Missed cares are the missing link in understanding why hospitals with lower registered nurse (RN) staff levels have a higher risk of death, say the researchers whose study was published online this week in the International Journal of Nursing Studies.

The findings are the latest analysis from the RN4CAST study that connected nursing levels, the outcomes of more than 400,000 patients and survey data from 25,000 nurses working across 300 hospitals in nine European countries (including England, the Netherlands and Ireland). The latest research was lead by Dr Jane Ball of the University of Southampton and fellow authors included co-director of the RN4CAST study, Professor Linda Aiken of the University of Pennsylvania.

Ball said for years it was known there was a relationship between nurse staffing levels and hospital variation in mortality rates, but there had not been a good explanation as to how or why. However, links had now been found between lower RN staffing levels, missed patient cares and increased risks of patient death. Each 10 per cent increase in cares left undone was associated with a 16 per cent increase in the likelihood of a patient dying.

The study analysed nurses’ responses to the survey question: “On your most recent shift, which of the following activities were necessary but left undone because you lacked the time to complete them?” and presented nurses with a list of 13 activities (see list below).

The nurses surveyed were also asked how many staff were providing direct care on their last shift and how many patients were on the ward at the time.

Previous analysis of the survey showed that lower nurse staffing levels are associated with higher mortality, but Ball said the further analysis gave the “clearest indication yet that RN staffing levels were not just associated with patient mortality, but that the relationship may be causal”.

“If there are not enough registered nurses on hospital wards, necessary care is left undone and people’s lives are put at risk,” added Dr Ball.

Co-author Luk Bruyneel from KU Leuven in Belgium said the findings had implications for healthcare managers and policymakers. “Monitoring missed care may offer a more responsive and sensitive early-warning system for hospitals to detect problems before patients die,” he said. “More work needs to be done worldwide to ensure we utilise this data for the benefit of patients.”

The analysis also looked at nurses’ qualifications and confirmed that hospitals with higher numbers of registered nurses trained at degree level had a lower risk of patient mortality.

Professor Peter Griffiths, Chair of Health Services Research at the University of Southampton, said the study reinforced the importance of RNs who were trained to degree level. “It is more evidence that shows that you cannot substitute fully qualified RNs with less qualified staff without taking a risk with patient safety,” said Griffiths. “It is the number of RNs on duty that is key to ensuring complete care and minimising the risk of patients dying.”

Article reference:

Jane Ball, Luk Bruynell, Linda H. Aiken et al (2017). Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies (published online open access)

The patient cares asked about in the RN4CAST nursing survey were:

  • adequate patient surveillance
  • skin care
  • oral hygiene
  • pain management
  • treatments and procedures
  • administering medication on time
  • frequently changing the patient’s position
  • comforting/talking with patients
  • educating patients and family
  • preparing patients and families for discharge
  • developing or updating nursing care plans/care pathways
  • documenting nursing care
  • planning care.




Please enter your comment!
Please enter your name here