# Understanding missed nursing care through felt accountability focus and task complexity: A prospective repeated-measures field study

## TL;DR

This study shows that how nurses are held accountable affects missed care differently depending on whether tasks are simple or complex.

## Contribution

It demonstrates that accountability systems should be tailored to task complexity to reduce missed nursing care in real-world settings.

## Key findings

- Outcome accountability reduces missed care for simple tasks, while process accountability does so for complex tasks.
- Interaction effects between task complexity and accountability focus were statistically significant.
- Adapting accountability to task complexity can improve patient safety and nursing care quality.

## Abstract

Missed nursing care is a key indicator of compromised care quality, often attributed to workload and staffing. Yet it may also be influenced by accountability focus—whether nurses are evaluated on outcomes or on processes. Evidence suggests that its effect on performance, and thus on missed care, may depend on task complexity, but this has not been tested in clinical practice

To investigate whether task complexity (simple vs. complex) moderates the association between nurses’ felt accountability focus (outcome vs. process) and missed nursing care.

A prospective repeated-measures field study with nurses nested within wards.

The study was conducted in one medium-sized public hospital, encompassing 10 internal medicine and surgical wards.

A total of 105 registered nurses providing direct patient care participated in the study.

Data were collected between November 2023 and April 2024. Each nurse completed anonymous mobile survey at the end of three different shifts, yielding 315 repeated observations nested within 105 nurses. Nurses completed questionnaires assessing missed nursing care, task complexity, felt accountability focus, and sociodemographic characteristics. Mixed linear modeling accounted for the repeated-measures design and nested data structure.

No direct effects of task complexity and felt accountability focus were found. However, both interaction effects were statistically significant: task complexity × felt process accountability focus (β = −0.04, p = 0.012) and task complexity × felt outcome accountability focus (β = 0.04, p = 0.006). Probing revealed a crossover pattern: under simple tasks, higher outcome accountability was associated with less missed care, whereas under complex tasks, higher process accountability was associated with less missed care.

Accountability should be adapted to task complexity rather than applied uniformly. Outcome accountability enhances consistency in routine care, whereas process accountability safeguards thoroughness in complex situations. These findings extend accountability research into real-world nursing practice and offer actionable guidance for designing systems that promote safe, high-quality care.

Accountability focus impacts missed nursing care differently by task complexity. This field study bridges lab findings & clinical practice, offering a framework to design smarter accountability systems that protect patients & support nurses. #NursingResearch #PatientSafety #HealthcareQuality #NurseLeadership