rochefort, Buckeridge, & Abrahamowicz, 2015). Considering all the instances of missed care, the course of it can be modeled in terms of structural, process, and outcome indicators:

Nurse-sensitive indicators Course of “Care Left Undone”
Structural indicator
  • An (un)expected increase in demand for care results in a shortage of staffing;
  • Inadequate skill level of nurses causes the omission of necessary activities.
Process indicator
  • An error inpatient assessment causes providing the client with unnecessary care activities and omitting the necessary ones;
  • Nurses’ job dissatisfaction / peer pressure / other environment issues result in negligence and missing care.
Outcome indicator Adverse client outcomes indicate omission-related problems with:
  • Staffing;
  • RNs’ proficiency;
  • Assessment and interventions;
  • The staff’s job satisfaction.

The outcomes can vary from general client dissatisfaction to higher readmission rates to increased mortality.

The impact of missed care on quality improvement, therefore, can be most precisely described as disastrous. To change the impact for the better, the most obvious goal would be to provide clients with care activities in full. Based on the evidence provided, it is possible to determine that the implementation of non-omission into practice would be on one of the later stages of translation. Indeed, the basic definitions of missed care and the effects of omission on client outcomes have been thoroughly investigated, which makes it possible to predict that non-omission will change the situation for the better.

Translation into practice will require additional staffing and call for documenting the intensity of the clients’ exposure to nursing activities and temporal duration of such exposure, as well as client outcomes and satisfaction rates related to non-omission practices. Because inadequate staffing seems to be the primary cause of missed care in the context of RNs, the research will require documentation of practices related to improved staffing. The main obstacles to implementation would be the cost of increased staffing and training of additional human resources. However, once the effects of non-omission are investigated, evidence-based practice is likely to be devised to improve the care quality in the long run.


Ball, J. E., Murrells, T., Rafferty, A. M., Morrow, E., & Griffiths, P. (2014). ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety, 23(2), 116-125.

Kalisch, B. J., Landstrom, G. L., & Hinshaw A. S. (2009). Missed nursing care: a concept analysis. Journal of Advanced Nursing, 65(7), 1509–1517.

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Papastavrou, E., Andreou, P., Tsangari, H., & Merkouris, A. (2014). Linking patient satisfaction with nursing care: the case of care rationing – a correlational study. BMC Nursing, 13, 26.

Rochefort, C. M., Buckeridge, D. L., & Abrahamowicz, M. (2015). Improving patient safety by optimizing the use of nursing human resources. Implementation Science, 10, 89.

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