Online survey exploring researcher experiences of research funding processes in the UK: the effort and burden of applying for funding and fulfilling reporting requirements.

OBJECTIVE: To explore researchers' experiences of funding processes, the effort and burden involved in applying for funding, obtaining funding and/or fulfilling reporting requirements with a UK health and social care research funder. DESIGN/SETTING: A cross-sectional online survey study with open (free-text) and closed questions (August to November 2021). PARTICIPANTS: Researchers with experience of applying for/obtaining funding and/or experience of fulfilling reporting requirements for UK health and social care research funded between January 2018 and June 2021. RESULTS: The survey was completed by 182 researchers, of which 176 had experience with applying for/obtaining funding, and 143 had experience with fulfilling reporting requirements during the timeframe. The majority of the 176 respondents (58%) completed between 7 and 13 key processes in order to submit an application and 69% felt that it was critically important to undertake these key processes. Respondents (n=143) reported submitting an average of 17 reports as part of research monitoring to a range of organisations (eg, funders, Higher Education Institutions). However, only 33% of respondents felt it was critically important to provide the requested reporting information to the different organisations. Thematic analysis of free-text questions on application and reporting identified themes relating to process inefficiencies including streamlining and alignment of systems, lack of understanding of processes including a need for improved communication and feedback from organisations with clear explanations about what information is needed, when and why, the support required by respondents and the time, effort and impact on workload and well-being. CONCLUSIONS: Through this study, we were able to identify funding processes that are considered by some to be effortful, but necessary, as well as those that were perceived as unnecessary, complex and repetitive, and may waste some researchers time and effort and impact on well-being. Possible solutions to increase efficiency and enhance value in these processes were identified.

An in-depth exploration of researcher experiences of time and effort involved in health and social care research funding in the UK: The need for changes.

The need to reform the way in which research is undertaken is clear, with reducing research bureaucracy and waste at the forefront of this issue for the UK government, funding organisations, higher education institutions and wider research community. The aim of this study was to describe researchers' experiences of the time, effort and burden involved in funding processes-namely applying for research funding and fulfilling reporting requirements. This was an in-depth qualitative study using semi-structured interviews with researchers who had experience applying for funding and/or completing reporting requirements for a UK health and social care research funder between January 2018 and June 2021. Following thematic analysis, five key themes were identified describing researcher experiences of key issues around time, efforts and burden associated with funding processes. These themes encompassed (1) issues with the current funding model for health and social care research, (2) time and effort involved in funding processes, (3) the need for a streamlined end-to-end process, (4) implications for work-life balance, and (5) addressing the need for better support and communication. The findings from this study describe researcher experiences of tasks in the research pathway that currently take considerable time and effort. It was clear that whilst some of this time and effort is considered necessary, some is exacerbated by inefficient and ineffective processes, such as perceived under-funding of research or lack of clarity with regards to funder expectations. This in turn contributes to unnecessary researcher burden, research waste and negative research culture. Better investment in health and social care research and in the researchers themselves who design and deliver the research, alongside improvements in transparency, streamlining and research support could ensure a more positive research culture, and improve the quality of funded research.

The use and acceptability of preprints in health and social care settings: A scoping review.

BACKGROUND: Preprints are open and accessible scientific manuscript or report that is shared publicly, through a preprint server, before being submitted to a journal. The value and importance of preprints has grown since its contribution during the public health emergency of the COVID-19 pandemic. Funders and publishers are establishing their position on the use of preprints, in grant applications and publishing models. However, the evidence supporting the use and acceptability of preprints varies across funders, publishers, and researchers. The scoping review explored the current evidence on the use and acceptability of preprints in health and social care settings by publishers, funders, and the research community throughout the research lifecycle. METHODS: A scoping review was undertaken with no study or language limits. The search strategy was limited to the last five years (2017-2022) to capture changes influenced by COVID-19 (e.g., accelerated use and role of preprints in research). The review included international literature, including grey literature, and two databases were searched: Scopus and Web of Science (24 August 2022). RESULTS: 379 titles and abstracts and 193 full text articles were assessed for eligibility. Ninety-eight articles met eligibility criteria and were included for full extraction. For barriers and challenges, 26 statements were grouped under four main themes (e.g., volume/growth of publications, quality assurance/trustworthiness, risks associated to credibility, and validation). For benefits and value, 34 statements were grouped under six themes (e.g., openness/transparency, increased visibility/credibility, open review process, open research, democratic process/systems, increased productivity/opportunities). CONCLUSIONS: Preprints provide opportunities for rapid dissemination but there is a need for clear policies and guidance from journals, publishers, and funders. Cautionary measures are needed to maintain the quality and value of preprints, paying particular attention to how findings are translated to the public. More research is needed to address some of the uncertainties addressed in this review.

Researchers' perspective of real-world impact from UK public health research: A qualitative study.

Research funded by the National Institute for Health Research Public Health Research Programme is being undertaken in a complex system which brings opportunities and challenges for researchers to maximise the impact of their research. This study seeks to better understand the facilitators, challenges and barriers to research impact and knowledge mobilisation from the perspective of UK public health researchers. A qualitative study using semi-structured interviews, informed by the Payback Framework, with public health researchers who held a research award with the National Institute for Health Research Public Health Research programme up to March 2017 was conducted. Following a thematic analysis, three strongly interlinked themes were extracted from the data and three key factors were highlighted as important for facilitating knowledge mobilisation and impact in UK public health research: (1) Public health researcher's perception of the purpose of the research (2) Approaches to undertaking Knowledge mobilisation activities (3) The complex nature of public health research in the wider research context. These have been reflected onto the Payback framework. Public health researchers can maximise the likelihood for impact by being aware of the context in which they are undertaking research, using different methods, and employing several strategies to take advantage of opportunities. There is a need to support researchers with knowledge mobilisation activities and for funders to identify their expectations of the impact resulting from research. Our findings have relevance to public health researchers and funders interested in increasing the benefit that research brings to society.

What works for peer review and decision-making in research funding: a realist synthesis.

INTRODUCTION: Allocation of research funds relies on peer review to support funding decisions, and these processes can be susceptible to biases and inefficiencies. The aim of this work was to determine which past interventions to peer review and decision-making have worked to improve research funding practices, how they worked, and for whom. METHODS: Realist synthesis of peer-review publications and grey literature reporting interventions in peer review for research funding. RESULTS: We analysed 96 publications and 36 website sources. Sixty publications enabled us to extract stakeholder-specific context-mechanism-outcomes configurations (CMOCs) for 50 interventions, which formed the basis of our synthesis. Shorter applications, reviewer and applicant training, virtual funding panels, enhanced decision models, institutional submission quotas, applicant training in peer review and grant-writing reduced interrater variability, increased relevance of funded research, reduced time taken to write and review applications, promoted increased investment into innovation, and lowered cost of panels. CONCLUSIONS: Reports of 50 interventions in different areas of peer review provide useful guidance on ways of solving common issues with the peer review process. Evidence of the broader impact of these interventions on the research ecosystem is still needed, and future research should aim to identify processes that consistently work to improve peer review across funders and research contexts.

Identification and comparison of key criteria of feedback of funding decisions: mixed-methods analysis of funder and applicant perspectives.

OBJECTIVE: This study investigated the content, quality and value of feedback given to applicants who applied to one of four research programmes in the UK funded (or jointly funded) by the National Institute for Health Research (NIHR). METHODS: A mixed-method phased approach was conducted using document analysis and an online survey. Phase 1 examined 114 NIHR applicant feedback documents comprised written feedback from funding committees and external peer-reviewers and a conceptual framework of the key components of feedback was developed using content analysis. Phase 2 was an online survey completed by 113 NIHR applicants. Frequencies of responses to closed questions were calculated. Perceptions of quality and value of feedback were identified using content analysis of open-text responses. RESULTS: In phase 1, a conceptual framework was developed with seven overarching categories: 'Study structure and quality'; 'Team and infrastructure'; 'Acceptability to patients and professionals'; 'Study justification and design'; 'Risks and contingencies'; 'Outputs'; 'Value for money'. A higher frequency of feedback was provided at stage 2 and for successful applications across the majority of components. In phase 2, frequency data showed that opinion on feedback was dependent on funding outcome. Content analysis revealed four main themes: 'Committee transparency'; 'Content validity and reliability'; 'Additional support'; Recognition of effort and constraints'. CONCLUSIONS: This study provides key insights and understanding into the quality, content and value of feedback provided to NIHR applicants. The study identified key areas for improvement that can arise in NIHR funding applications, as well as in the feedback given to applicants that are applicable to other funding organisations. These findings could be used to inform funding application guidance documents to help researchers strengthen their applications and used more widely by other funders to inform their feedback processes.

COVID-19: experiences of lockdown and support needs in children and young adults with kidney conditions.

BACKGROUND: During the initial COVID-19 pandemic, young United Kingdom (UK) kidney patients underwent lockdown and those with increased vulnerabilities socially isolated or 'shielded' at home. The experiences, information needs, decision-making and support needs of children and young adult (CYA) patients or their parents during this period is not well known. METHODS: A UK-wide online survey co-produced with patients was conducted in May 2020 amongst CYA aged 12-30, or parents of children aged < 18 years with any long-term kidney condition. Participants answered qualitative open text alongside quantitative closed questions. Thematic content analysis using a three-stage coding process was conducted. RESULTS: One-hundred and eighteen CYA (median age 21) and 197 parents of children (median age 10) responded. Predominant concerns from CYA were heightened vigilance about viral (68%) and kidney symptoms (77%) and detrimental impact on education or work opportunities (70%). Parents feared the virus more than CYA (71% vs. 40%), and had concerns that their child would catch the virus from them (64%) and would have an adverse impact on other children at home (65%). CYA thematic analysis revealed strong belief of becoming seriously ill if they contracted COVID-19; lost educational opportunities, socialisation and career development; and frustration with the public for not following social distancing rules. Positive outcomes included improved family relationships and community cohesion. Only a minority (14-21% CYA and 20-31% parents, merged questions) desired more support. Subgroup analysis identified greater negative psychological impact in the shielded group. CONCLUSIONS: This survey demonstrates substantial concern and need for accurate tailored advice for CYA based on individualised risks to improve shared decision making.

Decision-making approaches used by UK and international health funding organisations for allocating research funds: A survey of current practice.

Innovations in decision-making practice for allocation of funds in health research are emerging; however, it is not clear to what extent these are used. This study aims to better understand current decision-making practices for the allocation of research funding from the perspective of UK and international health funders. An online survey (active March-April 2019) was distributed by email to UK and international health and health-related funding organisations (e.g., biomedical and social), and was publicised on social media. The survey collected information about decision-making approaches for research funding allocation, and covered assessment criteria, current and past practices, and considerations for improvements or future practice. A mixed methods analysis provided descriptive statistics (frequencies and percentages of responses) and an inductive thematic framework of key experiences. Thirty-one responses were analysed, representing government-funded organisations and charities in the health sector from the UK, Europe and Australia. Four themes were extracted and provided a narrative framework. 1. The most reported decision-making approaches were external peer review, triage, and face-to-face committee meetings; 2. Key values underpinned decision-making processes. These included transparency and gaining perspectives from reviewers with different expertise (e.g., scientific, patient and public); 3. Cross-cutting challenges of the decision-making processes faced by funders included bias, burden and external limitations; 4. Evidence of variations and innovations from the most reported decision-making approaches, including proportionate peer review, number of decision-points, virtual committee meetings and sandpits (interactive workshop). Broadly similar decision-making processes were used by all funders in this survey. Findings indicated a preference for funders to adapt current decision-making processes rather than using more innovative approaches: however, there is a need for more flexibility in decision-making and support to applicants. Funders indicated the need for information and empirical evidence on innovations which would help to inform decision-making in research fund allocation.

The association between nurse staffing levels and a failure to respond to patients with deranged physiology: A retrospective observational study in the UK.

BACKGROUND: Responding to abnormalities in patients' vital signs is a fundamental aspect of nursing. However, failure to respond to patient deterioration is common and often leads to adverse patient outcomes. This study aimed to determine the association between Registered Nurse (RN) and Nursing Assistant (NA) staffing levels and the failure to respond promptly to patients' abnormal physiology. METHODS: This retrospective, observational study used routinely collected patients' vital signs and administrative data, including nursing staffing, from 32 general wards of an acute hospital in England between April 2012 and March 2015. Mixed-effects binomial regression was used to model the relationship between nurse staffing, measured as 'Hours per Patient Day' (HPPD), and a composite primary outcome representing failure to respond for patients with National Early Warning Score (NEWS) values ≥ 6 and ≥ 7. RESULTS: There were 189,123 NEWS values ≥ 6 and 114,504 NEWS values ≥ 7, affecting 28,098 patients. For patients with NEWS values ≥ 7, failure to respond was significantly associated with levels of RN HPPD ((IRR 0.98, 95% CI 0.96-0.99, p = 0.0001) but not NA HPPD (((IRR 0.99, 95%CI 0.96-1.01, p = 0.238). For patients with NEWS values ≥ 6, no such relationship existed. CONCLUSIONS: RN, but not NA, staffing levels influence the rates of failure to respond for patients with the most abnormal vital signs (NEWS values ≥ 7). These findings offer a possible explanation for the increasingly reported association between low RN staffing and an increased risk of patient death during a hospital admission.

Developing a web-based patient decision aid for gastrostomy in motor neuron disease: a study protocol.

INTRODUCTION: Motor neuron disease (MND) is a progressive, incurable disease, characterised by degeneration of the nerves in the brain and spinal cord. Due to the multisystem effects of the disease, patients are faced with many complex, time-sensitive decisions, one of which is the decision on gastrostomy feeding. There are currently no published decision aids (DAs) to support patients making this decision in the UK. This study will develop and pilot a patient DA to provide evidence-based information on gastrostomy placement and feeding that is relevant to people with MND; communicate the risks and benefits associated with each option; check understanding and clarify personal values and preferences, enabling patients to make a decision congruent with their values and appropriate for them. METHODS AND ANALYSIS: A two-phase process, observing the International Patient Decision Aid Standards, will be used to develop the DA, over 24 months starting January 2019. Phase 1 will use literature reviews and stakeholder interviews and surveys to identify essential content for the DA, and explore the best way to present this. In the second phase, a prototype DA will be developed and revised using stakeholder feedback in an iterative process. Stakeholders will include individuals with MND, their carers and the healthcare professionals working with them. ETHICS AND DISSEMINATION: Ethical approval for the study has been granted by West of Scotland Research Ethics Service, reference 19/WS/0078. Study findings will be disseminated through academic and non-academic publications, conference presentations, stakeholder websites and social media. A feasibility study will follow to explore the acceptability and practicality of the DA for patients, carers and HCPs in practice and to assess whether the DA shows promise of being beneficial for the intended population.

The association between nurse staffing levels and the timeliness of vital signs monitoring: a retrospective observational study in the UK.

OBJECTIVES: 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. DESIGN: Retrospective observational study. SETTING: 32 medical and surgical wards in an acute general hospital in England. PARTICIPANTS: 538 238 nursing shifts taken over 30 982 ward days. PRIMARY AND SECONDARY OUTCOME MEASURES: 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. RESULTS: 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. CONCLUSIONS: 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. STUDY REGISTRATION: The data and analyses presented here were part of the larger Missed Care study (ISRCTN registration: 17930973).

Impact of using data from electronic protocols in nursing performance management: A qualitative interview study.

AIM: To explore the impact of using electronic data in performance management to improve nursing compliance with a protocol. BACKGROUND: Electronic data are increasingly used to monitor protocol compliance but little is known about the impact on nurses' practice in hospital wards. METHOD: Seventeen acute hospital nursing staff participated in semi-structured interviews about compliance with an early warning score (EWS) protocol delivered by a bedside electronic handheld device. RESULTS: Before electronic EWS data was used to monitor compliance, staff combined protocol-led actions with clinical judgement. However, some observations were missed to reduce noise and disruption at night. After compliance monitoring was introduced, observations were sometimes covertly omitted using a loophole. Interviewees described a loss of autonomy but acknowledged the EWS system sometimes flagged unexpected patient deterioration. CONCLUSIONS: Introducing automated electronic systems to support nursing tasks can decrease nursing burden but remove the ability to record legitimate reasons for missing observations. This can result in covert resistance that could reduce patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Providing the ability to log legitimate reasons for missing observations would allow nurses to balance professional judgement with the use of electronic data in performance management of protocol compliance.

Nurses' 12-hour shifts and missed or delayed vital signs observations on hospital wards: retrospective observational study.

OBJECTIVES: 12-hour shifts worked by nurses on acute hospital wards have been associated with increased rates of missed care reported by nurses. This study aimed to measure the association between nurses working shifts of at least 12 hours and an objective measure of missed care: vital signs observations taken on time according to an acuity-based surveillance protocol. DESIGN: A retrospective observational study using routinely collected data from March 2012 to March 2015. SETTING: 32 general inpatient wards at a large acute hospital in England. PARTICIPANTS: 658 628 nursing shifts nested in 24 069 ward days. OUTCOME MEASURES: The rate of daily delayed and missed vital signs observations. We focused on situations where vital signs observations were required at least every 4 hours and measured the number of instances where observations were delayed or missed, per 24-hour period. For each ward and each day, shift patterns were characterised in terms of proportion of care hours per patient day deriving from 'long' shifts (≥12 hours) for both registered nurses and healthcare assistants. RESULTS: On 99 043 occasions (53%), observations were significantly delayed, and on 81 568 occasions (44%), observations were missed. Observations were more likely to be delayed when a higher proportion of the hours worked by healthcare assistants were part of long shifts (IRR=1.05; 95% CI 1.00 to 1.10). No significant association was found in relation to the proportion of hours registered nurses worked as long shifts. CONCLUSION: On days when a higher proportion of hours worked by healthcare assistants are from long shifts, the risk of delaying vital signs observations is higher, suggesting lower job performance. While longer shifts are thought to require fewer staff resources to maintain nurse-to-patient ratios, any benefits may be lost if staff become less productive.

Are long nursing shifts on hospital wards associated with sickness absence? A longitudinal retrospective observational study.

OBJECTIVE: To investigate whether working 12 hr shifts is associated with increased sickness absence among registered nurses and health care assistants. BACKGROUND: Previous studies reported negative impacts on nurses' 12 hr shifts; however, these studies used cross-sectional techniques and subjective nurse-reported data. METHODS: A retrospective longitudinal study using routinely collected data across 32 general inpatient wards at an acute hospital in England. We used generalized linear mixed models to explore the association between shift patterns and the subsequent occurrence of short (<7 days) or long-term (≥7 days) sickness absence. RESULTS: We analysed 601,282 shifts and 8,090 distinct episodes of sickness absence. When more than 75% of shifts worked in the past 7 days were 12 hr in length, the odds of both a short-term (adjusted odds ratio = 1.28; 95% confidence index: 1.18-1.39) and long-term sickness episode (adjusted odds ratio = 1.22; 95% confidence index: 1.08-1.37) were increased compared with working none. CONCLUSION: Working long shifts on hospital wards is associated with a higher risk of sickness absence for registered nurses and health care assistants. IMPLICATIONS FOR NURSING MANAGEMENT: The higher sickness absence rates associated with long shifts could result in additional costs or loss of productivity for hospitals. The routine implementation of long shifts should be avoided.

Development of Breast Cancer Choices: a decision support tool for young women with breast cancer deciding whether to have genetic testing for BRCA1/2 mutations.

PURPOSE: To develop a decision support tool for young women with breast cancer considering genetic testing for BRCA1/2 mutations soon after cancer diagnosis. METHODS: A four-stage iterative development process was employed; stage 1, literature review exploring the availability and efficacy of empirically tested decision support tools; stage 2, in-depth interviews with 29 young women (< 50 years) recently diagnosed with breast cancer, exploring information requirements and experiences of genetic testing decision making; stage 3, three focus groups (N = 21) exploring preferences for information presentation and prioritisation of content; stage 4, think-aloud interviews to refine the prototype (N = 16). RESULTS: Participants wanted information regarding the pros and cons of testing, the testing process and implications for their family, presented in a way that allowed them to choose the level of detail they required. They preferred the term 'altered gene', valued a medical word definition function and warnings before accessing sensitive information. CONCLUSION: Participants valued the decision support tool, the accessibility of the information and its clinical endorsement. The decision support tool has considerable clinical utility as an adjunct to genetic counselling or for use in busy oncology clinics where formal genetic counselling may be unavailable.

Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study.

OBJECTIVE: To determine the association between daily levels of registered nurse (RN) and nursing assistant staffing and hospital mortality. DESIGN: This is a retrospective longitudinal observational study using routinely collected data. We used multilevel/hierarchical mixed-effects regression models to explore the association between patient outcomes and daily variation in RN and nursing assistant staffing, measured as hours per patient per day relative to ward mean. Analyses were controlled for ward and patient risk. PARTICIPANTS: 138 133 adult patients spending >1 days on general wards between 1 April 2012 and 31 March 2015. OUTCOMES: In-hospital deaths. RESULTS: Hospital mortality was 4.1%. The hazard of death was increased by 3% for every day a patient experienced RN staffing below ward mean (adjusted HR (aHR) 1.03, 95% CI 1.01 to 1.05). Relative to ward mean, each additional hour of RN care available over the first 5 days of a patient's stay was associated with 3% reduction in the hazard of death (aHR 0.97, 95% CI 0.94 to 1.0). Days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05, 95% CI 1.01 1.09). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality. CONCLUSION: Lower RN staffing and higher levels of admissions per RN are associated with increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing and do not give support to policies that encourage the use of nursing assistants to compensate for shortages of RNs.

Relationships between healthcare staff characteristics and the conduct of vital signs observations at night: Results of a survey and factor analysis.

AIM: To explore the association of healthcare staff with factors relevant to completing observations at night. DESIGN: Online survey conducted with registered nurses, midwives, healthcare support staff and student nurses who had worked at least one night shift in a National Health Service hospital in England. METHODS: Exploratory factor analysis and mixed effects regression model adjusting for role, number of night shifts worked, experience and shift patterns. RESULTS: Survey items were summarized into four factors: (a) workload and resources; (b) prioritization; (c) safety culture; (d) responsibility and control. Staff experience and role were associated with conducting surveillance tasks. Nurses with greater experience associated workload and resources with capacity to complete work at night. Responses of student nurses and midwives showed higher propensity to follow the protocol for conducting observations. Respondents working night shifts either exclusively or occasionally perceived that professional knowledge rather than protocol guided care tasks during night shifts.

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

AIMS: To identify nursing care most frequently missed in acute adult inpatient wards and to 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 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 were abstracted on study design, missed care prevalence and measures of association. Synthesis was narrative. RESULTS: Eighteen studies gave subjective reports of missed care. Seventy-five per cent 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.

"It's Like We Don't Exist": Tailoring Education for Young Women Undergoing Surgery for Early-Stage Breast Cancer

PURPOSE: The implications of a diagnosis and consequent surgical treatment for breast cancer may be different for young women compared to older women. This study investigated the information requirements of young women to support their treatment decision making at diagnosis.
. PARTICIPANTS & SETTING: A purposeful sample of 20 women diagnosed with breast cancer aged 40 years or younger who had undergone surgery and had participated in a large cohort study in the United Kingdom.
. METHODOLOGIC APPROACH: Audio recordings of semistructured interviews were used to reveal information received at the time of surgical treatment.
. FINDINGS: Themes identified were types of breast cancer, surgical treatments, nonsurgical treatments, fertility, and surgery and after surgery. Participants felt that information required throughout treatment was influenced by individual life circumstances, such as children or plans for children, relationships, and career intentions. Participants felt information was lacking on the effects of treatment on body image, reconstructive surgery, and genetic predisposition to breast cancer.
. IMPLICATIONS FOR NURSING: Knowledge of the information requirements of young women diagnosed with breast cancer allows nursing staff to provide tailored support at times identified as most useful.

What impact does nursing care left undone have on patient outcomes? Review of the literature.

AIMS AND OBJECTIVES: Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes. BACKGROUND: A considerable body of evidence supports the hypothesis that lower levels of registered nurses on duty increase the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear. DESIGN: Systematic review. METHODS: We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses' aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review. RESULTS: Fourteen studies reported associations between missed care and patient outcomes. Some studies were secondary analyses of a large parent study. Most of the studies used nurse or patient reports to capture outcomes, with some using administrative data. Four studies found significantly decreased patient satisfaction associated with missed care. Seven studies reported associations with one or more patient outcomes including medication errors, urinary tract infections, patient falls, pressure ulcers, critical incidents, quality of care and patient readmissions. Three studies investigated whether there was a link between missed care and mortality and from these results no clear associations emerged. CONCLUSIONS: The review shows the modest evidence base of studies exploring missed care and patient outcomes generated mostly from nurse and patient self-reported data. To support the assertion that nurse staffing levels and skill mix are associated with adverse outcomes as a result of missed care, more research that uses objective staffing and outcome measures is required. RELEVANCE TO CLINICAL PRACTICE: Although nurses may exercise judgements in rationing care in the face of pressure, there are nonetheless adverse consequences for patients (ranging from poor experience of care to increased risk of infection, readmissions and complications due to critical incidents from undetected physiological deterioration). Hospitals should pay attention to nurses' reports of missed care and consider routine monitoring as a quality and safety indicator.