As the current COVID-19 pandemic demonstrates, nurses have a critical role in the coordination, delivery, and evaluation of care. In fact, prior to the pandemic, 2020 was designated as the “Year of the Nurse and Midwife” in recognition of nurses’ essential contributions to health care. Studies show, however, that nursing care is often “missed,” meaning that it is delayed, partially completed, or not completed at all. Missed care is problematic, as it is associated with worse patient care experiences and health outcomes as well as nurse ethical distress and burnout. In a recent study at Penn Nursing’s Center for Health Outcomes and Policy Research, my colleagues Eileen Lake, Douglas Sloane, and I investigated how changes in the hospital work environment and nurse staffing over time affect missed nursing care.

A supportive work environment for nurses provides capable nurse leaders, encourages nurse participation in hospital governance and decision-making, assures adequate resources and staffing, and fosters collaboration between doctors and nurses. Supportive work environments are associated with better patient health outcomes and nurse job outcomes. Previous research has also shown that nursing care is missed less frequently in hospitals with supportive environments and adequate staffing. This evidence, however, has been limited to cross-sectional studies that do not establish a causal link between organizational change and missed care.

To address this gap, we analyzed survey data from roughly 24,000 nurses in 2006 and 15,000 nurses in 2016 from 458 hospitals in four large and geographically diverse states to demonstrate how changes in the hospital work environment and nurse staffing over time led to less missed nursing care. We adjusted for hospital characteristics – such as bed size, teaching hospital status, and technology capability – that could impact work environment and staffing.

Over the ten-year study period, 67 percent of nurses surveyed in 2006 and 75 percent of nurses surveyed in 2016 reported missing one or more care activities on their last shift, such as adequate patient surveillance or pain management. Out of the 14 activities that encompass fundamental nursing responsibilities, on average, nurses missed 2.4 necessary activities in 2006 and 2.6 activities in 2016. However, in hospitals that reported “improved” or more supportive work environments during this period, 11 percent fewer nurses missed care compared to hospitals with “worse” or less supportive environments. Similarly, compared to hospitals where nurse staffing levels decreased, five percent fewer nurses missed care in hospitals that improved or maintained their staffing levels during the study period. The frequency of missed care activities decreased substantially in hospitals that improved their work environment (1.3 standard deviations), but changed only slightly in hospitals with improved staffing (0.5 standard deviations).

Our study is the first to provide evidence of the direct link between the hospital organizational environment and missed nursing care. Given nurses’ essential role in promoting patient health and healing, reducing missed nursing care should be a top priority for hospital managers and executives. By demonstrating that the hospital work environment and nurse staffing can be modified to reduce missed care, our results offer an important strategy for hospitals to improve patient care and outcomes.