Patient-Count and Perceived Workload Associations With Missed Nursing Care: A Multicenter Repeated-Measures Study

Missed nursing care threatens quality and safety, but patient counts may not capture shift-level demands. We examined associations of patient-count and perceived workload indicators with missed care, separating within- and between-nurse effects.

A multicenter observational study using repeated shift-level measurements.

The study included 502 shift records from 213 nurses in 16 medical-surgical units across six Italian hospitals; the primary analysis included 480 records from 196 nurses. Patient-count indicators were nurse-reported numbers of assigned, isolated, and specialist-care patients; perceived workload included work rhythm/quantity, mental workload, emotional workload, and work organization. Grouped-binomial generalized estimating equations modeled the proportion of applicable activities missed, with nurse clustering, robust standard errors, exchangeable correlation, and hospital fixed effects. Workloads were decomposed into within- and between-nurse components, and four missed-care domains were examined.

Nurses reported a mean of 6.5 missed activities per shift; 29.9% of shifts had no missed care. The seven workload indicators were jointly associated with missed care (robust Wald χ²[7] = 22.95, p = 0.002). Work rhythm/quantity was the only individual indicator with a nominal p-value below 0.05 (OR 1.24 per SD, 95% CI 1.03-1.49; p = 0.023), but it did not remain significant after Benjamini-Hochberg correction (q = 0.159). Assigned patient count was not clearly associated (OR 1.14, 95% CI 0.94-1.40; p = 0.192). In exploratory within-between analyses, the between-nurse work rhythm/quantity component was associated with missed care (OR 1.42, 95% CI 1.11-1.82; p = 0.005), whereas the within-nurse component was not (OR 1.03, 95% CI 0.90-1.17; p = 0.649). Domain-specific associations did not remain significant after multiplicity adjustment.

The workload indicators were jointly associated with missed nursing care, with secondary analyses indicating that the global signal was evident in the perceived-workload block. However, no individual workload indicator remained statistically significant after multiplicity adjustment. Work rhythm/quantity and its between-nurse component should therefore be regarded as exploratory signals requiring confirmation in studies with denser repeated measurements.

Workload surveillance research should evaluate patient-count and multidimensional perceived-workload indicators together. The present coefficient-specific findings are insufficient to support the operational use of work rhythm/quantity as a stand-alone workload indicator.