The incidence of missed care (of one or more cares) is 79% in even the best of work environments with a 92% incident rate found in the lower work environment deciles according to a 2013 study by Ball, Murrells, Rafferty et al.

Missed nursing care is considered  an error of omission defined as any aspect of required patient care that is omitted (either in part or whole) or significantly delayed. It first became recognised conceptually in 2006 in work conducted by Beatrice J Kalisch in the United States.

The quality of nursing care significantly determines (in part) patient outcomes. The patient safety in healthcare movement focuses on eliminating errors of commission (i.e. medications to wrong patient). Errors of omission (i.e. not ambulating a patient) are less detectable, problematic, more prevalent and detrimental than errors of commission.


imageSituations occur within the practice environment  causing a negative impact on nurses time availability for all of the cares required. Nurses at the bedside are very much aware of the care that they provide and those cares they omit.

The nature of providing nursing care lends itself to significant fluctuations in care requirements at any given time due to individual patient care requirements and demands. Flexibility and multi tasking are a necessary nurse characteristic in order to respond to these demands effectively.

Alarmingly there are increasingly more incidences where care needs to be prioritised, rationed or missed all together. Sound clinical reasoning and decision-making is required to ensure appropriate and safe decisions are being made most of the time.
Nursing is seen in healthcare budgetary terms as a ‘cost’ rather than ‘revenue’.


Increased restrictions placed on healthcare around the world mainly due to the global financial crisis is to reduce costs. Nursing labour resources is a significant drain on global health budgets making nursing a target for continual cost costing measures.
A negative correlation has been found between missed care and hours per patient day (HPPD) as well as registered nurse hour per patient day (RN HPPD). The higher the HPPD and RN HPPD the lower the amount of missed care.


There is no evidence in the literature that substitution of nurses with nursing assistants increases the rate of ‘missed care’. Studies conducted in medical, surgical, rehabilitation and intensive care units identified significant amounts of care being missed:

  • ambulation (84%)
  • assessing effectiveness of medications (82%).      image
  • patient teaching (80%)
  • mouth care (82%)
  • turning (82%)
  • timeliness prn medication (80%)

Interventions less likely to be missed include:

  • patient assessment each shift (17%)
  • glucose monitoring (26%)
  • hand washing (30%)
  • formal reassessment (36%)

One study in 2004 of frequency hallway ambulation by hospitalised older adults on medical units found that 73% of adult patients did not ambulate at all. This is despite clinical guidelines recommending the ambulation of adult inpatients at least three times each day.

Theoretically if ‘missed care’ could be reduced and surveillance increased would result in improved patient safety and better patient outcomes.

Patient satisfaction is accepted generally as a vital
indication of the quality of care provided.

Nurses, the care they provide and the organisational environment (cleanliness, meals) are strongly connected to patient satisfaction.Studies have demonstrated an association between nursing and patient satisfaction identifying nursing care as the only hospital service having a direct and strong relationship with overall patient satisfaction.

Other studies have found that patient perceived nurse caring is a major prediction of patient satisfaction. A 2011 European study of surgical patients spanning six countries reported that caring behaviours enacted by nurses determined a consistent proportion of patient satisfaction.

imageThe research is certainly out there that levels of HPPD and RN HPPD impact on rates of ‘missed care’, patient safety and outcome. Viewing nursing purely as a cost does not reflect ‘the whole picture’ on what appropriate levels of nurse staffing can have on healthcare budgets.

It could be argued that investing in nursing at the bedside in real terms by providing adequate staffing and skill mix whilst ensuring nurses have adequate resources at point of care will impact positively on the healthcare budget. Reduced adverse clinical outcomes, decreased length of stay, increased patient and staff satisfaction reduced errors of commission and errors of omission play a significant positive role and impact on healthcare costs.