Asian Nursing Research 12 (2018) 121e126

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Asian Nursing Research

journal homepage: www.asian-nursingresearch.com

Research Article

Exploring the Influence of Nursing Work Environment and Patient

Safety Culture on Missed Nursing Care in Korea
Kyoung-Ja Kim,1 Moon Sook Yoo,2 Eun Ji Seo2, *, *
1
Department of Nursing, Hannam University, Deajeon, Republic of Korea
2
College of Nursing and Institution of Nursing Science, Ajou University, Suwon, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study aimed to explore the influence of nurse work environment and patient safety culture
Received 1 December 2017 in hospital on instances of missed nursing care in South Korea.
Received in revised form Methods: A cross-sectional design was used, in which a structured questionnaire was administered to
12 April 2018
186 nurses working at a tertiary university hospital. Data were analyzed using descriptive statistics, t test
Accepted 16 April 2018
or analysis of variance, Pearson correlation, and multiple regression analysis.
Results: Missed nursing care was found to be correlated with clinical career, nursing work environment,
Keywords:
and patient safety culture. The regression model explained approximately 30.3% of missed nursing care.
environment
nursing care
Meanwhile, staffing and resource adequacy (b ¼ .31, p ¼ .001), nurse manager ability, leadership and
patient safety support of nurses (b ¼ .26, p ¼ .004), clinical career (b ¼ .21, p ¼ .004), and perception on patient
quality of health care safety culture within unit (b ¼ .19, p ¼ .041) were determined to be influencing factors on missed
nursing care.
Conclusion: This study has significance as it suggested that missed nursing care is affected by work
environment factors within unit. This means that missed nursing care is a unit outcome affected by nurse
work environment factors and patient safety culture. Therefore, missed nursing care can be managed
through the implementation of interventions that promote a positive nursing work environment and
patient safety culture.
© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction nursing care, refers to necessary nursing care that is delayed,

Patient safety at medical institutes is a matter that continues to
need quality improvement. Medical institutes have made consid-
erable efforts and implemented systemic improvements to prevent
accidents. Despite these efforts, however, two out of seven hospital
inpatients still experience accidents, and approximately 44% of
accidents in the United States are deemed preventable [1]. The
quality of nursing is an important factor in ensuring patient safety,
as substandard nursing care directly leads to negative patient
outcomes [2]. Accordingly, as a sensitive performance measure for
quality of nursing, missed nursing care that occurs while nurses are
performing routine work should be managed effectively [3,4].
Missed nursing care, also known as implicitly rationed care,
nursing care left undone, unmet patient needs, and unfinished
* Correspondence to: Eun Ji Seo, RN, PhD, Ajou University College of Nursing and
Institution of Nursing Science, 164, Worldcup-Ro, Yeongtong-Gu, Suwon 16499,
Republic of Korea.
E-mail address: silbia98@ajou.ac.kr
* missed nursing care.
ORCID: https://orcid.org/0000-0002-6565-0093
partially completed, or missing in a clinical, emotional, or admin-
istrative aspect or for any number of possible reasons [4]. Missed
nursing care reduces the quality of nursing, causes accidents and
inpatient complications, and ultimately results in negative patient
outcomes such as dissatisfaction and readmission [3,5,6].
A primary cause of missed nursing care is limited resources in
the work environment, such as insufficient workforce, time, and
peer support [7]. These factors result from problems with organi-
zation and the nursing system rather than individual nurses.
Several studies conducted in European nations support this,
reporting that missed nursing care is closely related to the practice
environment [3,6e8]. These studies explained that work environ-
ment factors such as resource level, communication among staff,
working system, and the leadership of head nurses has the greatest
effect on the occurrence of missed nursing care although the clin-
ical and academic career of each nurse also has a certain degree of
impact [4]. Thus, it is clear that a specific strategy is needed to
address the work environment factors and ultimately reduce

https://doi.org/10.1016/j.anr.2018.04.003
p1976-1317 e2093-7482/© 2018 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
122 K.-J. Kim et al. / Asian Nursing Research 12 (2018) 121e126
The patient safety culture of medical institutes also has a sig-
nificant influence on missed nursing care, along with the nursing
work environment. It refers to an organizational culture related
with the attitudes, norms, and beliefs of the members about patient
safety [9] and is identified as a factor of various safety behaviors [3].
When an organization has a positive patient safety culture, the
engagement of its staff in safety behaviors is enhanced. The nursing
staff can cope with unexpected circumstances or unsolved prob-
lems more effectively when they perform routine tasks, contrib-
uting to better patient safety and patient outcomes [9].
Furthermore, it creates an environment where nurses respond to
repeated incidents of missed nursing care, report such incidents
immediately, and discuss them together, which contributes to
resolving matters that may have led to major incidents if left un-
addressed. A practical example of the effectiveness of this approach
is shown in previous study, determining that the more positive the
patient safety culture in a hospital, the lower the occurrence of
missed nursing care [6].
Intensive management of missed nursing care in a nursing or-
ganization is essential in improving the quality of nursing care and
patient outcomes. Missed nursing care was affected by organiza-
tional factors, individual nurse characteristics such as clinical
career, and patient status such as severity of illness [7]. Among
them, organizational factors have more influence on missed
nursing care than individual ones [4,5,8]. The studies cited above
also suggested improving the nursing work environment and
building a patient safety culture as a critical factor to manage
missed nursing care. However, evidences are still far from
convincing because nursing work environment and patient safety
were studied separately in previous researches [3,5,6,8]. Besides,
large-scale studies identified related variables, but there were
insufficient studies in individual hospitals that perform practical
interventions. Therefore, the study was carried out to verify the
significance of nursing work environment and patient safety cul-
ture in individual hospital that should be taken into account to
develop and apply various programs to reduce frequency of missed
nursing care in each hospital. This study specially focuses on the
relationship between the organizational factors and missed nursing
care under clinical career control.
Hence, this study aimed to (1) describe the levels of the
nursing work environment, perception of the patient safety
culture, and missed nursing care and (2) identify the influence of
the work environment and patient safety culture on missed
nursing care.
Methods
Study design
The current study used a cross-sectional design, and the
sample consisted of nurses working in a tertiary university hos-
pital with over 1,000 beds, which is located in a province of South
Korea.
Setting and samples
The nonprobabilistic sample chosen for the study comprised 188
nurses who worked at a single hospital. The ratio of beds to nurses
in the hospital is ranged from 2.0 to 2.5. The study included nurses
who directly cared for patients and who worked in the general
ward or intensive care unit (ICU). Nurse managers were excluded
because they were not assigned directly to patients. Nurses with no
more than 3 months into their clinical career were also excluded to
control for possible exogenous variables that could be influenced by
new nurses' adaptation process.
To determine the appropriate sample size for this study, a power
analysis was performed using G*power 3.1 [10] based on a previous
study on missed nursing care [11]. It was determined that 147 pa-
tients were needed for a two-tailed analysis using multiple
regression with a .05 a-level, 90% power, 15 predictors, and 0.18
effect size from 0.15 coefficient of determination; therefore, our
sample size was sufficient.
Ethical considerations
The content and methods of this study were approved by the
institutional review board of Hannam University (Approval no. 16-
05-01-1221). Informed written consent was obtained from all
participants before they took part in the study. Participants were
informed that they could leave the study at any time without
penalty, and all personal information was kept confidential.
Measurements
All instruments used in this study were validated in previous
studies. Korean versions of each instrument have also shown
acceptable validity and reliability [12e14].
Nursing work environment
The nursing work environment indicates an organizational
feature of working conditions that expedite or interrupt the pro-
fessional work of nurses [15]. The study applied the Korean version
of the Practice Environmental Scale of Nursing Work Index, whose
reliability and validity was verified after it was developed by Lake
[15] and translated by Cho et al [12]. The instrument, used with the
author's approval, consists of five subscales and 29 items: nurses'
participation in hospital affairs (nine items) (i.e., staff nurses are
involved in the internal governance of the hospital); nursing
foundations for quality of care (nine items) (i.e., an active quality
assurance program); nurse manager ability, leadership, and sup-
port of nurses (four items) (i.e., a supervisory staff that is supportive
of the nurses); staffing and resource adequacy (four items) (i.e.,
enough staff to get the work done); and collegial nurseephysician
relations (three items) (a lot of teamwork between nurses and
doctors). Nurses were rated on a 4-point Likert scale, from 1
(strongly disagree) to 4 (strongly agree), with higher scores
denoting a more positive nursing work environment. In this study,
the Cronbach a of the instrument was .89.
Patient safety culture
The safety culture of an organization is the confluence of indi-
vidual and group values, attitudes, perceptions, competencies, and
patterns of behavior that determine the commitment to, and the
style and proficiency of, an organization's health and safety man-
agement [16]. In this study, we used a total of 28 items of psy-
chosocial domain regarding organizations' patient safety culture of
the “Perception of Patient Safety Culture Scale.” The scale, based on
a hospital survey of patient safety culture developed by the United
States Agency for Healthcare Research and Quality [16], was
translated and validated in a previous study [13]. This instrument
consists of the following three subdomains: (1) the perception of
patient safety culture within a work area/unit (18 items); (2) su-
pervisor/manager (four items), representing expectations and ac-
tions of supervisor/manager in each unit to promote patient safety;
and (3) perception of communication on patient safety (six items),
representing how open and active the communication about pa-
tient safety is. Nurses were rated on a 5-point Likert scale, from 1
(strongly disagree) to 5 (strongly agree), with higher scores indi-
cating more positive perceptions of patient safety. The Cronbach a
of this study was .92.
 K.-J. Kim et al. / Asian Nursing Research 12 (2018) 121e126 123

Missed nursing care Table 1 General Characteristics and Differences in Missed Nursing Care (N ¼ 186).
Missed nursing care means nursing care that was not delivered to
Characteristics Categories n (%) Missed nursing care
a patient in need because of certain issues [5]. For the purposes of
this study, it was measured using the MISSCARE instrument devel- Mean ± SD t or F p
oped by Kalisch et al [17], with the authors' approval. MISSCARE is Age (yrs) 25 70 (38.2) 1.33 ± 0.33 0.50 .738
divided into Part A, which measures the type and frequency of 26e30 67 (36.6) 1.39 ± 0.43
missed nursing care, and Part B, which deals with the causes of 31e35 21 (11.5) 1.39 ± 0.28
36e40 15 (8.2) 1.26 ± 0.13
missed nursing care. However, this study used only Part A to collect 41 10 (5.5) 1.31 ± 0.23
data. Part A has 24 items in total, but after consultation with three Sex Female 176 (94.6) 1.34 ± 0.34 1.80 .106
Korean nursing professors, only 18 were used for this study, as some Male 10 (5.4) 1.59 ± 0.40
of them (such as setting up meals, bathing, toileting assistance, Marital status Unmarried 137 (75.4) 1.39 ± 0.38 1.85 .067
Married 45 (24.6) 1.26 ± 0.22
feeding, ambulation, and interdisciplinary care attendance) were
Educational level Three-year diploma 33 (17.8) 1.42 ± 0.52 1.03 .361
inappropriate for nursing practice in a tertiary hospital in Korea. Bachelor's degree 118 (63.8) 1.35 ± 0.31
Validity was tested for these 18 items with expert panels that con-  Master's degree 34 (18.4) 1.29 ± 0.24
sisted of six nurses with clinical careers of 7 years or more. They Clinical career (yrs) 1 33 (18.0) 1.24 ± 0.20 0.75 .586
achieved a content validity index of 1.00 for all 18 items, indicating 2e3 63 (34.4) 1.40 ± 0.46
4e6 28 (15.3) 1.38 ± 0.33
high consistency among ratings of item relevance and clarity. The 7e9 22 (12.0) 1.35 ± 0.27
participants responded to the suggested nursing care on a scale from 10e12 13 (7.1) 1.36 ± 0.30
1 to 4, indicating “rarely missed,” “occasionally missed,” “frequently 13 24 (13.1) 1.33 ± 0.24
missed,” and “always missed,” respectively, during their last 7-day Working area General ward 66 (35.7) 1.41 ± 0.42 1.42 .158
ICU 119 (64.3) 1.33 ± 0.30
shift. Higher scores denoted a higher frequency of missed nursing
Position Staff nurse 130 (70.7) 1.38 ± 0.36 1.16 .250
care. The Cronbach a of this study was .87. Charge nurse 54 (29.3) 1.30 ± 0.32

Note. ICU ¼ intensive care unit; SD ¼ standard deviation; yrs ¼ years.

Data collection Included missing values.

Data were collected from July to August, 2017. The researchers

visited the nursing units to obtain consent of the nurses to partic- 82.2% (n ¼ 152) had at least a bachelor's degree in nursing. The
ipate in the study. Wards and ICUs that had similar nursing work mean clinical career was 5.77 years (SD ¼ 5.53), and 119 (64.3%)
were selected. On the other hand, outpatient clinics, operating were working in an ICU. The majority of the participants were staff
room, recovery room, and emergency room were excluded because nurses (70.7%, n ¼ 130). However, there were no differences in the
the work characteristics in these units were different from those in level of missed nursing care according to general characteristics.
wards and ICUs. Seven general wards for adults and six ICUs for
adults were conveniently selected, with pediatrics and psychiatrics
The level of nursing work environment, patient safety culture, and
excluded. The selected wards and ICUs were given 10 and 20
missed nursing care
questionnaires, respectively, in consideration of their size and
number of bedside nurses. As missed nursing care could be a sen-
The mean scores of the study variables are shown in Table 2. The
sitive variable to the nurses, the researchers visited each unit at
mean overall score of the nursing work environment was 2.58 out
around their shift change to explain the purpose, background,
of 4 (SD ¼ 0.38). The lowest subscale was “Staffing and Resource
method, and ethics of the study before giving out questionnaire to
Adequacy” (mean ¼ 1.84 out of 5, SD ¼ 0.66). The highest subscale
those who voluntarily agreed to participate in it. The completed
was “Nurse Manager Ability, Leadership, and Support of Nurses”
questionnaires were sealed in envelopes before collection to ensure
(mean ¼ 2.99 out of 5, SD ¼ 0.51). The mean overall score of patient
the anonymity and confidentiality of the participants. A total of 187
safety culture was 3.30 out of 5 (SD ¼ 0.37). The lowest subscale
questionnaires were collected. One questionnaire that lacked re-
was “Perception of Patient Safety Culture within Unit” (mean ¼ 3.07
sponses was excluded, and 186 questionnaires were used in the
out of 5, SD ¼ 0.35), followed by “Communication” and “Supervisor/
final analysis.
Manager” (mean ¼ 3.31, SD ¼ 0.54 and mean ¼ 3.43, SD ¼ 0.55,
respectively). The mean score of missed nursing care was 1.36 out
Data analyses
of 4 (SD ¼ 0.35). The highest and lowest items were “Emotional
Support for Patients and/or their Families” (mean ¼ 1.72, SD ¼ 0.64)
General characteristics were analyzed with descriptive statis-
and “Bedside Glucose Monitoring as Ordered” (mean ¼ 1.06,
tics. The difference of missed nursing care according to general
SD ¼ 0.30), respectively.
characteristics was analyzed with an independent t test and a one-
Additionally, we analyzed the causes of missed nursing care that
way analysis of variance with a post hoc test (Scheffe test). The
the participants answered for an open-ended question. According
Pearson's correlation coefficients were used to analyze the corre-
to the analysis, “sudden onset of clinical emergency situations”
lation among clinical career, nursing work environment, patient
represented 74.5% of the answers, followed by “individual human
safety culture, and missed nursing. Multiple regression analysis was
factors such as inappropriate work competency” at 8.7% and
used to examine the factors influencing missed nursing care. All
insufficient assistant personnel at 7.1% (data not shown).
analyses were two-tailed, and the significance level was set at .05.

Results The correlation between nursing work environment, patient safety

General characteristics and differences in missed nursing care
The participants' characteristics are shown in Table 1. The mean
age of the participants was 28.36 years [standard deviation
(SD) ¼ 5.85], and 176 (94.6%) were women. Of the 186 participants,
culture, and missed nursing care
Significant negative associations between missed nursing care
and nursing work environment (r ¼ .43, p < .001), patient safety
culture (r ¼ .37, p < .001), or clinical career (r ¼ .16, p ¼ .049)
were found. Furthermore, there was a significant negative
124 K.-J. Kim et al. / Asian Nursing Research 12 (2018) 121e126

Table 2 The Level of Nursing Work Environment, Patient Safety Culture, and Missed Table 4 The Influencing Factors of Missed Nursing Care (N ¼ 186).
Nursing Care (N ¼ 186).
Variables B b t p
Variables Mean ± SD
Constant 2.65 10.55 <.001
Nurse work environment 2.58 ± 0.38 Clinical career 0.01 .21 2.95 .004
Nurse participation in hospital affairs 2.49 ± 0.40 Nurse work environment
Nursing foundations for quality of care 2.87 ± 0.47 Nurse participation in hospital affairs 0.08 .09 1.01 .314
Nurse manager ability, leadership, and support of nurses 2.99 ± 0.51 Nursing foundations for quality of care 0.06 .08 0.71 .481
Staffing and resource adequacy 1.84 ± 0.66 Nurse manager ability, leadership, 0.13 .26 2.94 .004
Collegial nurseephysician relations 2.39 ± 0.67 and support of nurses
Patient safety culture 3.30 ± 0.37 Staffing and resource adequacy 0.21 .31 3.55 .001
Patient safety culture within unit 3.07 ± 0.35 Collegial nurseephysician relations 0.01 .02 0.23 .817
Supervisor/manager 3.43 ± 0.55 Patient safety culture
Communication 3.31 ± 0.54 Patient safety culture within unit 0.17 .19 2.06 .041
Missed nursing care 1.36 ± 0.35 Supervisor/manager 0.02 .04 0.46 .647
Mouth care 1.27 ± 0.59 Communication 0.01 .02 0.19 .854
Emotional support to patient and/or family 1.72 ± 0.64
Full documentation of all necessary data 1.59 ± 0.56 Note. R2 ¼ .35, Adj. R2 ¼ .30, F ¼ 8.18, p < .001.
Patient teaching about procedures, tests, 1.43 ± 0.58
and other diagnostic studies
Turning patient every 2 hours 1.52 ± 0.62 Nurse manager ability, leadership, and support of nurses (b ¼ .26,
Assist with toileting needs within 5 minutes of request 1.52 ± 0.61 p ¼ .004), staffing and resource adequacy (b ¼ .31, p ¼ .001),
±
Assess effectiveness of medications 1.40 0.59
perception of patient safety culture within unit (b ¼ .19, p ¼ .041),
Hand washing 1.48 ± 0.65
Skin/wound care 1.50 ± 0.61 and clinical career (b ¼ .21, p ¼ .004) were presented as the
PRN medication requests acted on within 15 minutes 1.37 ± 0.61 influential factors.
Medications administered within 30 minutes 1.20 ± 0.46
before or after scheduled time
IV/central line site care and assessments according 1.19 ± 0.43 Discussion
to hospital policy
Focused reassessments according to patient condition 1.36 ± 0.54 The study found that “staffing and resource adequacy” and
Patient discharge planning and teaching 1.23 ± 0.51
“nurse manager ability, leadership, and support of nurses” among
Response to call light is initiated within 5 minutes 1.38 ± 0.61
Patient assessments performed each shift 1.33 ± 0.58 the various nursing work environment factors had an influence on
Monitoring intake/output 1.13 ± 0.40 missed nursing care. The perception of “patient safety culture
Vital signs assessed as ordered 1.12 ± 0.38 within the unit” and nurses' clinical careers as general character-
Bedside glucose monitoring as ordered 1.06 ± 0.30 istics were also influence factors.
Note. IV ¼ intravenous; PRN ¼ pro re nata; SD ¼ standard deviation. First of all, the nurses' perception of staffing and resource ade-
quacy was observed to be the most influential factor on missed
correlation between missed nursing care and all the subscales of nursing care. This finding is in line with the findings of previous
nursing work environment, respectively (Table 3). studies that missed nursing care resulted from staffing inadequacy
and limited resources for the nurses [8,14]. Staffing adequacy also
has a positive impact on reducing instances of failure to rescue,
The factors influencing missed nursing care
inpatient mortality, and admission periods [18]. For securing the
staffing adequacy, skill mix and turnover as well as the number of
A multiple regression analysis was carried out to identify the
nurses are needed to manage. Skill mix representing composition
influence of each environment factor and the subscales of patient
of nursing staff can directly affected patient outcomes such as falls
safety culture on missed nursing care after adjusting for clinical
and ulcers [6,14]. High turnover causes lack of skilled nurses,
career (Table 4). The possible presence of auto-correlation and
resulting in a negative impact on staffing adequacy [19]. Therefore,
multicollinearity for the regression model were assessed through
improper skill mix caused by high turnover should also be proac-
DurbineWatson's statistic (2.01), tolerance (0.55e0.80), and the
tively managed to improve the quality of nursing care and prevent
variance inflation factor (1.24e1.81), confirming that the basic re-
missed nursing care.
quirements of regression analysis were satisfied.
Nursing field issues such as a sudden increase in workloads
Regression analysis revealed that the explanatory power of this
need to be taken into account to ensure adequate staffing and
regression model were approximately 30.3% (F ¼ 8.18, p < .001).
resources management. According to an additional analysis con-
ducted as part of this study, 74.5% of the participants reported the
Table 3 The Correlation Among Nurse Work Environment, Patient Safety Culture, and
sudden onset of an emergency as a major reason for missed
Missed Nursing Care (N ¼ 186).
nursing care. An unexpected emergency and the subsequent delay
Variables Missed nursing care of routine work is the factor most responsible for missed nursing
r p care [14,20]. Previous studies also found that working overtime
causes 1.86 times as many incidents of missed nursing cares when
Clinical career .16 .049
Nurse work environment .43 <.001
compared with normal working group and is associated with ac-
Nurse participation in hospital affairs .17 .032 cidents such as falls, pressure ulcers, medication error, and urinary
Nursing foundations for quality of care .40 <.001 tract infections [21,22]. Therefore, it is clear that adequate staffing
Nurse manager ability, leadership, .38 <.001 such as proper skill mix and resources such as enough nurses
and support of nurses
should be taken into consideration to manage the missed nursing
Staffing and resource adequacy .44 <.001
Collegial nurseephysician relations .32 <.001 care. In practice, staffing support strategies need to be established
Patient safety culture .37 <.001 to divide the nursing work suitably and to provide quick and
Patient safety culture within unit .41 <.001 skilled support during urgent situations. Particularly with regard
Supervisor/manager .04 .598 to skill mix, training strategies for complicated interventions and
Communication .04 .661
emergency in each unit have to be developed and applied in
 K.-J. Kim et al. / Asian Nursing Research 12 (2018) 121e126
consideration of the reality where nurses with different compe-
tencies work together.
On the other hand, individual factors such as the clinical career
also affected missed nursing care. This study presented the clinical
career as one of the key factors influencing missed nursing care.
Previous studies have also suggested that nurses' clinical career is a
significant causal factor for missed nursing care [9]. In particular,
under Korean circumstances where most registered nurses are
responsible for nursing in the clinical field, different competency of
nurses may lead to skill mix of each unit. According to another
study, however, clinical career was not significantly related to
missed nursing care [8,14]. Thus, the influence of nurses' individual
factors on missed nursing care is still controversial. Therefore,
further studies are needed to clarify the relationship between in-
dividual or organizational factors and missed nursing care.
Second, the perception of “nurse manager ability, leadership,
and support of nurses” of the nursing work environment also af-
fects missed nursing care, meaning that excellent nurse manager
ability and leadership, accompanied by sufficient support for
nurses, decreased the frequency of incidents of missed nursing
care. This finding is consistent with that of previous study [23]
that suggested that nurse manager ability and leadership is
associated with missed nursing care because nurse managers are
responsible for managing nurses' working conditions, assigning
duties, and coordinating available resources. Moreover, effective
management leadership enhances the work engagement of
nurses, affecting clinical practice [24]. It has also been suggested
that it is one of the main influencing factors in regard to patient
safety outcomes [25,26]. In particular, as nurse managers can
change the general dynamics of a unit such as communication
pattern and the quality of nurses [27], they can affect the occur-
rence of missed nursing care. Nurse managers should pay atten-
tion to minor missed nursing care that happens frequently
because such issues may lead to major nursing errors. Nurse
managers should also improve their managing capacity so that
they can manage missed nursing care appropriately, which in-
cludes classifying frequently missed nursing care and significant
incidents of missed nursing care depending on the characteristics
of each unit. Furthermore, they must recognize that missed
nursing care is attributed to nurses' working conditions, available
resources, and leadership issues, rather than to capabilities of
bedside nurses, and must proactively work to correct these
problems. To achieve this, they will have to systemically explore
the causes of missed nursing care, improve the working condi-
tions if necessary, efficiently provide required staff and resources,
and help design and settle a working system capable of supporting
and assisting nurses.
Third, it was found in this study that missed nursing care was
affected by the perception of patient safety culture within a unit.
This is supported by previous studies that patient safety culture is
associated with rationed activities of daily living, caring, moni-
toring, and social care [28]. A large-scale study surveying nurses
also reported that patient safety culture was the second most sig-
nificant variable influencing missed nursing care [6]. As missed
nursing care may vary depending on an individual unit or person
instead of the entire organization, patient safety culture within a
unit may have a very significant influence on missed nursing care.
Pronovost et al [29] recommended that each unit manage its own
safety culture because each nursing unit is different, and unique
safety culture in each unit would have a greater impact on the
behaviors of the staff. It is important for bedside nurses to share
safety issues they experience in their daily work and make sug-
gestions on improving patient safety culture [10]. Their clinical
practices and decisions can be critical for determining the causes
125
and types of missed nursing care. Therefore, creating a positive
patient safety culture is a prerequisite for decreasing missed
nursing care.
The theoretic significance of this study is its suggestion that
missed nursing care is a nursing outcome affected by work envi-
ronment factors such as staffing and resource adequacy, manager
leadership, and safety culture within units. It also has practical
implications for nurse managers, as it presented specific matters to
be considered to manage instances of missed nursing care in the
future.
This study has some limitations. First, the study found that a few
subdomains of nursing work environment and patient safety cul-
ture did not have an influence on missed nursing care. However,
significance of these subdomains on missed nursing care could not
be overlooked because of the restrictions of the study design and
the possibility of other statistical models. Second, the findings have
the lack for generalization because the sample size was small and
data were collected from a single hospital to control exogenous
variables such as the hospital size, patients' characteristics, and
patient-to-nurse ratio. Besides, considering that some units such as
emergency room were excluded, further studies are necessary to
expand the including criteria to all adult units in a hospital and/or
representative hospitals. Third, the study measured missed nursing
care based on nurses' self-reporting rather than an objective
assessment of parameters, thereby allowing the possibility of
measurement errors.
Conclusion
This study found that missed nursing care could be managed by
work environment and patient safety culture. Specifically, missed
nursing care can be controlled by maintaining adequate staffing
and resources and developing nurse managers' abilities, along with
effective leadership and safety culture within units. This requires an
understanding that missed nursing care is not an outcome associ-
ated with individual skills but an organizational quality of nursing
affected by nursing work environment factors.
Nursing organizations should therefore create strategies from
the perspectives of staffing and resources, manager leadership, and
organizational culture to address the missed nursing care issue.
Significantly, as adequate staffing and resources was the most
important factor, the strategies are needed for proper composition
of skilled staffs and effective management on nurses and resources
depending on patients' characteristics and severity beyond simply
increasing the number of nurses. A program should also be devel-
oped that will improve nurse managers' abilities and build effective
leadership. With such a program, nurse managers should be able to
pay attention to the missed nursing care overlooked by bedside
nurses that occurs every day, identify the reason for these over-
sights, and design and propose a work system to reduce its occur-
rence. Lastly, patient safety culture within unit should be ensured
by better staff awareness of the cause and type of missed nursing
care through proactive and open communication among nursing
staff and an improved work system.
Conflicts of interest
The authors declared no conflict of interest.
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