Impact of a two-year transition programme on patient and nurse perceived missed nursing care — A comparative cross-sectional study

Abstract

Background

The nursing shortage is influenced by an often-reported transition shock among newly graduated nurses, and transition programmes may support both retention and improve the quality of nursing care.

Objective

To measure patients’ and nursing staffs’ perceptions of missed nursing care in study wards following a two-year transition programme for newly graduated nurses compared to wards following a standard transition program

Design

A comparative cross-sectional survey design was used.

Setting(s)

Three medical inpatient wards with a two-year transition program and three comparable medical inpatient wards with a standard transition programme.

Participants

Data collection started March 3rd 2025. Based on a power calculation, 206 hospitalised patients, comprising 103 from the study wards and 103 from the standard wards, were included. 239 nursing staffs was invited to participate; of these, 159 responded to the survey.

Methods

The validated MISSCARE Survey–Patient and MISSCARE Survey were used to collect data from patients and nursing staff. The responses were dichotomised and compared using the Chi-squared test. The sum scores were compared using the Wilcoxon Rank Sum test or the Student’s t-test. The study was not registered.

Results

Patients in wards with a two-year transition programme reported less missed psychosocial care (p=0.03), particularly for involvement in decisions (p=0.02), receiving needed information (p=0.03), and being treated with dignity (p=0.05), but they reported with more missed care related to help with walking (p=0.03).

Nursing staff in study wards reported less missed nursing care for patient teaching (p=0.01), complete documentation (p=0.04), and timely medication administration (p= 0.05), but more missed care in responding to call lights within 5 minutes (p=0.01). They also rated urgent patient situations (p=0.02,) lack of team backup (p=0.03) and insufficient assistive personnel (p<0.001) as less important reasons for missed care than staff in standard wards.

Conclusions

The results indicate that a longer and more comprehensive transition programme may contribute to improved psychosocial care and a supportive clinical environment, potentially at the expense of assistance with ambulation or call-light response times. Further research on patient outcomes is needed.

What is already known.

•Newly graduated nurses may experience a transition shock and need support

•Transition programmes improve newly graduated nurses’ skills and make them feel safe

•Research on how transition programmes affect missed nursing care is limited

What this paper adds

•Wards with a two-year transition programme saw less missed psychosocial nursing care

•A two-year transition programme may enhance support from team members

•Transition programmes may alter the prioritisation of given nursing care

Alt-text: Unlabelled box dummy alt text

1. Background

The transition from student nurse to registered nurse is often complex and challenging (Duchscher, 2009; Graf et al., 2020; Hampton et al., 2021). Upon graduation, nurses may experience a transition shock when they are confronted with a broad range of physical, emotional, and intellectual changes in the unfamiliar professional practice role (Duchscher, 2009). This period is marked by a significant gap between theoretical training and the realities of clinical practice, which can be overwhelming without adequate support (Gellerstedt et al., 2019).

Meanwhile, the health care sector is facing a massive nursing shortage in Denmark as well as internationally (Birk et al., 2024; World Health Organisation, 2020). More than one-third of newly graduated nurses expect to leave their positions in the near future (Ulupinar & Aydogan, 2021). One contributing factor to this shortage is the high turnover among nurses, which is closely associated with patient safety. Research indicates that high turnover leads to higher patient mortality, more readmissions, and an increase in length of hospital stay (Hølge-Hazelton et al., 2020; Nelson-Brantley et al., 2018). Consequently, retaining these nurses is not only essential to ensure a sufficient nursing workforce, but also to improved quality of health care.

Evidence indicated that support provided during transition programmes positively affects retention rates and turnover (Berthelsen & Hansen, 2025; Slabbekoorn et al., 2025). To retain newly graduated nurses in clinical practice during this critical phase of adapting to the demands of a dynamic health care environment, structured support is essential. Transition programmes are a vital part of that support (Lay & Masingboon, 2025; Phillips et al., 2014; Willman et al., 2020). In hospital settings, transition programmes vary in duration, ranging from a few days to one year. Longer programmes have a greater impact on retention (Kenny et al., 2021; Missen et al., 2014; Pasila et al., 2017; Vazquez-Calatayud & Eseverri-Azcoiti, 2023). While transition programmes generally improve confidence, clinical skills, and retention (Kenny et al., 2021), links between transition programmes and patient outcomes remain unclear; only one study reported improved patient satisfaction with supported newly graduated nurses (Varner & Leeds, 2012), while others found no association with outcomes as infection rates (Webb et al., 2024).

Along with the nursing shortage, it is evident that missed nursing care is an increasing global health problem (Chaboyer et al., 2021; Jones et al., 2015). Missed nursing care is referred to as any aspect of nursing care that is not performed, partially performed, or delayed including care left undone, unfinished care, or unmet nursing care needs (Jones et al., 2015; Kalisch & Williams, 2009). Missed nursing care is associated with lower job satisfaction among nurses; thus, nurses who experience less missed nursing care at their workplace tend to be more satisfied with their current position than nurses who experience more missed nursing care (Bragadottir et al., 2020). Therefore, measuring missed nursing care may serve as an indicator of job satisfaction, nursing staff retention, and patient safety.

Studies measuring missed nursing care (Cohen et al., 2025; Kalisch et al., 2014), along with a review by Bagnasco et al. (2020) synthesising inpatients’ perceptions of unmet nursing care needs, indicate that patients often experience unmet needs regarding basic care such as hygiene, nutrition, and mobilisation. These findings highlight persistent challenges in meeting patients’ fundamental care needs.

Labrague and De Los Santos found an association between high extent of transition shock and more adverse events such as falls, hospital-acquired infections and errors in medication administration (Labrague & De Los Santos, 2020), indicating that it is essential for patients’ safety to reduce a potential transition shock among newly graduated nurses. One contributing factor may be the preparedness of newly graduated nurses entering clinical practice. An umbrella review (Kaldal et al., 2023) indicated that newly graduated nurses continue to experience inadequate competencies in relational and managerial aspects of nursing care, as well as a lack of knowledge, despite implementation of various transition programmes. Thus, ensuring that newly graduated nurses possess the requisite competencies is necessary. Transition programmes may support newly graduated nurses throughout the transitional phase and reduce a potential transition shock, increase clinical knowledge, skills and professional confidence (Charette et al., 2023; Jeong, 2025).

Several transition programmes were developed to support newly graduated nurses’ transition into general hospital settings, and speciality-specific programmes were targeted to transition into intensive care units or acute care settings (Kim et al., 2025, Kwon et al., 2025). However, limited research was conducted in medical wards (Kenny et al., 2021). Understanding how organisationally implemented transition programmes in medical wards influence missed nursing care, as assessed by both patients and nursing staff, is important, as it provides insight into perceived quality of care and may serve as an indicator of job satisfaction and patient safety in this setting. Therefore, this study does not focus solely on nurses enrolled in transition programmes; rather, it examines how such programmes function as organisational learning and support initiatives that may affect nursing practice at the ward level. Limited evidence exists on how transition programmes influence missed nursing care at both the ward and organisational levels.

The aim of the present study was to compare hospitalised patients’ and nurses’ perceptions of missed nursing care across medical inpatient wards that had implemented a two-year transition programme with those following a standard transition programme.

2. Methods

The study employed a comparative cross-sectional survey design. To assess perceptions of missed nursing care, the Danish validated version of the MISSCARE Survey–Patient (originally developed by Kalisch et al., 2014 and adapted for the Danish context and validated by Albrechtsen et al., 2025) was used for patients, while the Danish validated version of the MISSCARE Survey (Sections A and B; originally developed by Kalisch & Williams, 2009 and translated and validated by Lisby et al., 2023) was used for nurses.

The questionnaires were distributed to hospitalised patients and authorised nursing staff in medical wards that had implemented either a two-year transition programme or a standard transition programme for newly graduated nurses. We expected the transition programme to affect the overall provision of nursing care within the wards in ways that could be observed and reported by all nurses, regardless of their experience level. Therefore, participation was not limited to newly graduated nurses.

2.1. Settings and participants

The study was conducted in two teaching hospitals in the Central Denmark Region, each comprising three medical inpatient wards. One hospital used the two-year transition programme while the other used the standard programme.

2.2. Description of the wards

• •The hospital wards using the two-year transition programme (study wards) comprised a total of 65 beds (19, 21, and 25 beds, respectively) and 119 nursing staff (39, 48, and 32 nursing staffs, respectively). A total of 83 registered nurses, 30 nursing assistants, and six other educated health workers were employed and present during the data collection period. One of the wards had care assistants who performed practical tasks but had no administrative or clinical responsibilities related to patient care. The study wards handle approximately 6700 patient admissions per year, with 99 % classified as acute cases. The hospital serves an area encompassing four municipalities, with 237,000 inhabitants, of whom 10.2 % are aged 75 or older (Denmark, 2025).
• •The hospital wards using the standard transition programme (standard wards) comprised a total of 75 beds (18, 28, and 29 beds respectively) and 120 nursing staff (37, 36, and 47 nursing staff, respectively). A total of 63 registered nurses, 33 nursing assistants, and two other educated health workers were employed and present during the data collection period. All three wards had care assistants. The hospital handles approximately 8600 patient admissions pr year, with 98 % classified as acute cases. Similarly, the hospital serves four municipalities with 231,000 inhabitants, of whom 10.0 % are aged 75 or older (Denmark, 2025).

The medical specialities were similar in the study and standard wards and included patients with pulmonary diseases, gastroenterological diseases, rheumatological diseases, cardiac diseases, and geriatric conditions.

The participants included patients and nursing staff from study and standard wards:

• 1) Inclusion criteria for patients were:

• •Admitted more than 48 hours to one of the wards included,
• •Aged ≥18 year and
• •Able to speak Danish

Patients with delirium, dementia or other cognitive diseases were excluded, as cognitive impairment may preclude their ability to provide valid informed consent or to adequately comprehend and respond to a questionnaire.

• 2) Inclusion criteria for the nursing staff were:

• •Had completed a healthcare education
• •Employed at one of the wards included regardless of their experience and
• •Providers of direct patient care

Based on strong interdisciplinary collaboration it was considered that all physiotherapists, occupational therapists, care assistants, healthcare assistants and registered nurses meeting the inclusion criteria can assess the quality of nursing care in the wards. Regardless of the exact education the study participants will be referred to as nursing staff.

2.3. Two-year transition program

At one of the teaching hospitals, a two-year transition programme for newly graduated registered nurses was developed in 2018 and fully implemented in 2022. The transition programme has been mandatory for all newly graduated nurses employed in the wards since its implementation. The programme aimed to support clinical competence and professional development through a variety of structured activities, including simulation and clinical skills training, four scheduled meetings with a preceptor and nurse manager, and supervised clinical followership. Newly graduated nurses also engaged in group supervision, short stays in outpatient clinics related to relevant medical conditions, and visits to collaborating departments—such as homecare services and the mortuary. Additionally, the programme included three reflective ‘Life Lab’ sessions facilitated by hospital priests. To present an overview of the transition programme and support learning, an app provided access to short educational videos and a timeline. Based on the newly graduated nurses’ prior clinical experience, elements such as departmental visits and followership were tailored to individual needs (Table 1)(Rothenberg et al., 2026).

Table 1.

Transition programmes: Study and standard.

		Study: Two-year transition program	Standard: One-year transition program
Elements	Duration
Time outside the staffing norm	3–4 weeks	X
Preceptorship	The entire period	X	X
Tailored followership	The entire period	X	X
Four planned meetings with mentor and nurse manager	4 × 1 hours	X	X
Observations and interventions regarding acutely ill patients, including ABCDE	1 half-day session	X	X
Teaching and training in physical environment and ergonomics	3 - 4 hours	X	X
Teaching in nutrition, hygiene, well-being/work environment, and discharge	1-hour sessions	X
Teaching and training in 1) ward rounds, interdisciplinary collaboration, and discharge, 2) hygiene and IT and 3) nutrition and fluids balances incl insertion of peripheral venous catheter	3 × 7 hour		X
Teaching and training in 1) ethics, communication, empathy, 2) conflict management and 3) work-life balance, sustainability, labour law	3 × 4 hours		X
Teaching and training in 1) respiratory conditions, 2) nutritional and pressure ulcer risk patients, and 3) medication management	3 × 3 hours		X
Clinical skills training	The entire period	X	X
Supervision in groups of 4–6	4 × 2½ hours	X
Life lab with the hospital priest	3 session of 2 hours	X
Visits in collaborating departments, e.g. emergency unit, surgical unit.	2 to 4 visits of 14 hours each	X
Homecare visits in the municipality	14 hours	X
Stays to outpatient clinics related to relevant medical diseases	3 to 4 weeks	X
An app with short learning videos and an overview of the two years	The entire period	X
A dedicated webpage with department-related information for new employee starts	The entire period		X

2.4. Standard one-year transition program

At the other teaching hospital, the standard one-year transition programme for newly graduated nurses in medical wards was fully implemented in 2022 and provided to support professional development (Table 1). The programme included mandatory one-day training courses covering topics such as the physical work environment, ethics, communication, empathy, conflict management, work-life balance, sustainability, and labour law. In addition, optional courses were offered on clinical subjects including respiratory conditions, nutritional and pressure ulcer risk, medication management, acute patient observation, hygiene, fluid balance, ward rounds, discharge procedures, interdisciplinary collaboration, and peripheral venous catheter insertion. Tailoring of the programme was based on the individual nurse’s competencies, with input from the nurse manager, mentor, and/or introduction nurse. Prior to employment, nurses received department-specific information and access to a dedicated webpage. The programme also included four scheduled meetings with a mentor and nurse manager, as well as followership and bedside teaching with either a mentor or a ward nurse.

2.5. Patient reported measures

The Danish version of the MISSCARE Survey–Patient (Albrechtsen et al., 2025) was used to collect data on patients’ perceptions of missed nursing care. The questionnaire consists of three sections: 1) nursing care received (or not received), 2) patient-reported adverse events, and 3) background information. Section 1 comprises 23 items covering nursing care elements within three domains: physical care (9 items), psychosocial care (9 items), and timeliness (5 items), as well as a global item on the overall rating of nursing care received during hospitalisation. Responses in the physical and psychosocial care domains were provided on a five-point Likert-type scale ranging from 1 = ‘never’ to 5 = ‘always’, where patients indicated how often specific care activities were performed in accordance with their needs. For timeliness, responses were given on a three-point scale (less than 5 min, 5–10 min, more than 10 min), where patients reported how long it usually took to receive the requested nursing care. A ‘not applicable’ response option was also available for selected items.

2.6. Data collection and management of the misscare survey-patient

Data were collected from March 3rd to April 2nd, 2025. A nurse or nursing student from the research team included patients by visiting the wards three to four times a week on weekdays, and a coordinating nurse in each ward identified patients who met the inclusion criteria. The nurse or nursing student invited the patients to participate and provided oral and written information. The questionnaire was available on a tablet. Since most patients in the medical wards were older adults, they were offered human support to use the tablet if needed. The items could be read aloud. Patients could answer verbally, and a member of the research team could tap the tablet. The inclusion was completed when 103 patients from the study wards and 103 from the standard wards were included. Consistent with Kalisch et al. (Kalisch et al., 2014), responses for each item in the questionnaire were dichotomised for easier interpretation and comparison with other studies. For the domains ‘physical care’ and ‘psychosocial care’ as nursing care received ‘never’, ‘rarely’, or ‘sometimes’ were classified as missed nursing care. Care received ‘usually’, or ‘always’ was classified as no missed nursing care. For the domain ‘timeliness’, missed nursing care was defined waiting time >10 min and no missed nursing care was defined as waiting time of <5 min or 5–10 min. Responses marked as ‘not applicable’ was excluded before comparison. Then a percentage for missed nursing care was calculated. Responses in the domains ‘psychosocial care’ and ‘physical care’ were coded reversely; thus, a higher score indicated a higher extent of missed nursing care. A sum score for each of the three domains and a total sum score were calculated.

2.7. Nursing staff reported measures

The MISSCARE Survey includes a Background section followed by Section A and B (Lisby et al., 2023). Section A consists of 24 items designed to measure care elements including ambulation, patient bathing, emotional support, discharge planning, and documentation. The nursing staff were asked how often, in general, nursing care elements were missed, and they responded on a five-point Likert-type scale ranging from 1 = ‘never missed’ to 5 = ‘always missed’. In this section, there was an option to respond, ‘not applicable’. Section B consists of 17 items that measured reasons for missed nursing care, including communication issues, material resources, and labour resources. The responses were measured on a four-point scale ranging from 1 = ‘not a reason’ to 4 = ‘a significant reason’.

2.8. Data collection and management of the misscare survey

Data were collected from March 3rd to April 10th, 2025. All nursing staff employed and scheduled for shifts in the medical wards during the data collection period were invited to participate. At all wards, the first author conducted short informational meetings and distributed written materials. The questionnaire was made available to the nursing staff in both paper and online formats. During the data collection period, the first author sent reminders to participate three times via email and also in person.

In Section A of the questionnaire, we dichotomised the responses. Consistent with Kalisch & Williams (Kalisch & Williams, 2009), ‘always missed’, ‘frequently missed’, or ‘occasionally missed’ were classified as missed nursing care. ‘Rarely missed’ or ‘never missed’ were classified as no missed nursing care. The response ‘not applicable’ was excluded before comparison. In Section B, we dichotomised the responses considering a reason for missed nursing care if the nursing staff reported either a ‘significant reason’ or a ‘moderate reason’. Questionnaires with all responses missing in Sections A and B was excluded from the analysis. If Section A was completed the questionnaires were included.

The questionnaires were built into REDCap, an online application for collecting and managing data (Harris et al., 2019; Harris et al., 2009).

2.9. Statistical analysis

A power calculation was based on the results from a study by Dabney and Kalisch (2015) using the MISSCARE Survey–Patient, that showed an overall mean sum score of 1.82 (SD = 0.62)(Dabney & Kalisch, 2015). As no comparable survey has been conducted in the Nordic countries, these data from the US were used as a reference. We expected a reduction to an overall mean sum score of 1.57 in wards following the two-year transition programme. With a power of 80 % and a significance level (α) of 0.05, the required sample size was 98 patient responses per group. To account for potential missing data, we added five additional patients to each group. No power calculation was performed for the number of nursing staff required to detect differences in the MISSCARE Survey, as all available nursing staff during the data collection period were included.

As the aim of this present study was to compare missed nursing care in wards with and without a two-year transition programme, the results will be presented in tables with a p-value to show if there were a significantly difference across characteristics and missed nursing care. Patient and nursing staff characteristics were compared between the study and the standard wards using the Chi-squared (X²) test, the Wilcoxon Rank Sum test, or Fisher’s Exact test, as appropriate. A percentage for missed nursing care were calculated. The dichotomised answers were tested using the Chi-squared (X²) test. To compare patients’ responses between the study and the standard wards, the Wilcoxon Rank Sum test was applied for each domain score, and the overall total score. The total sum score of the MISSCARE Survey was compared between groups using Student’s t-test, as the sum scores were assumed to follow a normal distribution. A higher total sum score indicates a greater extent of missed nursing care. The significance level was set at p-value ≤ 0.05. Data were analysed in Stata version 19.5 (StataCorp, 2025).

2.10. Stakeholders’ involvement

Patient and public involvement was integrated from the outset of the project planning process through the establishment of an expert advisory group (Research, 2021; Smits et al., 2020). The expert group consisted of patients, student nurses, graduate nurses, and ward managers. In a workshop, the group stated the need for a study investigating how nursing care was perceived by the patients and the nurses in hospital medical wards with and without a two-year transition programme. After the planning, the expert group was involved every six months throughout the project.

2.11. Ethical considerations

This study was conducted following the principles of the Declaration of Helsinki to ensure ethical conduct and the protection of participants’ rights and well-being(World Medical Association, 2024). Participation involved minimal risk, and all survey data was pseudonymised and securely stored in REDCap (Harris et al., 2019; Harris et al., 2009) The study was approved by the Danish Data Protection Agency through the Central Denmark Region (journal number 1-16-02-104-23). The study was not registered. All participating patients were given verbal and written information regarding the study’s aim, their rights to withdraw at any time, and how their data were protected. Nursing staff received written information and had the opportunity to contact the first author. Both patients and nursing staff signed an informed consent form prior to completing the questionnaire.

3. Results

3.1. Patient characteristics

In total, 206 hospitalised patients−103 from the study wards and 103 from the standard wards−agreed to participate. The patients from each participating hospital were comparable in terms of sex, civil status, housing type, level of education, employment status, length of hospital stay, and health status. The groups differed in age, as the patients in the study wards were older with a median age of 78 [interquartile range (IQR): 72–83] years compared to 74 [IQR:61–81] years in the standard wards (p=0.01) (Table 2).

Table 2.

Characteristics of hospitalised patients responding to the MISSCARE Survey–Patient questionnaire.

	Study wards N=103 n ( %)	Standard wards N=103 n ( %)	p-value
Sex			0.26
Females	53 (51)	45 (44)
Males	50 (49)	58 (56)
Age groups, (years)			0.01
< 50	4 (4)	6 (6)
51–75	32 (31)	54 (52)
>75	65 (63)	43 (42)
Not informed	2 (2)	0 (0)
Civil status			0.26
Married/cohabitant	51 (50)	59 (57)
Living alone	52 (50)	43 (42)
Other	0 (0)	1 (1)
Housing type			1.00
Lives in own home	95 (92)	95 (92)
Lives in nursing home	3 (3)	4 (4)
Other	5 (5)	4 (4)
Highest level of education			0.87
Primary school	28 (27)	29 (28)
Vocational education	42 (5)	36 (5)
High school	5 (41)	5 (35)
Higher education	26 (25)	29 (28)
Other	2 (2)	4 (4)
Employment status			0.45
Employed	16 (15)	23 (22)
Unemployed	2 (2)	4 (4)
Retired /early retirement	82 (80)	72 (70)
Caring for home/homemaker	1 (1)	1 (1)
Other	1 (1)	3 (3)
Not informed	1 (1)	0 (0)
Days of hospital admission, median (IQR)	4 (3–6)	5 (3–7)	0.19
Number of admissions the last 5 years median (IQR)	2 (0–4)	1 (0–3)	0.17
Health status			0.19
Very poor	0 (0)	0 (0)
Poor	0 (0)	3 (3)
Fair	9 (9)	15 (15)
Good	38 (37)	34 (33)
Very good	56 (54)	51 (49)

IQR = interquartile range.

A p-value ≤ 0.05 shows a significantly difference across characteristics in the two groups.

3.2. Patients’ perception of missed nursing care

The prevalence of dichotomised missed nursing care is presented in Table 3 and responses distributed in all categories in the supplementary material. The responses are presented in the three domains: ‘Psychosocial care’, ‘physical care’, and ‘timeliness’. In the domain of ‘psychosocial care’, the study wards reported the lowest prevalence of missed nursing care for each care element, with statistically significant differences for the items ‘involved in decisions’ (p=0.02), ‘received needed information’ (p=0.03), and ‘treated with dignity’ (p=0.05). In both the domains ‘physical care’ and ‘timeliness’, there were no differences in missed nursing care; except that the patients in the study wards reported more missed nursing care related to ‘help with walking’ (p=0.03). No significant differences were found in ‘adverse events’ between the study and the standard wards.

Table 3.

Patient-reported missed nursing care shown as dichotomised responses. Dichotomised responses¹ of how many patients reported missed nursing care, adverse events and sum score using MISSCARE Survey–Patient (Albrechtsen et al., 2025).

Domain/Item	Study wards N=103, n ( %)		Standard wards N=103, n ( %)		Comparison of Missed Nursing Care
Psychosocial care domain	Not applicablea n ( %)	Missed Nursing Careb n ( %)	Not applicablea n ( %)	Missed Nursing Careb n ( %)	p-value
Aware of assigned nurse	0	57 (55)	0	67 (65)	0.15
Privacy for talking	87 (85)	8 (50)	84 (86)	10 (53)	0.88
Involved in decisions	0	34 (34)	0	50 (49)	0.02
Opinions considered	31 (30)	22 (31)	39 (38)	23 (36)	0.51
Informed about tests	24 (23)	15 (19)	8 (8)	27 (29)	0.15
Listened to	8 (8)	13 (14)	7 (7)	15 (15)	0.71
Shown empathy	0	10 (10)	0	14 (14)	0.40
Received needed information	0	10 (10)	0	21 (21)	0.03
Treated with dignity	0	2 (2)	0	8 (8)	0.05
Psychosocial care sum score, median (IQR)		13 (11–16)		15 (11–19)	0.03
Physical care domain
Help with bathing	49 (48)	27 (50)	50 (48)	20 (38)	0.20
Help with eating	83 (81)	10 (50)	84 (82)	9 (47)	0.87
Oral care	65 (63)	16 (42)	64 (62)	18 (46)	0.72
Repositioned in bed	66 (64)	15 (41)	64 (62)	10 (26)	0.17
Help with walking	57 (55)	18 (40)	56 (54)	(9) 19	0.03
Followed up on pain meds	55 (53)	19 (40)	62 (60)	20 (49)	0.38
Help to a chair	55 (53)	13 (27)	51 (50)	10 (20)	0.87
Restful environment	0 (0)	28 (27)	0 (0)	28 (27)	1
Help with drinking	53 (51)	6 (12)	37 (36)	16 (10)	0.81
Physical care sum score, median (IQR)		8 (4–13)		6 (3–13)	0.72
Timeliness domain
Time to receive pain meds	61 (59)	12 (29)	61 (59)	13 (31)	0.81
Time to respond to monitor beep	60 (58)	8 (19)	59 (57)	3 (7)	0.10
Time to assist with toilet needs	59 (57)	8 (18)	62 (61)	9 (22)	0.66
Time to answer call light	12 (12)	16 (18)	9 (9)	15 (16)	0.77
Time to receive requested help	11 (11)	11 (12)	10 (10)	14 (15)	0.54
Timeliness sum score, median (IQR)		6 (3–8)		5 (3–7)	0.22
Total sum score, median (IQR)		27 (22–38)		30 (20–41)	0.79
Adverse events2
Nosocomial infection		13 (13)		11 (11)	0.79
Subcutaneous fluid		11 (11)		12 (12)	0.82
Decubitus		6 (6)		4 (4)	0.52
Fall		6 (6)		4 (4)	0.51
Medication errors		4 (4)		4 (4)	0.98
Other errors		3 (3)		4 (4)	0.65
Thrombosis in leg or lung		1 (1)		2 (2)	0.52

IQR=Interquartile range

¹Missed nursing care was defined as: nursing care received ‘never’, ‘rarely’, or ‘sometimes’; and waiting time > 10 min.

²Responded ‘yes’ to the adverse event.

^aResponses ‘not applicable’ was used when the nursing care was not relevant

^bResponses of missed care

The median of the total sum score for the study wards was 27 [IQR:22–38], and for the standard wards 30 [IQR:20–41], with no statistically significant difference (p=0.79). The sum score for the domain ‘psychosocial care’, showed that the patients reported less missed nursing care in the study wards (p= 0.03). In the domains ‘physical care’ and ‘timeliness’, there were no significant differences in the sum scores.

3.3. Sub-group analysis - age

As patients in the study wards were statistically significantly older than those in the standard wards, we tested for differences between wards stratified by patients age ≤75 years and >75 years for the four elements with a difference. In the study wards, patients aged ≤75 years reported less missed nursing care in three out of four elements: ‘involved in decisions’ (p=0.004), ‘received needed information’ (p=0.02), and being ‘treated with dignity’ (p=0.05) compared to standard wards. For patients aged >75 years, no differences were found between wards across any care elements.

3.4. Nursing staff characteristics

In total, 14 questionnaires were excluded, because they had no responses in either section A or B. In five questionnaires, section A was completed; but all responses in section B were missing. These five questionnaires were included, as well as questionnaires where only one or two responses were missing.

In total, 239 nursing staffs were invited to participate; of these, 159 responded, comprising 81 from the study wards (response rate, 68 %) and 78 from the standard wards (response rate, 65 %). The two groups were comparable, except that the number of nursing staff whose main work was in inpatient wards was significantly higher in the study wards (p=0.001); thus, the standard wards had a higher proportion of nursing staff working across both inpatient wards and associated outpatient clinics (Table 4). In both groups, most nursing staff were females, with 84 % in the study wards and 91 % in the standard wards. The professional roles were similarly distributed across the two groups, with registered nurses constituting the largest professional group, with 69 % in the study wards and 76 % in the standard wards. The category ‘others’ included physiotherapists, occupational therapists, and care assistants. In both groups, almost all nursing staff worked more than 30 hours per week.

Table 4.

Characteristics of the nursing staff responding to the MISSCARE survey questionnaire.

	Study wards N= 81, n ( %)	Standard wards N=78, n ( %)	p-value
Sex
Females	68 (84)	71 (91)	0.15
Males	11 (14)	5 (6)
Other	1 (1)	0 (0)
Not informed	1 (1)	2 (3)
Age groups, (years)			0.19
< 25	7 (9)	1 (1)
25–34	40 (49)	31 (40)
35–44	15 (19)	20 (25)
45–54	11 (14)	14 (18)
55–64	6 (7)	9 (12)
>64	2 (2)	3 (4)
Title/role			0.34
Nurse assistants	23 (28)	16 (20)
Registered nurse	56 (69)	59 (76)
Others⁎	2 (3)	2 (3)
Not informed	0 (0)	1 (1)
Work experience from the present ward			0.01
< 6 months	7 (9)	8 (11)
6 months – 2 years	11 (13)	22 (28)
2 years -5 years	29 (36)	19 (24)
5 years – 10 years	22 (27)	10 (13)
> 10 years	11 (14)	19 (24)
Not informed	1 (1)	0 (0)
Working hours per week			0.44
<30 hours	5 (6)	2 (3)
≥30 hours	76 (94)	76 (97)
Normally work
Day shifts	38 (47)	37 (48)	0.57
Evening shifts	2 (3)	1 (1)
Night shifts	1 (1)	4 (5)
Different shifts	40 (49)	36 (46)
Have their main work in the bed ward
Yes n, ( %)	75 (92)	57 (73)	0.001
No n, ( %)	3 (4)	16 (21)
Not informed	3 (4)	5 (6)
Overtime the last month			P=0.32
None	19 (24)	11 (14)
1–12 hours	53 (67)	57 (75)
>12 hours	7 (9)	8 (11)
Highest education level
Nurse assistant	23 (28)	14 (18)	0.22
Registered Nurse	52 (63)	58 (74)
Master’s degree	5 (6)	2 (3)
Other	1 (1)	4 (5)
Not informed	2 (2)	0 (0)
Days on sick leave the three last month			0.36
No days	20 (25)	27 (35)
1 day	17 (21)	11 (14)
2–3 days	31 (38)	23 (30)
4–6 days	9 (11)	12 (15)
>6 days	3 (4)	5 (6)
Not informed	1 (1)	0 (0)

^⁎ physiotherapists, occupational therapists and care assistants

A p-value ≤ 0.05 shows a significantly difference across characteristics in the two groups.

3.5. The nursing staffs’ perception of missed nursing care

In the study wards, the nursing staff reported ‘patient personal hygiene’ as the most frequently missed element of care (81 %). In the standard wards, ‘turning patients every second hour’ was the most frequently missed element (74 %). In both study and standard wards, the care element ‘setting up meals for patients who feed themselves’ was the least frequently missed (11 %). In the study wards, more missed nursing care was reported for the element ‘response to call light is initiated within 5 min’ (p=0.01) was and less missed nursing care for the elements ‘full documentation of all necessary data’ (p=0.04), ‘teaching patients about illness, tests, and diagnosis’ (p=0.01), and ‘medications administration within 60 min of scheduled time’ (p= 0.05) compared to the standard wards. For the other care elements, there were no significant differences between the two groups. The total sum score for the study wards was 57.5 (SD: 11.5) and for the standard wards 59.2 (SD: 12.4), p=0.37. The prevalence of dichotomised missed nursing care is presented in Table 5. Responses distributed across all categories are presented in the supplementary material.

Table 5.

Nursing staff-reported missed nursing care shown as dichotomised responses. Dichotomised responses of how many participants reported missed nursing¹ care and reasons for missed nursing² care using the MISSCARE survey (Lisby et al., 2023).

Item	Study wards N=81 n ( %)		Standard wards N=78 n ( %)		Comparison of Missed Nursing Care
Elements of missed nursing care (Section A)	Not applicablea n ( %)	Missed Nursing Careb n ( %)	Not applicablea n ( %)	Missed Nursing Careb n ( %)	p- value
Patient personal hygiene	1 (1)	65 (81)	0 (0)	57 (73)	0.22
Mouth care	1 (1)	62 (78)	0 (0)	54 (70)	0.29
Response to call light is initiated within 5 min	1 (1)	59 (74)	0 (0)	41 (53)	0.01
Turning patients every 2 hours	3 (4)	56 (73)	2 (3)	56(74)	0.89
Monitoring intake/output	0 (0)	52 (65)	0 (0)	42 (54)	0.15
Ambulation three times per day or as ordered	0 (0)	52 (64)	0 (0)	56 (72)	0.31
Assist with toileting needs within 5 min. of request	1 (1)	45 (56)	1 (1)	37 (48)	0.34
Emotional support to patient and/or family	0 (0)	45 (55)	1 (1)	50 (65)	0.23
Assess effectiveness of medications	2 (2)	42 (53)	1 (1)	48 (63)	0.25
Full documentation of all necessary data	0 (0)	42 (53)	1 (1)	52 (69)	0.04
Attend interdisciplinary care conferences whenever held	13 (16)	36 (53)	13 (17)	40 (62)	0.32
Intravenous/central line site care	1 (1)	41 (52)	3 (4)	43 (57)	0.45
Teaching patients about illness, tests, and diagnosis	0 (0)	40 (50)	2 (3)	53 (69)	0.01
Wound care	1 (1)	39 (49)	0 (0)	48 (62)	0.09
P.n. medication requests acted on within 15 min	0 (0)	31 (38)	1 (1)	35 (45)	0.36
Feeding patient when the food is still warm	2 (2)	25 (32)	1 (1)	34 (45)	0.09
Medications adm. within 60 min. of scheduled time	2 (2)	22 (28)	1 (1)	33 (43)	0.05
Focused reassessments according to patient condition	2 (2)	19 (24)	4 (5)	23 (31)	0.35
Patient discharge planning	2 (2)	19 (24)	4 (5)	28 (38)	0.07
Hand washing staff	0 (0)	17 (21)	0 (0)	19 (24)	0.61
Bedside glucose monitoring as ordered	0 (0)	16 (20)	0 (0)	17 (22)	0.72
Vital signs assessed as ordered	0 (0)	12 (15)	2 (3)	13 (17)	0.69
Patient assessments performed each shift	2 (2)	10 (13)	2 (3)	9 (12)	0.88
Setting up meals for patients who feed themselves	0 (0)	9 (11)	3 (4)	8 (11)	0.93
Total sum score, Mean (SD)		57.5 (11.5)		59.2 (12.4)	0.37
Reasons for missed nursing care (Section B)		N=79		N=74
Unexpected rise in patient volume and/or acuity on the unit		66 (83)		63 (84)	0.94
Inadequate number of staff		58 (73)		65 (85)	0.06
Heavy admission and discharge activity		55 (60)		61 (81)	0.09
Urgent patient situations		51 (64)		61 (81)	0.02
Unbalanced patient assignments		43 (55)		44 (59)	0.53
Nursing staff did not communicate that care was not provided		36 (46)		40 (54)	0.29
Supplies/equipment not available when needed		29 (37)		33 (45)	0.32
Caregiver off unit or unavailable		27 (35)		25 (34)	0.96
Inadequate hand-off from previous shift or sending unit		28 (35)		29 (39)	0.68
Tension or communication breakdowns with the medical staff		27 (34)		26 (34)	0.95
Medications were not available when needed		27 (34)		25 (33)	0.91
Other departments did not provide the care needed		21 (27)		28 (37)	0.17
Supplies/equipment not functioning properly when needed		21 (27)		26 (35)	0.28
Tension or communication breakdowns within the nursing team		18 (23)		24 (32)	0.20
Lack of backup support from team members		16 (20)		27 (36)	0.03
Tension or communication breakdowns with ancillary departments		14 (18)		18 (25)	0.32
Inadequate number of assistive and/or clerical personnel		11 (14)		32 (43)	<0.001

¹Missed nursing care was defined as: nursing care ‘always missed’, ‘frequently missed’ or occasionally missed’’.

²Summarised percentage of responses ‘significant reason’ and ‘moderate reason’

^aResponses ‘not applicable’ was used when the nursing care was not relevant

^bResponses of missed care

3.6. Sub-group analysis

Including only nursing staff who worked in the inpatient wards, the previously observed differences were no longer present for the elements: ‘medications administration within 60 min of scheduled time’ (p= 0.27), ‘full documentation of all necessary data’ (p=0.25), and ‘teaching patients about illness, tests, and diagnosis’ (p=0.45). The element ‘response to call light is initiated within 5 min’ was not sensitive to this exclusion, and missed nursing care remained higher in the study wards (p=0.01). In the analysis, 4 % of the nursing staff from the study wards were excluded, and 21 % of the nursing staff from the standard wards. In addition, ‘monitoring intake and output’ was significantly more missed in the study wards (p=0.02).

3.7. Reasons for missed nursing care

The reasons for missed nursing care are presented in Table 5. Overall, the nursing staff in the study wards was less likely to report significant or moderate reasons than nursing staff in the standard wards. Differences between groups were identified across three reasons, which were considered minor by the study wards compared to the standard wards. The reasons were ‘urgent patient situations (e.g. a patient's condition worsening)’(p=0.02), ‘lack of backup support from team members’(p=0.03) and ‘inadequate number of assistive and/or clerical personnel’ (p<0.001).

3.8. Sub-group analyses

Including only nursing staff who had their main job in the inpatient wards, the reason ‘inadequate number of assistive and/or clerical personnel’ remained a minor reason in the study wards compared to the standard wards (p<0.001). Another difference was found in the reason ‘nursing staff did not communicate that care was not provided’ (p=0.05), which was also a minor reason in the study wards compared to the standard wards.

4. Discussion

This discussion addresses differences in missed nursing care across wards with and without a two-year transition programme. By discussing the results within the broader research field and considering relevant organisational and contextual factors, the section aims to clarify potential explanations for the observed variations.

4.1. Missed nursing care perceived by patients

There was no difference in reported missed nursing care for patients older than 75 years; however, the patients aged < 75 years reported significantly less missed nursing care for three elements within the psychosocial care domain in the study wards. Several studies indicate that older hospitalised patients are more satisfied with the treatment and nursing care compared to younger patients (Alharbi et al., 2023; Harp et al., 2024). However, a study from 2003 indicates that the general satisfaction decreases for patients older than 80 years (Jaipaul & Rosenthal, 2003). The age difference across the two groups in our study were driven by patients < 75 years.

Patients in wards with a two-year transition programme reported less missed nursing care than those in wards with a standard transition programme in being involved in decisions, receiving needed information, and being treated with dignity. On the other hand, patients in the study wards reported that they less frequently received help with walking when needed. These measures of missed nursing care indicate which nursing care activities that nursing staff prioritize when resources are limited (Papathanasiou et al., 2024). Nursing staff in wards with the two-year transition programme was more likely to involve patients in decisions about treatment and care. A prerequisite for involvement and shared decision-making is the nurse’s ability to translate professional knowledge into information that is comprehensible and meaningful for patients (Elwyn et al., 2017; Waddell et al., 2021). The two-year programme included placements in collaborating outpatient clinics, specifically designed to deepen newly graduated nurses’ understanding of the medical specialty. These cross-departmental experiences likely supported a more coherent understanding of the patient pathway across the hospital and municipality. By bringing this broader systems knowledge back to the ward, newly graduated nurses may be better equipped to situate individual treatment decisions within the full patient pathway. This, in turn, enables them, and potentially their colleagues, to provide patients with more complete and contextualized information, thereby strengthening the conditions for shared decision-making.

Involving patients meaningfully in decisions about their treatment and care requires an organisational culture that supports partnership between patients and nursing staff, where patients are explicitly invited to articulate what matters to them (Elwyn et al., 2017). However, research indicates that clinicians often overestimate the extent to which they involve patients or assume that patients prefer not to engage in decision-making (Joseph-Williams et al., 2017). Such assumptions can create a structural barrier to shared decision-making and may limit the patients’ opportunities to exercise autonomy in clinical encounters.

Preceptorship offers newly graduated nurses sustained support and reflective space, which may strengthen their ability to integrate communication competencies into practice. Likewise, the ward culture, which includes preceptorship and interdisciplinary collaboration, may facilitate a shared professional understanding that patient involvement is an integral component of high-quality care. This present study found no differences in the ability to talk in a private room; however, the literature showed results that a private room was identified as a barrier for shared decision making (Waddell et al., 2021). The physical environment of one-bedded or multi-bedded rooms was similar across the wards and therefore not an influencing factor.

In the study wards, 2 % of the patients reported that they were not treated with dignity, which was significantly lower than in the standard wards (8 %). A scoping review showed that patients had unmet needs regarding being treated as unique individuals with dignity (Bagnasco et al., 2020). In the Life Lab sessions in the study wards, the newly graduated nurses discussed and trained how to care for and talk to critically ill patients and their relatives. This training may affect how patients experience their encounter and relationship with newly graduated nurses. Also in the psychosocial domain, a difference in the sum score was observed, with less missed nursing care in the study wards, which may be attributed to the fact that nurses in the study ward having received training through followership, supervision, and participation in Life Lab activities over the two years period. This focus on psychosocial nursing care may partly explain the result, where patients in the study wards to a lower extent get the help to walk when needed.

4.2. Missed nursing care perceived by nursing staff

The results demonstrated that nursing staff in the study wards reported less missed nursing care compared to the standard wards in ‘full documentation of all necessary data’ and ‘teaching patients about illness, tests, and diagnosis’. Notably, documentation was not a targeted part of the transition programme in neither the study nor the standard wards. The transition programme in the study wards was designed to provide newly graduated nurses with knowledge about medical diseases, and the stay in the outpatient clinics provides the nurses with knowledge on how the medical treatment and follow-up meetings at the hospital may proceed after discharge, thereby enhancing them and their colleagues’ ability to complete the educational process for the patients. The nursing staff in the study wards manage to teach the patients, which is supported by the results showing patients from these wards reporting a lower extent of missed nursing care related to receiving information as needed. The nursing staff in the study wards reported less missed nursing care related to ‘medications administration within 60 min of scheduled time’, and they reported more missed nursing care related to ‘responding to the red light within 5 min’. This prioritisation of medication administration in time, along with a waiting time of more than 5 min for the patients, may be a part of the culture among the nursing staff. Feedback from preceptors or the nurse manager may as well affect this prioritisation of care (Kitson, 2018).

4.3. Reasons for missed nursing care perceived by nursing staff

‘Urgent patient situations’, inadequate number of assistive personnel´, and ‘the lack of backup from team members’ were less frequently reported as a reason for missed nursing care in the study wards than in the standard wards. Particularly, the support from team members may be related to the culture and the length of the two-year transition programme during which newly graduated nurses received preceptorship and followership as needed. In the literature, preceptorship is an acknowledged and essential part of supporting newly graduated nurses to improve their clinical competence and confidence (Charette et al., 2023; Kim et al., 2025; Koh et al., 2023). The strongest way to support new professionals is on-the-job-training (Frogeli et al., 2023). This support and backup may improve teamwork culture, which is a reducing factor in the incidence of missed care (Waddell et al., 2021). When ‘urgent patient situations’ was a minor reason in the study wards, it may be due to either a lower frequency of such situations or an efficient structure to handle them when they occur. The area the hospitals serve were similar, and thereby not the reason for this difference. However, the training from the transition programs may affect how the newly graduated nurses handle urgent situations. An inadequate number of assistive personnel is a part of the nursing context and not linked to the two-year transition programme. From the literature, we know that staffing and work environment were stronger reasons for missed nursing care than individual characteristics of the nurses such as age, sex, and experience (Jones et al., 2015). Therefore, it will be essential that transition programs include the work environment, rather than just providing skills to the individual nurse. The programme length of two years was considered long-term. The literature found that the largest impact is seen in the first six months (Koh et al., 2023). Programmes lasting at least one year have been shown to be particularly effective (Cochran, 2017), and intention to leave has been shown to peak approximately one year after graduation, indicating a period of heightened vulnerability (Failla et al., 2021).

4.4. Strengths and limitations

In this present study, it was unclear how culture and management at the wards affected the nursing care and how the nursing staff prioritised care. The overall context, including hospital and ward size and medical specialities, was similar across the wards, while the transition programme differed among them. A limitation is that patient-nurse ratios were unavailable; thus, staffing levels influence missed nursing care (Waddell et al., 2021). Nursing is a complex practice that encompasses both the physical and psychosocial domains of care, while simultaneously being shaped by the broader context in which it is practised (Feo et al., 2018; Kitson, 2018). While the study included responses from different health care professionals with different levels of experience, we do not consider this a major limitation. All participants, regardless of level of experience and professional background, completed the same questionnaire that described which aspects of nursing care were performed and which were missed, rather than defining missed care themselves. Also, responses from others, other than nurses and nurse assistants, included only two responses from the study wards and standard wards, respectively. Since the distribution of professionals across wards was comparable, we assume this does not affect observed differences. Therefore, differences in formal education are unlikely to cause over- or underestimation in this study. Moreover, this study does not focus solely on nurses enrolled in transition programmes; rather, it examines how such programmes function as organisational learning and support initiatives that may affect nursing practice at the ward level. In this case, including responses from different professionals can be seen as a strength, as et reflects the collaborative nature of nursing care and shared responsibility for ensuring care delivery. The participating nursing staff in this study were not limited to newly graduated nurses who had participated in either the standard or the two-year transition programs. It entails that over half of the participating nursing staff has not completed these current transition programs, and their responses were an overall assessment of the nursing care in the wards and not specifically related to these programs. However, a transition programme which has been implemented for several years will presumably affect the overall nursing care at the wards.

Including responses from both patients and nursing staff, combined with the use of culturally adapted and validated surveys, strengthened our study. Demographic characteristics were not available for patients who decided not to participate; however, the characteristics for the patient participants at the two hospitals were overall similar. Selection bias may have been introduced because the coordinating nurse at the wards identified eligible patients. If unsatisfied patients were excluded, intentionally or unintentionally, it would reduce the amount of missed nursing care reported by patients. Using a survey regarding missed nursing care raises potential recall bias. Additionally, there is a risk of over- or underestimating responses for various items when missed nursing care is self-reported. Also, social desirability bias can lead to an underreporting of missed nursing care, as individuals may wish to present themselves in a more favourable light (Koller et al., 2023). Social desirability may also lead to underreporting of missed nursing care among patients, particularly for patients who needed support to answer the questionnaire. However, since this study aimed to compare the reported missed nursing care, it is reasonable to assume that the study wards and the standard wards were affected in the same way by the risk of over- or underestimation. The response rates of 65 % and 68 % for the nursing staff were considered satisfactory, compared to other studies using the MISSCARE Survey (Bragadottir et al., 2017; Mainz et al., 2025; Mainz et al., 2024).

The use of validated surveys and a relatively large sample size strengthen the reliability and external validity of the study. However, the two-year transition programme was developed in the context of a medical ward, and it needs to be adapted to improve nursing care in other healthcare settings.

Dichotomising the survey responses may oversimplify complexity and increase a risk of misclassification. Another limitation of this study is that the questionnaires provided a simplified representation of nursing practice and does not fully capture its complexity. It is therefore possible that aspects of care, particularly those influenced by the transition program, such as specific medical knowledge and skills, remain unaddressed.

5. Conclusion

Overall, the results indicate that extended transition support may enhance aspects of psychosocial care, including patient involvement. The elements of a two-year transition program, including outpatient clinic stays, interdepartmental collaboration, and followership, may have contributed to these improvements. In several areas, no significant differences in missed nursing care were found. However, the wards with the two-year transition programme demonstrated more missed nursing related to ambulation assistance and response times to call lights. Nursing staff in wards with the two-year programme appeared to experience stronger team support, as they were less likely to report ‘lack of support from team members’ as a reason for missed nursing care. Transition programmes function as integrated systems rather than isolated elements. Consequently, it is not possible to attribute specific outcomes to individual programme elements. Therefore, the findings should therefore be interpreted as indicative rather than causal. Overall, these results suggest that a prolonged and comprehensive transition programs may help create a more supportive work environment and improve the quality of psychosocial patient care.

Funding

This work was supported by the Health Research Foundation of Central Denmark Region.

CRediT authorship contribution statement

Manja Bjerring Rothenberg: Writing – original draft, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Louise Bang Grode: Writing – review & editing, Supervision, Methodology, Formal analysis, Data curation, Conceptualization. Maria Schiønning Olsen: Writing – review & editing, Supervision, Data curation. Maja Thomsen Albrechtsen: Writing – review & editing, Supervision, Methodology, Formal analysis. Connie Berthelsen: Writing – review & editing, Supervision, Conceptualization. Merete Gregersen: Writing – review & editing, Supervision, Methodology, Formal analysis, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.