Patients and staff perspectives on hospital ward strain and its impacts on patient care and the workforce: A mixed-methods systematic review

Abstract Background Hospital ward strain occurs when care demands exceed available staffing, beds, and resources, posing a significant threat to safe inpatient care. While emergency department and intensive care settings have been extensively studied, ward-level pressures have received less attention, particularly from the perspectives of patients and frontline staff. This review aimed to synthesise current evidence on how hospital ward strain is experienced by staff and patients, and its implications for care quality, safety, and workforce sustainability. Methods A mixed-methods systematic review was conducted on patient and staff perspectives on hospital ward strain. MEDLINE, CINAHL, PsycINFO, and HMIC were searched for empirical studies published from January 2000 to March 2025. Three reviewers screened titles and abstracts in pairs; full-text assessment was conducted by one reviewer with independent verification of a random 20% sample. The Mixed-Methods Appraisal Tool was used to assess methodological quality. Findings were analysed using Donabedian’s Structure-Process-Outcome (SPO) model and Hollnagel’s Resilience framework. Results Of 9,943 studies identified, 16 observational and non-randomised studies met the inclusion criteria, representing diverse healthcare settings across multiple countries. Most studies (87.5%) focused exclusively on staff perspectives; only two included patient experiences. Structural pressures (inadequate staffing, bed capacity constraints) consistently led to process failures (care delays, missed care, coordination breakdowns), resulting in burnout, turnover, quality and safety trade-offs, and compromised patient safety. Ward resilience was mainly reactive: respond and monitor were evident, but anticipate and learn were mostly absent. Patient acuity was inconsistently reported, limiting cross-study comparison. Conclusion Ward strain is a systemic patient safety issue requiring structural solutions beyond staff resilience. Patient perspectives remain underrepresented and must be prioritised in future research. Policymakers should invest in anticipatory and learning resilience capacities, through workforce planning, real-time monitoring, and formal learning mechanisms, to ensure sustainable, safe ward care.