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<jats:sec><jats:title>Objectives</jats:title><jats:p>Omissions and delays in delivering nursing care are widely reported consequences of staffing shortages, with potentially serious impacts on patients. However, studies so far have relied almost exclusively on nurse self-reporting. Monitoring vital signs is a key part of nursing work and electronic recording provides an opportunity to objectively measure delays in care. This study aimed to determine the association between registered nurse (RN) and nursing assistant (NA) staffing levels and adherence to a vital signs monitoring protocol.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Retrospective observational study.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>32 medical and surgical wards in an acute general hospital in England.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>538 238 nursing shifts taken over 30 982 ward days.</jats:p></jats:sec><jats:sec><jats:title>Primary and secondary outcome measures</jats:title><jats:p>Vital signs observations were scheduled according to a protocol based on the National Early Warning Score (NEWS). The primary outcome was the daily rate of missed vital signs (overdue by ≥67% of the expected time to next observation). The secondary outcome was the daily rate of late vital signs observations (overdue by ≥33%). We undertook subgroup analysis by stratifying observations into low, medium and high acuity using NEWS.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Late and missed observations were frequent, particularly in high acuity patients (median=44%). Higher levels of RN staffing, measured in hours per patient per day (HPPD), were associated with a lower rate of missed observations in all (IRR 0.983, 95% CI 0.979 to 0.987) and high acuity patients (0.982, 95% CI 0.972 to 0.992). However, levels of NA staffing were only associated with the daily rate (0.954, CI 0.949 to 0.958) of all missed observations.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Adherence to vital signs monitoring protocols is sensitive to levels of nurse and NA staffing, although high acuity observations appeared unaffected by levels of NAs. We demonstrate that objectively measured omissions in care are related to nurse staffing levels, although the absolute effects are small.</jats:p></jats:sec><jats:sec><jats:title>Study registration</jats:title><jats:p>The data and analyses presented here were part of the larger Missed Care study (ISRCTN registration: 17930973).</jats:p></jats:sec>

Original publication




Journal article


BMJ Open



Publication Date





e032157 - e032157