Background

Professionalization is one of the fundamental concepts of nursing and the result of the interaction between person, work environment and interpersonal communication [1]. The nursing profession has changed drastically in the last three decades with the expansion of roles and independence in different societies [2].

Professionalism in nursing is often shown by attitudes, knowledge, behaviors [3], belief in serving people, and in most cases, sense of commitment which is the foundation of successful clinical practice [1]. Professionalism in nursing is a critical component of maintaining a healthy work environment [4]. Professional commitment means determining the identity with the profession, which includes commitment to the profession, acceptance of professional goals and ethics [5] and strong belief in the goals and values ​​of the profession [6].

Professional commitment is related to a person’s respect and beliefs of his profession and makes him to be satisfied with his profession and its continuation [7]. Nursing is a profession that requires high professional commitment, and the future of nursing is determined by nurses who are committed to their profession [8].

The indicators of professional commitment are: (1) believing and accepting professional values, (2) satisfaction with activity and effort in the profession and (3) strong will and desire to remain as a part of the profession [9]. Compliance with this issue is one of the most important factors determining job qualification in medical professions [10]. Compliance with professional commitment in the service delivery process improves the efficiency and effectiveness of the organization [5]. It also increases the level of trust between medical personnel, patients and the community which is the key to effective communication [10].

In different regions and societies, the level of nurses’ professional commitment varies from low to high [11,12,13]. many factors cause the level of commitment to be different among individuals. Among these factors, we can mention religious beliefs, ethics, level of education, personality traits, work experience and job satisfaction [14].

Since compliance with the principles of professional commitment directly leads to increasing patient safety and improving the quality of patient care, if these principles are neglected, the quality and effectiveness of care will suffer an important gap [13]. Therefore, it can be concluded that nurses’ professional commitment can play the final role in the quality of patient care.

Care is the central concept that distinguishes nursing from other health professions. Care is defined as the essence of nursing and complementary to the four meta-paradigmatic concepts of nursing [15]. One of the rights of hospitalized patients is to ensure that they receive safe and comprehensive care from the health care system and meet their care needs. But in some situations, some care activities are being missed [16].

Missed Nursing Care is one of the important indicators of the quality of nursing care in the field of health services, which was first introduced by Kalisch in 2006 [17]. Missed nursing care has recently been identified as any element of essential patient care that is partially or completely omitted by a nurse [18]. The rate of missed nursing care varies from 10 to 50% in the world and it’s a global challenge that threatens patient safety and quality of nursing care [19].

missed nursing care is not only a type of nursing error, but it can also lead to ignoring patients’ rights and endangering their rehabilitation and recovery. since nurses can only handle a number of responsibilities in one shift, therefore, they tend to prioritize cares, and based on that decide which care to omit or which care to prioritize, which leads to forgetting some cares [16].

According to some studies, factors such as the inexperience of some nurses, type of work shift, nurses’ job satisfaction, inappropriate organizational environment [20], long-term involvement with patients [21], unexpected increase in the number of patients or overcrowding in the wards, Unfair division of responsibilities, tension or poor communication in the nursing team, excessive activities related to admission and discharge of patients [22] and “it’s not my job” syndrome have been mentioned in missed nursing care [23].

The rate of missed nursing care in the world varies between 10 and 50%. Some of the most common types of missed nursing care from the nurses’ point of view include: lack of oral care, failure to administer medicine at the appropriate time, lack of skin care, failure to pay attention to the patient’s religious needs [19], failure to rotate patients, delay in feeding and missing patient education and their discharge planning [21].

Studies conducted in different countries show that the occurrence of missed nursing care can lead to adverse complications. Among these, decrease in patient satisfaction, re-hospitalization, medication errors, increase in psychological pressure in the work environment, decrease in job satisfaction or intention to leave the job [24] and increase in pain and discomfort of patients can be mentioned [21].

Comprehensive and high-quality of care and patient safety is the ultimate goal of health care systems around the world [25]. the phenomenon of missed nursing care is still a serious threat to achieving comprehensive and safe nursing care, which also threatens the lives of patients [26]. Identifying the type of missed nursing care allows for effective strategies that can help maintain a healthy nursing care [27]. missed nursing care is one of the important indicators of the quality of nursing care, and the knowledge of this science is in its early stages [24], and there are reports about the variable rate of missed nursing care in different regions [18].

Considering the above information and the fact that the nurses’ professional commitment plays an important role in the correct implementation of nursing care, patients safety and their satisfaction, therefore, during this research, the relationship between nurses’ professional commitment and missed nursing care was investigated.

Methods

Design and aim

This is a cross-sectional and descriptive-analytical study, which was conducted with the aim of determining the relationship between nurses’ professional commitment and missed nursing care among nurses working in selected hospitals affiliated to Tehran University of Medical Sciences. This study was carried out from September to December 2023.

Study setting and participants

In the current study, the research community included all nurses working in medical-surgical wards of selected hospitals affiliated to Tehran University of Medical Sciences, including: Sina and Dr. Shariati Hospital. These two hospitals were chosen purposefully as the research environment due to their alignment with the aim of this study as well as laws and guidelines they use. It should be noted that each of these hospitals has 16–18 medical surgical wards and nurses from various regions of Iran are busy working there. This maybe made research result more generalizable.

The inclusion criteria were; willing to participate in the study, being a nurse with a bachelor’s degree or higher education level, working in the medical-surgical wards, and having at least six months of clinical work experience, mental and physical health and the absence of stressful events such as divorce and death of relatives in the last six months. Exclusion criteria included incomplete answers to the questionnaire.

Sample size and power

To determine the sample size at the confidence level of 95% and the test power of 90%, assuming that the correlation coefficient between nurses’ professional commitment and missed nursing care is at least 0.2 [28, 29], so that the relationship between the two variables is considered statistically significant, the sample size calculated 265 according to following formula:

$$\eqalign{ n = & {{{{\left( {{z_{1 - {\alpha \over 2}}} + {z_{1 - \beta }}} \right)}^2}} \over {{w^2}}} + 3,\,{\rm{w}} = {1 \over 2}ln{{1 + r} \over {1 - r}} \cr & {\rm{w}} = {1 \over 2}ln{{1 + 0/2} \over {1 - 0/2}} = 0/2, \cr & n = {{{{\left( {1/96 + 1/28} \right)}^2}} \over {0/{2^2}}} + 3 = 265 \cr}$$

A total of 270 nursing staff, including nurses with bachelor’s degree, master’s degree and doctorate working as clinical nurses was selected by targeted and quota method. (168 nurses in DR. Shariati Hospital and 102 nurses in Sina Hospital).

Instruments

The data collection in this study was based on the self-reporting method via three following questionnaires:

Demographic information questionnaire

Was used to collect information such as age, gender, marital status, employment status, work experience, education level, type of shift, and number of work shifts per month.

Nursing professional commitment scale (NPCS)

This questionnaire was designed for the first time by Lachman and Aranya in 1968, including 26 items in five areas: perception of nursing (6 items), satisfaction with the nursing profession (4 items), involvement with the nursing profession (6 items), devotion to the nursing profession (5 items) and remaining in the nursing profession (5 items) [30]. The answer includes a 5-point Likert scale ranging from completely disagree (1 point) to completely agree (5 points). The score of the questionnaire is between 26 and 130, so that a higher score means a higher professional commitment. The reliability of this questionnaire was calculated by the designers of the questionnaire to be 0.87, and validity and localization of this tool was done by Jolaee et al. (2014) in Iran, and its reliability was 0.74 [31]. The reliability of this questionnaire was calculated as 0.91 using Cronbach’s alpha coefficient during this research.

MISSCARE questionnaire

Which was designed by Kalisch in 2006 to determine the items of missed nursing care and was psychometrically evaluated by the same researcher in 2009 [32]. Part A of the MISSCARE Questionnaire was used in this research and deals with the factors related to missed nursing care, which includes 24 nursing activities such as turning patient every 2 h, mouth care, patient teaching and medication administration [33]. This questionnaire has four subscales, which includes Assessment (8 items), Interventions-Individual needs (6 items), Interventions-Basic Care (7 items) and planning (3 items). The answer to each item of this questionnaire is on a 5-point Likert scale including: never missed (score 1) to always missed (score 5) [24]. Scores of this questionnaire varies between 24 and 120, and a higher score indicates higher missed care [22]. The Persian translation and psychometric properties of this questionnaire was first done by Hosseini et al. and its’ validity and internal consistency was measured 0.93 [34]. The reliability of this questionnaire was calculated as 0.94 using Cronbach’s alpha coefficient during this research.

Data collection

After obtaining the approval of ethics committee and the necessary permits from the relevant officials of the Faculty of Nursing and Midwifery of Tehran University of Medical Sciences, the researcher presented himself to the directorates of selected hospitals. Then at the appropriate place and time the researcher explained the study objectives to nurses and obtained a written consent from them. All three questionnaires were equally distributed among nurses in three work shifts (morning, evening and night) and the samples were given 3 days to collect the questionnaires so that people can complete the questionnaires when they feel free and relaxed.

Statistical analysis

Data were analyzed in SPSS software version 25. Data evaluation was done using descriptive statistics such as frequency and percentage, mean and standard deviation as well as inferential statistics such as independent t-test, ANOVA and Pearson’s correlation coefficient. The significance level of the data was considered as p < 0.05.

Ethical considerations

This study was conducted by obtaining the code of ethics (IR.TUMS.FNM.REC.1402.091) from the ethical committees of the Nursing & Midwifery Faculty of Tehran University of Medical Sciences. After obtaining the approval of ethics committee and the necessary permits from the relevant officials, the researcher presented himself to the directorates of selected hospitals. A well-trained and experienced research assistant explained to nurses about the study objectives and their participation was voluntary and refusal to participate would not result in any negative consequences. All the participants were assured of the confidentiality of all the information of the research and only the researchers have access to the data. Then informed consent was obtained from all of the participants in the study. Finally, the results of the study were given to the hospitals under research.

Results

After distributing about 330 questionnaires, 270 participants who had completed all three questionnaires were participated in the study. Of these 270 participants who completed the questionnaires 215 (79.6%) were female, 156 (57.8%) were single. The average age was 31.41 ± 7.56 and the average work experience was 6.91 ± 6.68. 238 (88.1%) had a bachelor’s degree and more than 220(81.5%) had no children. Other demographic information’s are given in Table 1.

Table 1 Demographic characteristics of the nurses participating in the study
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The mean score of nurses’ professional commitment was 83.72 ± 16.02, which indicates moderate to high professional commitment. The highest score of the dimension of nurses’ professional commitment related to “devotion for the nursing profession” with a mean score of 3.82 ± 0.71 and the lowest score related to “remaining in the nursing profession” with a mean score of 2.62 ± 0.90 (Table 2).

Table 2 Nurses’ professional commitment and missed nursing care scores of the participants (n = 270)
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The mean score of missed nursing care was calculated as 47.84 ± 16.48 (1.99 ± 0.68), which indicates that the missed care is at a low level. Also, “planning for nursing care” has the highest rate of missed care compared to other aspects of nursing care with a mean score of 2.20 ± 0.81 and “patient assessment” with a mean score of 1.72 ± 0.75 has the lowest rate of missed care based on score of 1–5 (Table 2). In this research, " Attend interdisciplinary care conferences whenever held” had the highest degree of missed care and “Bedside glucose monitoring as ordered” had the lowest degree of missed care (Table 2).

Nurses over 40 years old, morning shift nurses and employed nurses showed higher nursing professional commitment. Also, nurses less than 29 years old and male nurses had more missed cares than other participants. no relationship was observed between other demographic variables with nurses’ professional commitment and missed nursing cares (Table 3).

Table 3 The relationship between demographic characteristics of participants with nurses’ professional commitment and missed nursing care (n = 270)
Full size table

The results of the Pearson correlation test showed that there is a significant negative relationship between nurses’ professional commitment and missed nursing care (p < 0.001 and r=-0.23). Also, devotion to the nursing profession (p < 0.001 and r=-0.23) and remaining in the nursing profession (p < 0.001 and r=-0.23) have the highest negative correlation with missed nursing care. Also, with the decrease in nurses’ professional commitment, the cares that were related to “planning for nursing care” suffered the most effectiveness (p < 0.001 and r=-0.24) (Table 4).

Table 4 Pearson correlation between nurses’ professional commitment and missed nursing care
Full size table

Discussion

The present study was conducted in order to determine the relationship between nurses’ professional commitment and missed nursing care in the medical-surgical wards of selected hospitals affiliated to Tehran University of Medical Sciences.

The results of this research showed that nurses’ professional commitment had a meaningful negative relationship with missed nursing care. The results indicate moderate to high professional commitment in Iranian nurses. Consistent with our findings, mean scores of nurses’ professional commitment in Iran [11, 29], China [35] and Turkey [13] reported at a moderate level. While in some others study in Iran [12] and Egypt, mean scores was reported at a low level [36], and on other study in china mean scores reported at a high level [37]. The difference in nurses’ professional commitment scores can be attributed to different working conditions, the presence or absence of supporting systems, appropriate distribution of the nursing workforce in each country. Also countries may have very different cultural and social backgrounds that could affect nurses’ professional commitment [3].

Consistent with some previous studies, no relationship was observed between sex, marriage and level of education with professional commitment [12], and consistent with this study, it was shown in some studies that there is a significant relationship between organizational commitment and work experience. As the work experience increases, the organizational commitment increases. Also, in supervisors, compared to nurses and then head nurses, organizational commitment had a higher score, and also women had a higher professional commitment score [11]. In Tuna et al.‘s study, consistent with this study, higher professional commitment was reported by working in the morning shift [13].

It can be said that a natural result of the relationship between increasing age and increasing work experience of nurses with professional commitment is the result of reaching emotional balance and stability. Also, the higher nurses’ professional commitment in the morning shift can be attributed to the presence of stronger support systems in morning shift. [11]. Besides, it was determined that female nurses had higher professional commitment since nursing is perceived as a female profession [13].

Consistent with other studies, the highest score of the dimension of professional commitment was related to the subscale of “devotion for the nursing profession”, which can be attributed to the nature of the nursing profession. Because nurses, more than anything, try to serve patients with all their heart and soul and meet their patient needs [29]. The lowest score was related to “remaining in the nursing profession “. Dissatisfaction of nurses with the salary payment system accordance with their work responsibilities can be one of the reasons for obtaining lower scores related to this subscale [7].

Professional commitment has been one of the most influential factors in the nursing profession. What is important is that professional commitment directly affects the way and quality of work in organizations and especially the nursing profession that deals with human souls. Also, increasing the level of professional commitment in the form of a two-way interaction leads to the patients’ satisfaction with the services and increasing the nurses’ satisfaction with their profession [14]. In addition, nurses, as one of the main members of the health service delivery team, have a direct relationship with patients, so it can be expected that any intervention to increase their professional commitment will ultimately improve the quality of nursing cares [7].

The findings of the research showed that the mean score of missed nursing care in Iranian nurses is at a low level. Also, “planning for nursing care” and “interventions-basic care” each have the highest rate of forgetting with 8% and “patient assessment” with 4% have the lowest rate of forgetting compared to other aspects of nursing care. The overall rate of missed nursing care during this study was 5%.

Consistent with our findings scores of missed nursing care in Jordanian and Iranian nurses was reported at a below moderate level [38, 39]. While in another study which was conducted on Jordanian and Iranian nurses, scores were reported at upper moderate level [40, 41]. Also, In other studies conducted in Iran [42, 43] and Taiwan [44] scores of missed nursing care were reported at a high level.

In a recent same study conducted by Hendy et al. (2024) to investigate the relationship between nursing professional commitment and missed nursing care in Jordan, scores of missed nursing care was at a moderate level and scores of nursing professional commitment was at a low level. Also, during that study, the correlation between two variables was found as r=-0.42 and p < 0.005, which is much higher than current research [36].

The difference in the rate of missed care can be attributed to the difference in the workload of the personnel and the lack of workforce, in addition to the existence of cultural and organizational differences in the study areas. With increasing workloads coupled with ongoing nurse shortages, it is not surprising that many nurses are prioritizing clinical care over those activities that are not documented and deemed necessary [45].

It seems that missed care such as attend interdisciplinary care conferences whenever held, assess effectiveness of medications, Response to call light and in general, cares that are not recorded in any part of the nursing report and are not checked by nurses during shift delivery, can be one of the causes of missing such cares. Also, according to attend interdisciplinary care conferences, which had the highest rate of forgetting, it can be said that the absence of a codified program and synchronization with nurses’ free time and the lack of importance of such conferences for nurses caused nurses to forget this part of care [16].

In this study “patient assessment” has the lowest rate of missed care. It can be said that nurses pay a lot of attention to this type of care due to recording these cares in the patient’s file and transferring this information during shift delivery. On the other hand, in our studied society, laws, regulations and guidelines have the first power from nurses’ viewpoint, and they consider themselves obliged to comply with them. That’s why cares that needs to be recorded and documented, such as the cares that are associated with the examination and assessment of the patient, are less neglected [38].

Conclusions

The results of this study support the presence of a negative correlation between nurses’ professional commitment and missed nursing care. A high level of nurses’ professional commitment leads to higher quality of care and less missed nursing care. The future of the nursing profession is determined by the presence of nurses with high professional commitment. Also, the ultimate goal of all health care systems is to increase the quality of care and increase patients’ satisfaction. For this reason, it seems necessary for health care providers and nursing managers to adopt programs to increase nurses’ professional commitment and consequently reduce missed nursing care. This study suggests that studies should be conducted to measure the impact of in-service education programs focusing on nurses’ professional commitment and missed nursing care.

Strengths and limitations

Since 2006, many studies have been conducted on missed nursing care and its causes. However, there has been no study in Iran that wants to examine the relationship between nurses’ professional commitment and missed nursing care.

Research limitations include

The psychological condition of the participants which is beyond the researcher’s control and using the data collection method based on the participants’ self-report. Moreover, this study used a cross-sectional design, which means the study results are limited to reflecting only those conditions experienced during the data collection process.