Missed nursing care in emergency departments: A scoping review

BackgroundPatient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts.AimThe aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs.MethodA scoping review following the framework suggested by Arksey and O’Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation.ResultsIn total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe.ConclusionThe findings from this scoping review indicate that patients’ fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.     

Missed Nursing Care in the Postanesthesia Care Unit: A Cross-Sectional Study

PurposeThis study aimed to investigate the prevalence, activities, and reasons for missed nursing care in the postanesthesia care unit (PACU) and the effect of intensive care unit (ICU) overflow patients.DesignThis is a single-center, cross-sectional survey.MethodsNineteen PACU-registered nurses of a tertiary care hospital participated. Over a 7-month period, participants were asked to complete a validated questionnaire, which included 19 items related to missed nursing care activities and 10 items related to reasons for missed nursing care. χ² test and 1-way analysis of variance were used for data analysis.FindingsQuestionnaires (N = 397) were completed. Prevalence of missed nursing care activities was 78.1% and was significantly higher in cases of ICU overflow patients (P < .001). The three most reported missed nursing care activities were “drug preparation, administration, and assessment of effectiveness," “patient surveillance and assessment," and “care associated with pain”; prevalence was significantly higher in cases of ICU overflow patients (P = .036, P = .003, and P = .004, respectively). The three most reported reasons for missed nursing care were “inadequate number of nursing personnel," “unexpected rise in patient volume or acuity," and “heavy admission or discharge activity".ConclusionsThe findings indicated missed nursing care was common in the PACU and increased in case of ICU overflow patients. Therefore, missed nursing care needs to be identified and minimized, while the number and length of stay of critically ill patients admitted to the PACU should be limited.     

Supportive care for older people with frailty in hospital: An integrative review

BackgroundGrowing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care.AimTo identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation.DesignAn integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term ‘supportive care’. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken.Data sourcesLiterature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n = 52) were integrated using synthesis of themes.ResultsRelevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings.ConclusionThe findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.     

Missed infection control care and healthcare associated infections: A qualitative study

BackgroundResearch on missed nursing care reveals individual and systems failure. Research on infection control missed care is minimal.AimsInvestigate nurse perceptions of missed infection control.DesignQualitative in-depth interviews with 11 Australian infection control nurse experts.MethodsParticipants were asked whether nursing and hospital-wide care tasks fundamental to infection control were missed, and what were the underlying causes and contributing factors for these omissions. Qualitative data was mapped against fundamental nursing practice and Australian infection control guidelines.FindingsOmission of infection control care occur at the individual clinician and organisational level. Nurses describe failure to perform standard precautions as well as failure to perform basic care activities. Participants identified a range of institutional and cultural factors which contributed to cascade iatrogenesis resulting in healthcare associated infections for patients. Some factors are outside nurses’ control and include: environmental cleanliness; ward layout; ward culture; resourcing and staffing; integration of infection control into clinical governance; action following audit results; and reviewing evidence base of protocols.DiscussionCare occurs in complex and conflicted settings, with prioritisation essential. Potentially harmful practices are generally done with the intention of care. Nurses are key, but not sole performers in the creation of quality infection control.ConclusionMapping missed care related to infection control against standard frameworks of nursing practice revealed “gaps in the chain of infection” that contribute to “cascade iatrogenesis” with negative outcomes for patients.     

How does the length of day shift affect patient care on older people's wards? A mixed method study

BackgroundInternationally, studies have focused on whether shift length impacts on patient care. There are also ongoing concerns about patient care for older people in hospital. The study aim was to investigate how length of day shift affects patient care in older people’s hospital wards.Objectives1) To explore how length of day shift affects patient care in older people’s wards; 2) To explore how length of day shift affects the quality of communication between nursing staff and patients/families on older people’s wardsDesignA mixed method case study.SettingsThe study was based on two older people’s wards in an acute hospital in England. One ward was piloting two, overlapping 8 h day shifts for 6 months while the other ward continued with 12 h day shifts.Participants and methodsQualitative interviews were conducted with 22 purposively recruited nursing staff (17 registered nurses; 5 nursing assistants). An analysis of patient discharge survey data was conducted (n = 279). Twenty hours of observation of nursing staff’s interactions with patients and families was conducted, using an adapted version of the Quality of Interaction Schedule (301 interactions observed), with open fieldnotes recorded, to contextualise the observations.ResultsThere were no statistically significant differences in patient survey results, or quality of interactions, between the two wards. There were three overall themes: Effects of day shift length on patient care; Effects of day shift length on continuity of care and relationships; Effects of day shift length on communication with patients and families. Nursing staff believed that tiredness could affect care and communication but had varied views about which shift pattern was most tiring. They considered continuity of care was important, especially for older people, but had mixed views about which shift pattern best promoted care continuity. The difficulties in staffing a ward with an 8 h day shift pattern, in a hospital that had a 12 h day shift pattern were highlighted. Other factors that could affect patient care were noted including: ward leadership, ward acuity, use of temporary staff and their characteristics, number of consecutive shifts, skillmix and staff experience.ConclusionsThere was no conclusive evidence that length of day shift affected patient care or nursing staff communication with patients and families. Nursing staff held varied views about the effects of day shift length on patient care. There were many other factors identified that could affect patient care in older people’s wards.     

加速康复外科理念下信息化延续护理在老年髋部脆性骨折患者中的应用

目的探讨基于加速康复外科(ERAS)理念的信息化延续护理在老年髋部脆性骨折患者中的应用效果。方法采用便利抽样法,选择2018年5—12月北京积水潭医院收治的186例老年髋部脆性骨折患者为对照组,采用ERAS理念下常规延续护理,选择2019年5—12月北京积水潭医院收治的193例老年髋部脆性骨折患者为试验组,采用ERAS理念下信息化延续护理,依托微信多元化、信息化平台,组建ERAS多学科协作团队,实施多元化、精准化、连续性的信息化延续护理。采用t检验、χ²检验和Fisher精确检验比较干预后两组患者延续护理依从性和延续护理效率指标。结果试验组主动寻求建议、康复训练、按时复诊、规范用药及合理饮食依从率均高于对照组,差异均有统计学意义(χ²值分别为50.846、37.408、6.916、14.108、17.111;P<0.01)。出院6个月后试验组患者Harris髋关节功能评分量表得分为(89.3±5.1)分、骨质疏松药物正确使用率为99.0%(191/193)、患者满意度为97.9%(189/193),均高于对照组,差异均有统计学意义(t/χ²值分别为29.598、50.746、11.017;P<0.01);试验组患者二次骨折发生率为1.6%(3/193)、并发症发生率为5.2%(10/193),均低于对照组,差异有统计学意义(χ²值为4.177、9.369;P<0.05)。结论基于ERAS理念的信息化延续护理能提高老年髋部脆性骨折患者居家护理的依从性,利于患者加速康复。     

Nurses’ perspectives on responding to elder abuse in a hospital setting

BackgroundNurses caring for hospitalised older people are well situated to identify and respond to elder abuse. However, little is known about how nurses working in acute and subacute care recognise and respond to suspected abuse.AimThe project team aimed to explore how nurses detect, assess and respond to elder abuse as part of a quality improvement activity to develop a model of care to address elder abuse.MethodFocus group interviews were conducted with ward nurses and nurse educators (n = 19) working in both acute and subacute care settings in a tertiary teaching hospital. Transcribed interviews were coded and analysed thematically.FindingsPrimary themes identified included: perceived flags for elder abuse; the importance of relationship building to elicit disclosures; the challenges involved in substantiating abuse; and dealing with uncertain outcomes.DiscussionDifficulties encountered in substantiating abuse were often compounded by organisational factors and time constraints. Having the time to build a relationship with the older person enabled a more comprehensive assessment of risk factors, but for those working in fast-paced wards this was not always possible.ConclusionEffective responses to elder abuse require an organisational culture that recognises the importance of a relationship-based model of care.     

Factors related to aggressive behaviors among older adults in nursing homes of Korea: A cross-sectional survey study

BackgroundAggressive behavior is one of the most challenging behavioral psychological symptoms for older adults and their caregivers in nursing homes.ObjectivesThe purpose of this study was to examine and identify contributing factors of aggressive behaviors among older adults in nursing homes in South Korea.DesignThis is a secondary analysis of a national survey on health and functional status among older nursing home residents.SettingsParticipants were recruited from 91 nursing homes.ParticipantsA total of 1447 older adults were included for final analysis and they were randomly selected from a nationally representative sample of people 65 years and older at the sampled nursing homes.MethodsPresence of aggressive behaviors was identified when participants showed at least one of the five symptoms in the Korean interRAI Long-Term Care Facility Assessment Tool such as physical abuse, verbal abuse, socially inappropriate or destructive behaviors, and resistance to care. Theory-based contributing factors were selected and examined. Multivariate logistic regression analyses were performed.ResultsAbout 19% of older nursing homes residents had aggressive behaviors, and several health and social factors including social engagement are associated with aggressive behaviors.ConclusionsAggressive behavior is prevalent in older nursing home residents with and without dementia in South Korea and individual and institutional level interventions are necessary.     

Enhancing students’ preparedness to care for older people: A mixed methods analysis

BackgroundNursing students’ positive attitudes towards ageing and older people are central to developing person-centred care. Perceptions about older people are influenced by social and generational values and beliefs, including a general understanding that older people need to be cared for. Nursing students often undertake early clinical placements in aged care settings, where residents’ needs are complex, yet the nursing experience is often considered ‘basic’ care. Illustrating that older people have rich personal histories and are valuable contributors to society can balance students’ perceptions and expectations and outcomes of clinical placements. Educational interventions using photo-elicitation and in-depth dialogue may surface students’ assumptions and challenge their misperceptions of older people before the first clinical placement.AimTo examine the impact of the innovative Depth of Field: Exploring Ageing © (DOF) resource as preparation for nursing students’ clinical placement in residential aged care facilities.MethodsMixed methods, block randomised controlled study with first year students. Students attending clinical laboratory groups received either usual preparation (control, n = 108) or DOF plus usual preparation (intervention, n = 99). Pre/post surveys included: Geriatric Attitudes Scale (GAS) and demographics. Eight students from the intervention group participated in focus groups post-clinical.FindingsGroups were similar at baseline. There were statistically significant changes following the intervention (p ≤ .05) for 9/13 individual GAS items and difference in overall mean scores (intervention group: M = 0.26; SD = 0.27; control group: M = 0.01; SD = 0.27). Focus group themes included: preconceptions toward older people; feelings of being emotionally unprepared; and perceptions of the DOF intervention in preparing students to connect with the older person.DiscussionThe DOF vignette provided opportunity for students to preflect on ageing. Translation to practice was evidenced with students seeing beyond residents’ physical care requirements to the value of connecting with the older person’s story to facilitate person-centred care.ConclusionsThe DOF intervention assisted students to adopt positive attitudes and a broader perspective of older people, as preparation for placement in residential aged care facilities.     

Missed nursing care in Australia: Exploring the contributing factors

BackgroundNurses are increasingly ending their shifts with outstanding tasks and missing vital aspects of patient care. Research has indicated that this could have a detrimental effect on both nurse and patient outcomes. The connection between inadequate staffing levels and missed nursing care is well documented in the research. However, other contributing factors leading to missed nursing care remain uncertain. This scoping review seeks to identify the contributing factors to missed nursing care in an Australian context.AimTo determine the contributing factors to missed nursing care by registered nurses in Australian hospitals.MethodsMEDLINE, CINAHL, and PubMed were searched for primary and secondary research articles. A scoping review was conducted using the Joanna Briggs Institute methodology for scoping reviews. Data from the studies was analysed by two independent reviewers and presented with a narrative synthesis of the findings.FindingsSeventeen studies were conducted in Australia. The main contributing factors to missed nursing care were: Inadequate staffing, environmental factors, and urgent situations. Nurses’ poor insight into personal and professional accountability was also found to contribute to missed nursing care.DiscussionThis review adds an important perspective to the impact of staffing on missed nursing care due to the mandated nurse-to-patient ratios in Australia, which has not been investigated in other countries. It found that mandated nurse-to-patient ratios can lead to a reduction in missed nursing care.ConclusionFurther research is required into mandated nurse-to-patient ratios and a nurse's personal and professional accountability and missed nursing care.     

Inpatient mortality of hip fracture patients in the Veterans Health Administration.

Hip fractures among elderly people frequently result in permanent disabilities, nursing home placement, and death. The bulk of hip fracture research focuses on elderly women. Within the Veterans Health Administration (VHA), the majority of patients are men. There are no published national reports on hip fractures with large male samples, or on related inpatient mortality among veterans. This retrospective study of 13,546 veterans with hip fracture discharges from 1998-2002 found unadjusted mortality rates are higher in the VHA, compared with the general population. VHA patients tend to be older men in poor health who stay in the hospital longer Increased knowledge about the risks and outcomes associated with hip fractures in men could lead to improved primary and secondary injury-prevention programs. Rehabilitation nurses in acute care can be catalysts in proactively incorporating protective devices, screening for osteoporosis, and initiating lifestyle changes in their plans of care to optimize outcomes for hip fracture patients.     

Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: A systematic review.

BACKGROUND: While hip fractures are an important cause of disability, dependency and death in older adults, the benefit of multi-disciplinary rehabilitation for people who have sustained hip fracture has not been demonstrated. METHODS: Systematic review of randomized controlled trials which compare co-ordinated multi-disciplinary rehabilitation with usual orthopaedic care in older people who had sustained a hip fracture. Outcome measures included: mortality, return home, "poor outcome", total length of hospital stay, readmissions and level of function. RESULTS: We identified 11 trials including 2177 patients. Patients who received multi-disciplinary rehabilitation were at a lower risk (Risk Ratio 0.84, 95% CI 0.73-0.96) of a "poor outcome" - that is dying or admission to a nursing home at discharge from the programme, and showed a trend towards higher levels of return home (Risk Ratio 1.07, 95% CI 1.00-1.15). Pooled data for mortality did not demonstrate any difference between multi-disciplinary rehabilitation and usual orthopaedic care. CONCLUSION: This is the first review of randomized trials to demonstrate a benefit from multi-disciplinary rehabilitation; a 16% reduction in the pooled outcome combining death or admission to a nursing home. This result supports the routine provision of organized care for patients following hip fracture, as is current practice for patients after stroke.     

Nurses’ perception of missed nursing care in a Western Australian teaching hospital: A cross-sectional study

BackgroundMissed nursing care (MNC) has gained increasing emphasis in nursing literature because of its association with nurse and patient outcomes in healthcare settings. While missed care has been widely studied, little evidence is available on the types and frequency of missed care, reasons for its occurrence, and predictors of missed care in Western Australia.AimsTo determine nurses’ perceptions of the types of MNC, reasons for missed care and to identify factors predicting missed care occurrence in Western Australian acute care settings.MethodsA cross-sectional study in medical and surgical wards was performed. The nurse MISSCARE survey tool was used to capture self-reported types and reasons for missed care and level of nurse job satisfaction from a sample of 204 nurses working in 16 acute care wards. Data analyses were carried out in International Business Machines Corperation located in Armonk, New York United States (IBM SPSS Statistics) (v 29).FindingsThe most common perceived missed activities included ambulation (87%), patient teaching (79%), interdisciplinary conference attendance (78%), mouth care (78%), intake and output (77%), and patient turning (75%). Labour resources ranked highest for reasons for missed care followed by material resources and communication. Significant relationships were observed between missed care and job satisfaction, role satisfaction, and teamwork.DiscussionWorking overtime, job dissatisfaction, inadequate staffing, and heavy admissions and discharges were related to increased likelihood for missed care occurrence.ConclusionAlthough further studies examining the link between MNC and staffing methodologies are needed, this study provides evidence on nurse-reported missed care and the impact of missed care in Western Australia.     

Nurses' perceptions of quality and the factors that affect quality care for older people living in long-term care settings in Ireland

Aim. The aim of this research was to determine the factors that facilitate or hinder high quality nursing care for older people in long‐term care settings in Ireland. Background. The quality of care for older people living in long‐term care has been identified as an issue of concern in many nursing research studies. While many factors which have an impact on care have been identified, it is difficult to determine key factors from current research. Method. This was a mixed method study, which involved qualitative and quantitative approaches. A self‐response questionnaire was generated from data gathered by interview and analysis of literature. Information was collected from 498 nurses working in long‐term care settings within a Health Board. A 68% response rate was achieved. Factor analysis was used to identify facilitating and hindering factors of quality care for older people. Results. Nine factors where identified six facilitating factors of quality and three hindering factors of quality care. The six factors, which facilitate quality, were: an ethos of promoting independence and autonomy; a homelike social environment; person centred, holistic care; knowledgeable, skilled staff; knowing the person and adequate multidisciplinary resources. The three factors which hindered quality care; these were: a lack of time and patient choice, resistance to change and bound by routine. Conclusions. The findings of this research provide nurses with a clear set of facilitating and hindering factors of quality care for older people and reveal some of the complexities and challenges of providing this care. Relevance to clinical practice. Long‐term care is the home of many older people and attention within these environments to the facilitating and hindering factors of quality is required. It is hoped that the factors generated in this study add to understanding in relation to quality care and the factors that influence this.     

Missed nursing care in the critical care unit,before and during the COVID-19 pandemic: A comparative cross-sectional study

ObjectivesTo describe and evaluate reported missed nursing care in the critical care context during different phases of the COVID-19 pandemic in Sweden.Research methodologyA comparative cross-sectional design was used, comparing missed nursing care in three samples: before the COVID-19 pandemic in 2019, during the second wave of the pandemic in spring 2020, and during the third wave of the pandemic in fall 2021.SettingThe study was conducted at critical care units at a university hospital, Sweden.Main outcome measuresThe MISSCARE Survey-Swedish version was used to collect data along with two study-specific questions concerning perception of patient safety and quality of care.ResultsSignificantly more overtime hours and number of days absent due to illness were reported during the pandemic. The nurse/patient ratio was above the recommended level at all data collection time points. Most missed nursing care was reported in items concerning basic care. The most reported reasons for missed nursing care in all samples concerned inadequate staffing, urgent situations, and a rise in patient volume. Most nurses in all samples perceived the level of patient safety and quality of care as good, and the majority had no intention to leave their current position.ConclusionThe pandemic had a great impact on the critical care workforce but few elements of missed nursing care were affected. To measure and use missed nursing care as a quality indicator could be valuable for nursing managers, to inform them and improve their ability to meet changes in patient needs with different workforce approaches in critical care settings.     

Teamwork,clinical leadership skills and environmental factors that influence missed nursing care – A qualitative study on hospital wards

AimTo explore how nursing teams in clinical inpatient nursing hospital wards perform teamwork to prevent or reduce missed nursing care and how teamwork is influenced by clinical leadership skills and environmental factors.BackgroundEarlier studies on missed nursing care identified teamwork and leadership skills as promising factors in inpatient care that can positively influence quality of care and reduce missed nursing care. The effective use of teamwork in hospitals requires understanding what it is, how it is performed by nursing teams and how it is influenced by clinical leadership skills and environmental factors.DesignA qualitative exploratory study was undertaken between January and March 2021.MethodsA total of 16 registered nurses who worked on various hospital wards, participated in three online focus groups. Data were analyzed with thematic analysis according to Braun and Clarke.ResultsThematic analysis revealed four themes. First, nurses perform teamwork and clinical leadership skills in various ways. Some nurses work in pairs and have common goals, while other nurses work individually. This influences teamwork. Second, nurses are informal teachers, visible in teaching and learning from each other, contributing in constructive teamwork. Third, senior nurses are seen as informal leaders, forming connection between nursing wards and formal leaders, resulting in awareness of each other and the progress of patientcare. Finally, environmental factors influence the performance of teamwork.ConclusionsResults of this study show how knowledge regarding missed nursing care can be increased. Results can be used for developing training programs and embedding education in practice aimed at constructive teamwork, clinical leadership skills and missed nursing care.     

Delivering high quality hip fracture rehabilitation: the perspective of occupational and physical therapy practitioners

Aim: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners’ perspectives on the practices that constitute high quality hip fracture rehabilitation.

Methods: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners’ perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach.

Results: Seven themes emerged: objectives of care; first 72?h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration.

Conclusions: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners’ perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes.

• Implications for Rehabilitation

• This study highlights occupational and physiotherapy therapy practitioners’ perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation.

• While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers.

• Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

     

Why do nurses miss infection control activities? A qualitative study

BackgroundHospital acquired infections (HAIs) increase length of hospital stay and lead to poorer clinical outcomes. HAIs are viewed as preventable through risk monitoring and prevention of transmission. These activities are frequently missed. This study explores missed infection control activities through the lens of missed or rationed care.AimTo determine the factors that contribute to infection control activities being missed.MethodsSemi-structured interviews were conducted with eleven nurses with infection control expertise.FindingsFour major factors were identified as contributing to infection control activities being missed. These are systemic factors such as poor staffing and skillmix which contribute to time constraints and difficulties with identifying signs of infection; environmental factors such as ward layout and access to Personal Protective Equipment (PPE); organisational factors including lack of managerial support and interprofessional relationships; and personal factors, primarily the priority given to infection control by the nurse and knowledge, understanding and application of the principles of infection control.DiscussionPolicy responses to HAI frequently focus upon surveillance and education however, resourcing, organisational and interprofessional support and hospital layout all contribute to infection control activities being missed.ConclusionFurther research is required into the impact of systemic factors upon infection control activities being missed.