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

Background 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 Aim To investigate whether task complexity (simple vs. complex) moderates the association between nurses’ felt accountability focus (outcome vs. process) and missed nursing care. Design A prospective repeated-measures field study with nurses nested within wards. Setting The study was conducted in one medium-sized public hospital, encompassing 10 internal medicine and surgical wards. Participants A total of 105 registered nurses providing direct patient care participated in the study. Methods 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. Results 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. Conclusion 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. Social media abstract 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.