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

Introduction: 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. Design: A multicenter observational study using repeated shift-level measurements. Methods: 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. Results: 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. Conclusion: 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. Clinical relevance: 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.