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

Peter Griffiths, Alejandra Recio-Saucedo, Chiara Dall'Ora, Jim Briggs, Antonello Maruotti, Paul Meredith, Gary B. Smith, Jane Ball

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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 was 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.
Original languageEnglish
JournalJournal of Advanced Nursing
Early online date8 Mar 2018
Publication statusEarly online - 8 Mar 2018


  • hospital
  • systematic review
  • nursing staff
  • skill mix
  • missed care
  • care left undone
  • implicit rationing
  • quality
  • workforce


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