J Nurs Care Qual

Vol. 00, No. 00, pp. 1–7

Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved.

Work Intensification and Quality

Assurance
Missed Nursing Care
Eileen Willis, PhD; Clare Harvey, PhD, RN;
Shona Thompson, PhD; Maria Pearson, MPhEd;
Alannah Meyer, MN, RN

This article examines nurses’ commentaries from a survey conducted in New Zealand that studied
contradictions between quality assurance and work intensification in nursing care. Nurse man-
agers were blamed for either avoiding or not recognizing work intensification affecting quality
care delivery. However, the data illustrate key structural issues resulting in missed care that impact
on patient safety, rather than a problem directly attributable to managers. Until these structural
issues are addressed, missed care and adverse events will continue to affect the quality of care.
Key words: missed care, New Zealand, nurse managers, quality assurance, risk, work inten-
sification

D ATA presented in this article come from

a survey that expanded on the MISS-
CARE questionnaire1 by exploring the rea-
sons why nurses avoid, delay, or leave care
undone. The survey targeted New Zealand2
nurses during 2015-2016 and was promoted
through the Nursing Council of New Zealand.
Author Affiliations: College of Nursing and Health
Sciences, Flinders University, Adelaide, Australia (Dr
Willis); School of Nursing and Midwifery, Central
Queensland University, Queensland, Australia (Dr
Harvey); and School of Nursing (Dr Thompson and
Ms Meyer) and School of Recreation and Sport and
School of Nursing (Ms Pearson), Eastern Institute of
Technology, Taradale, Hawke’s Bay, New Zealand.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article
on the journal’s Web site (www.jncqjournal.com).
Correspondence: Eileen Willis, PhD, College of Nurs-
ing and Health Sciences, Flinders University, GPO
Box 2100, Adelaide SA 5001, Australia (Eileen.willis@
flinders.edu.au).
Accepted for publication: June 1, 2017
Published ahead of print: August 24, 2017
DOI: 10.1097/NCQ.0000000000000277
The qualitative results showed that nurses on
the unit directed blame for missed care at man-
agement (nurse managers, senior members of
clinical directorates, and district health boards
[DHB]) who were perceived to be responsi-
ble for poor staffing levels and being out of
touch with the pace of clinical work. These
comments led us to consider the tensions be-
tween nurses’ observations about their work-
place and the care they reported as missed,
the intensification of their labor, issues of qual-
ity assurance, and their identification of man-
agers as the problem.
MISSED CARE: EVIDENCE FOR WORK
INTENSIFICATION
The phenomenon of missed or rationed
care is not new.3,4 In these studies, nurses
identify lack of staffing, unexpected rise in
patient acuity, or too few resources as key
determinants in missed care. In the study by
Blackman et al,5 a path analysis illustrated
the implications of unexpected events (eg, a
patient admitted, discharged, or with a sud-
den illness, or a lack of equipment) on the
pace of work, overtime, and consequent ra-
tioned care, arguing that for publically funded
1

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 2 JOURNAL OF NURSING CARE QUALITY/00 2017
hospitals, missed care is well beyond the con-
trol of local managers and more to do with
productivity and efficiency targets set by gov-
ernments. From the first study by Kalisch et
al1 in 2009, there is a common thread of work
intensification, defined as both an increase in
the pace of work and the number of hours
spent on the job. This is seen across all coun-
tries, regardless of how the health care system
is organized. It occurs whether the nursing
work is in the acute, aged care, or commu-
nity sectors, public or private. There also is a
consistency in results with medically ordered
tasks less often missed, than nurse directed
tasks.6 In one Australian study, these tasks
were organized according to Alfaro-Lefever’s7
hierarchy of nursing tasks with missed care re-
sults consistent with her typology as outlined
in Supplemental Digital Content Table, avail-
able at: http://links.lww.com/JNCQ/A356.7-11
In the public sector, work intensification is
seen as a direct outcome of neoliberal ide-
ology with the introduction of new public
management (NPM), a managerial practice
whereby the competitive practices of the pri-
vate sector are introduced into government-
run services. This is the case in New Zealand
where the health system is predominantly
government funded. Any permanent resident,
refugee, or citizen is eligible for free hospital
and community care services, including phar-
maceutical subsidies and disability support.
Private health insurance is optional, affording
those who choose it access to private hospi-
tals and choice of medical care. Within the
public-funded system, NPM structures are in
place. The government has divested author-
ity to manage allocated funding to the DHB,
which are responsible for managing regional
health care. Outcomes are made public on a
quarterly basis, with DHB ranked by perfor-
mance for each specified target.12
New public management has changed the
way government and not-for-profit hospitals
are managed, taking them from public ser-
vices to market-based business units,13 with
responsibility for quality and patient out-
comes transferred from health care profes-
sionals to managers in clinical directorates
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
and/or DHB who themselves are subject
to government budget constraints.13 Overall,
quality in public hospitals is now defined by
metrics such as patient length of stay and de-
termined by a particular case mix, as well
as by unpredictable events such as readmis-
sion rates or the waiting times for elective
surgery.14
As well as this, the Care Capacity Demand
Management (CCDM) program is in place in
New Zealand. This initiative is a government
and multi-union agreement to staff hospitals
based on patient acuity and demand. It has
had considerable resource input from gov-
ernment in recognition that work intensifica-
tion is a major factor impacting on patient
safety and quality outcomes. In the 2015 eval-
uation of the CCDM rollout across the DHB,
Henry and colleagues15 reported strong evi-
dence linking adequate staffing levels and ap-
propriate skills mix on patient/nurse sensitive
outcomes. A key component of the CCDM ap-
proach is the variance indicator, which high-
lights the gap between staffing capacity and
requirements of care tasks in real time, mea-
sured through the use of a commercial tool for
predicting nurses’ workload.16 This tool pro-
vides a trigger for managers to move nurses
across the hospital to areas of higher work
intensification.
The relationship between work intensi-
fication, quality assurance, patient safety,
adverse events, and rationed/missed care has
been at the forefront of nurse research over
the last decade. For example, Schubert and
colleagues17 have done considerable research
on rationed care, a concept closely aligned to
missed care. The RN4Cast consortium made
a strong argument in support of the impact of
the working environment on quality patient
outcomes, noting that workforce planners
failed to take account of nurse numbers and
skill mix.18 Work on the relationship be-
tween work intensification and patient safety
goes back even further, with Aiken et al19
exploring the impact of nurse shortages on
patient outcomes, including nurse-sensitive
outcomes. These studies demonstrated
relationships either between the number of
 Work Intensification and Quality Assurance
hours nurses worked (referred to as work
concentration) or the number of nurses
rostered and patient mortality.19
METHODS
This study set out to measure nurses’ per-
ceptions of care tasks left undone using the
Kalisch MISSCARE survey tool, which was
specifically designed to measure the amount
and type of missed nursing care, and the
reasons for missed care as perceived by the
nurse.1(p4) The survey is divided into 3 sec-
tions: nurse demographics, specific routine
nursing tasks missed across the various shifts
in the 24-hour day, and questions asking
nurses why they think these are missed.1 In
our study in New Zealand, some questions
on missed care were modified to more fully
understand whether tasks were delegated to
other staff, such as personal care workers
or graduate or enrolled nurses, either during
the shift or at a later time in the day. The
survey was distributed through the Nursing
Council of New Zealand to its membership of
50 343. It was available through an electronic
survey software program and operational for
6 months from late December 2015 to mid-
2016, with 1 reminder sent.
A total of 400 nurses responded fully to
the survey, providing 3566 lines of qualita-
tive responses. This is an extremely low re-
sponse rate to the survey, with the pattern
of responses suggesting some hesitancy on
the part of nurses to answer questions. For
example, a number of questions in which re-
spondents were asked to identify missed care
were left blank, but a comment was provided
suggesting that the omission was deliberate.
As a consequence, we have presented quan-
titative data only from full surveys but have
used the qualitative data from all the survey
responses to develop a template analysis us-
ing key themes linked to work intensification.
Our aim was to search the qualitative re-
sponses to understand how nurses explained
work intensification, if they viewed this as
a challenge to patient safety, and what they
identified as being the root of the problem.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
3
In presenting the argument, we first provide
the nurses’ views of the challenges to patient
safety through work intensification. We then
draw on quotes from the data to expand on
what nurses identified as contributing factors.
These are rosters, skill mix, overtime, prob-
lems with the staffing tool’s predictive ca-
pacity, failure to fully implement the CCDM
process, and the nurses’ relationship to man-
agement. In presenting the concept of nurses’
relationships with management, we highlight
both positive and negative comments.
FINDINGS
While the number of respondents was low,
the overall profile reflects the nursing work-
force in New Zealand with the male to fe-
male percentages 7.7/92.7 and the public pri-
vate split 75.1/24.9. The category “manager/
nurse” is broadly defined as any personnel in
a managerial role from nurses on the ward
to those working at district level. It should
be noted that the nurse managers who re-
sponded to the survey (34 in all) also reported
high levels of work intensification although
their number is predictably low.
Work intensification: Rosters as a
challenge to patient safety
Comments were made about patient safety
by 60 respondents who identified work inten-
sification in its various guises as a contribut-
ing factor. Fifty-eight (14.5%) nurses saw the
organization of rosters (work schedules) as
contributing to patient safety. Rosters were
too long, extending beyond 5 days without
a break leading to exhaustion, or were not
organized in a way that enhanced continu-
ity of care, thus compromising safety. Nurses
also reported that staffing levels were often so
low that there were too few nurses on each
shift. This meant that it was not possible to
discuss issues of concern with experienced
colleagues. It also led to failures to sign off
on medication checks or to assist physicians
with medications or colleagues with patient
lifts.
 4 JOURNAL OF NURSING CARE QUALITY/00 2017
Skill mix and work intensification
Nurses also reported that they missed
care they knew would compromise patient
safety, such as ambulation, mouth care, and
toileting. This was exacerbated by poor skills
mix. In some cases, staff numbers might
appear to be adequate, but the skills mix was
skewed toward junior or unlicensed staff,
leaving the more experienced registered
nurses with the major responsibility for all
the clinical tasks. Nurses reported that ward
coordinators had a patient load as well as a
role in management leading to unsafe prac-
tice, given the constant interruptions to their
work. They also reported that in some cases
in which staffing appeared to be adequate,
safety was still an issue. This was particularly
the case in mental health settings and on
night duty where safe practice required that
staff not work alone. Several nurses reported
that the use of the CCDM meant that staff
might be taken away from their ward to
support another, leaving their ward vulner-
able to safety issues. A major issue was that
nurses felt that management did not act on
complaints about staffing levels or staff mix as
contributing to compromised patient safety
and were unsympathetic when staff were
sick.
Two comments illustrate these issues:
“Working mix of mornings, afternoons and
nights—frequently/usually within a 3-4 day work-
ing week is exhausting, disorientating and unsafe.
It is common, for example, to work 1 morning, 1
night, 1 morning, 1 afternoon consecutively.”
As another example:
“Of the shifts I did when I was unwell, I requested
to end my shift as I didn’t feel good enough or safe
to continue. Unfortunately, the Team Manager on
that day wouldn’t let me go home, due to the lack
of staff.”
Work intensification and overtime
Our argument is that working conditions
are a key component of quality assurance
and safe practice. This includes the hours of
work as well as the pace or speed. The sur-
vey asked nurses whether they had worked
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
overtime in the last 3 months to complete
their work and not miss care. Approximately
22% reported that working overtime was not
an issue for them, 38% reported that they
had been required to work overtime fewer
than 5 times, and 33.2% worked overtime
between 5 and 15+ shifts (Supplemental
Digital Content Table 2, available at: http://
links.lww.com/JNCQ/A357).
A qualitative response demonstrates the in-
crease in pace of work when colleagues are
sick, which requires others to complete the
work:
I currently work 0.95 FTE and have applied to go
to 0.8 FTE, but the Managers have said I can’t yet as
I have a nursing colleague off on sick leave (with-
out pay) for another 21 weeks whose workload I
need to help cover. Management has chosen not
to advertise for coverage . . . The 3 of us are re-
ally fed up with the intensification of our workload
over this time. All indications from the managers
are that nothing is going to change, and they are
doing everything they can to help us.
Another nurse explained:
On my last week’s rostered work of 4 shifts, I
worked 2 hours overtime without pay. This was
due to high workloads, high acuity that did not al-
low for me to start my notes/paperwork, etc until
the next RN had taken over my patients.
In response to questions about whether the
ward or work area was adequately staffed,
the 389 responses ranged from those who be-
lieved staffing was adequate 75% of the time
(45.8%) to those who thought that it was
never adequate (5.9%) (Table). Eighty-four
nurses provided qualitative comments to this
question. Many highlighted the difficulties
arising when nurses are moved to another
ward as a result of the CCDM process used
Table. Adequacy of Staffing Ward/Area
Time, % n (%)
100 62 (15.9)
75 178 (45.8)
50 77 (19.8)
25 40 (10.3)
None 23 (5.9)
 Work Intensification and Quality Assurance
to identify variances in staff shortages:
If staffing is ‘adequate,’ staff are often moved to
an area even more short staffed. It is often difficult
and stressful for the staff member to be moved to an
unfamiliar area and expected to function at 100%,
take a full workload, attend family meetings, etc
even though unfamiliar with ward and patients.
Added to this was the issue of inadequate
skill mix:
The skill mix is also poor at times. Last night, I
worked overtime. After a full morning shift, I got
a different patient load for the afternoon. There
was me, a casual bureau nurse, a new grad, and an
enrolled (licensed practical) nurse to look after a
full surgical ward in the afternoon.
Safety, work intensification, and CCDM
Forty-three (10%) nurses made reference to
the use of nurse staffing tool and the imple-
mentation of the CCDM project. Of the 363
participants who responded to the question
asking them how patients were allocated and
staff numbers determined, only 12% indicated
that the staffing tool was used in their work-
place, with 28.65% noting that the clinical
nurse manager assigned patient loads. Some
nurses reported that even when the staffing
tool demonstrated the need for more staff,
this was not followed through because of DHB
budget issues or no staff being available. One
nurse explained:
Our DHB also uses a predictive tool to allocate
[staff]. Unfortunately it is not often that extra staff
are brought in when the ward is full even when the
variance shows more staff are required. The usual
reason given is due to short staff numbers available.
Others argued that the staffing tool did not
accurately estimate staffing needs or was not
completed in time for more staff to be as-
signed to the workplace:
Mostly, it’s just that the staffing is not adequate for
the number and acuity of patients. Patients who
should be specialled are not because there is no one
available to do so. The level of patient acuity has
increased significantly over recent years - patients
who once went to the Intensive Care Unit now
are in the ward, and patients who once spent days
in the hospital after minor surgery now go home
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
5
the day of surgery. The predictive tool (even if it
is updated correctly) is an inaccurate reflection of
acuity.
However, it was also evident that many
nurses saw the staffing tool and the CCDM
as positive. While extra staff were not always
assigned, the predictive staffing tool provided
nurses with the evidence that more staff were
required to provide safe care.
Role of management in work
intensification and safety
The predominant view taken by the survey
participants toward management, whether at
ward or DHB level, was one of cynicism for
their inability to manage workloads or provide
the resources or broader working conditions
required for safe care. Management was seen
to be responsible primarily for the budget and
not for patient care or safety. As noted earlier,
this included managers in some hospitals in-
sisting shift coordinators take a case load, and
team managers not allowing ill staff to take
time off or tired staff to take up lower work
fractions. Where the staffing predictive tool
was not used and managers assigned patient
loads, nurses argued that patient acuity was
not considered and rostering did not take ac-
count of the skills mix. This resulted in lower
paid staff being assigned during weekends
and after hours and left wards with inexperi-
enced staff and inadequate resources. A nurse
commented:
I frequently feel as though the DHB is totally fo-
cussed on finance with scant regard to quality,
although they would never openly admit this. I
understand the need for fiscal governance, but a
balance needs to be struck between that and qual-
ity, while valuing the contributions of your staff.
Stronger leadership on the unit is also essential,
something we are sadly lacking.
This last quotation epitomizes one of the
difficulties in identifying “management” as
the problem. It is not clear what nurses on
the ward mean when they refer to man-
agers, and indeed a small number of nurses
commented on the way in which shift man-
agers solved problems, as illustrated with this
 6 JOURNAL OF NURSING CARE QUALITY/00 2017
quotation: “My unit is comprised of mainly
experienced nurses. We do not work nights or
weekends. We support each other and com-
municate well. We have a good manager who
supports us.”
DISCUSSION
There was considerable cynicism displayed
by survey participants regarding the rollout of
the CCDM, of the way management does not
adhere to nurse-staffing predictive tool estima-
tions of workload, and of the way nurses are
reassigned to a ward leaving their home ward
short-staffed. Lawless20 highlights, in her re-
view of the CCDM, the need to get base-level
resourcing accurate, for strong buy-in by DHB
leadership at executive level, and to have pre-
dictive staffing tools, which in turn are con-
strained by the capacity of boards to raise
the funds either to introduce these tools or
upgrade them. Part of the difficulty appears
to be the assumption that increased staff lev-
els will lead to budget problems and a reduc-
tion in metrics measuring productivity gains,
while the evidence on patient safety is less
definitive.
The contemporary approach to quality as-
surance and risk management is to focus on
organizational factors and less so on individual
culpability. Our analysis suggests that the par-
ticipants believe that managers appear not to
see a link between staffing levels and patient
safety and quality. This finding is consistent
with a systematic review that indicated that
there was little evidence that managers had
a strong influence on quality assurance and
patient safety. Parand et al21 suggest that not
all managers understand clinical knowledge,
meaning the burden of ensuring patient safety
within the climate of work intensification is
left to the clinician to sustain. In the case of
nursing, this leads to considerable overtime,
some of it unpaid, all of it done to help ensure
that care is not missed and patients are safe.
However, more importantly, when we ex-
amined the quality and safety data on ad-
verse events for the period 2015-2016 from
the DHB, we found that these events were
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
not addressed through systems reform but
through processes more aligned with organi-
zational psychology. For example, a number
of DHB reported on hospital-acquired pres-
sure injuries, presumably caused by nursing
staff failing to do an initial assessment or ad-
equate follow-up care. This is clearly missed
care. The solutions outlined include increased
nurse education, the use of reminder stick-
ers, and hourly rounding. While admirable,
all of these remedies assume that the missed
care arises from a lack of knowledge or a fail-
ure to have reminder systems in place and
is simply a matter of making sure that tasks
are remembered. Repeatedly in DHB reports,
poor communication was identified as a key
factor with systemic communication proto-
cols introduced as solutions. No board asked
whether communication gaps might be the
result of work intensification for both nurses
and physicians.22
In our view, the problem is more com-
plex than that articulated by clinical nurses
on the wards or education programs insti-
gated by DHB. Managers are responsible for
both budget efficiency and clinical outcomes.
A further difficulty lies with the tools avail-
able to managers for assigning staffing. Not all
nurses viewed the commercial predictive tool
as providing an accurate estimation of staffing
needs, but the main concern was its lack
of use, rather than any inaccuracies within
the tool, which is fundamentally a budget is-
sue. In the case of public hospitals in New
Zealand, issues of work intensification, subse-
quent missed care, and possible patient qual-
ity can be traced back from the ward to the
DHB. The review of the CCDM program con-
ducted by Henry et al15 and Lawless20 demon-
strates that many boards cannot afford to pur-
chase automated staffing predictive tools, nor
meet targets.
The problem is better defined as inade-
quate funding for public hospitals services
pitted against NPM-inspired targets for pro-
ductivity and staffing. This issue is not unique
to New Zealand, as evidence across most
Organization for Economic Cooperation and
Development countries attests.23 The recent
 Work Intensification and Quality Assurance
establishment of the European consortium for
investigation into rationed/missed care has
called for further research into the issues fac-
ing nurse managers, given the austerity facing
most public acute hospitals in Organization
for Economic Cooperation and Development
REFERENCES
1. Kalisch B, Landstrom G, Hinshaw A. Missed nursing
care: a concept analysis. J Adv Nurs. 2009;65(7):1509-
1517.
2. Zuniga F, Ausserhofer D, Hamers JP, Engberg S, Simon
M, Schwendimann R. The relationship of staffing and
work environment with implicit rationing of nursing
care in Swiss nursing homes—a cross-sectional study.
Int J Nurs Stud. 2015;52(9):1463-1474.
3. Kalisch B. Missed nursing care: a qualitative study.
J Nurs Care Qual. 2006;21(4):306-313.
4. Bragadóttir H, Kalisch B, Tryggvadóttir GB. Correlates
and predictors of missed nursing care in hospitals.
J Clin Nurs. 2017;26(11-12):1524-1534.
5. Blackman I, Henderson J, Willis E, et al. Factors in-
fluencing why nursing care is missed. J Clin Nurs.
2014;24(1-2):47-56.
6. Papastavrou E, Andreou P, Vryonides S. The hid-
den ethical elements of nursing care rationing. Nurs
Ethics. 2014;21(5):583-593.
7. Alfaro-Lefevre R. Critical Thinking and Clinical
Judgement: A Practical Approach to Outcome—
Focused Thinking. 4th ed. St Louis, MO: Saunders/
Elsevier; 2008.
8. Willis E, Blackman I, Henderson J, Toffoli L, Verrall
C, Hamilton P. Rationed or Missed Nursing Care: Re-
port to the ANMF, Victoria. Adelaide, South Australia:
Flinders University; 2015.
9. Phelan A, McCarthy S. Missed Care: Community
Nursing in Ireland. Dublin, Ireland: University Col-
lege Dublin and Irish Nurses and Midwives Organisa-
tion; 2016.
10. Henderson J, Willis E, Xiao L, Blackman I. Missed care
in residential aged care in Australia: an exploratory
study. Collegian. 2016. doi: http://dx.doi.org/10.
1016/j.colegn.2016.09.001
11. Willis E, Blackman I, Henderson J, Xiao L, Toffoli
L. Rationed or Missed Nursing Care: Report to the
ANMF (Victorian Branch). Adelaide, South Australia:
Flinders University; 2015.
12. Ministry of Health NZ. Publicly funded health and dis-
ability services. In: Ministry of Health N, ed. Welling-
ton, New Zealand: New Zealand Government; 2017.
http://www.health.govt.nz/new-zealand-health-
system/publicly-funded-health-and-disability-services.
Accessed December 1, 2016.
13. Santiago R, Carvalho t, Sousa S. NPM reforms
and professionals in health and higher education
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
7
countries.23 This is a timely call given that, as
this study illustrates, nurses at ward level at-
tribute the problems to their immediate man-
agers, to DHB, or to hospital managers. Ac-
curately naming the underlying causes is an
important first step.
in Portugal. Int J Public Admin. 2015;38:757-
768.
14. Willis EM. Purgatorial Time in Hospitals. Berlin,
Germany: Lambert Academic Publishing; 2009.
15. Henry C, Aileone L, Kyle M. An Evaluation of the Im-
plementation, Outcomes and Opportunities of the
Care Capacity Demand Management (CCDM) Pro-
gram: Final Report. Christchurch, New Zealand: The
New Zealand Institute of Community Health Care;
2015.
16. West Coast DHB. TrendCare user-guidelines.
http://www.trendcare.com.au/index.php/product/
patient-acuity-and-workload-management. Accessed
July 5, 2017.
17. Schubert M, Clarke SP, Glass TR, Schaffert-Witvliet
B, De Geest S. Identifying thresholds for relation-
ships between the impact of rationing of nursing
care and nurse- and patient-reported outcomes in
Swiss hospitals: a correlation study. Int J Nurs Stud.
2009;46(7):884-893.
18. Sermeus W. RN4Cast Nurse forecasting in Europe: ra-
tionale, design and methodology [Internet]. RN4Cast
consortium; 2011. Podcast. https://www.yumpu.
com/en/document/view/33430633/nurse-forecasting-
in-europe-rn4cast-rationale-. Accessed 1 December
2016.
19. Aiken L, Clarke S, Sloane D, Sochalski J, Silber J. Hospi-
tal nurse staffing and patient mortality, nurse burnout,
and job dissatisfaction. JAMA. 2002;288(16):1987-
1993.
20. Lawless J. The Right Care in the Right Place at the
Right Time: The Safe Staffing Healthy Workplaces
Unit 2007-2014. New Zealand: SSHW unit; 2014.
21. Parand A, Dopson S, Renz A, Vincent C. The role
of hospital managers in quality and patient safety: a
systematic review. BMJ Open. 2014;4(9):e005055.
22. New Zealand Commission for Quality and Safety.
Our programs. https://www.hqsc.govt.nz/our-pro-
grammes/. Published 2016. Accessed November 20,
2016.
23. Papastavrous E, Leino-Kilpi H, 27 European Partners.
Rationing-Missed Nursing Care: An International
and Multidimensional Problem. Vol Euro 500,000.
Europe, USA, Australia, New Zealand, Canada, and
Israel: European Cooperation in Science and Tech-
nology; 2016. https://www.rancare-action.eu/. Ac-
cessed September 30, 2016. Cyprus