The impact of clinical nursing work environment, moral sensitivity, and humanistic care ability on missed nursing care: A longitudinal study

Abstract

Objectives

Missed nursing care is a widespread issue in clinical practice and represents a global challenge. Reducing missed nursing care is crucial for improving care quality and implementing high-quality nursing services. This study conducted a longitudinal survey among clinical nurses to investigate the impact and underlying mechanisms of the nursing work environment, moral sensitivity, and humanistic care ability on missed nursing care, aiming to provide theoretical evidence for optimizing the work environment and enhancing nursing quality.

Methods

From October 2024 to April 2025, a longitudinal survey was conducted at three time points among 989 clinical nurses using the Nursing Work Environment Scale, Missed Nursing Care Scale, Moral Sensitivity Questionnaire, and the Nurse Humanistic Care Ability Scale. A total of 902 valid responses were included in the final analysis. Structural equation modeling and mediation pathway analysis were performed using AMOS 26.0, and data analysis was conducted using SPSS 25.0.

Results

The mean score of missed nursing care among clinical nurses was 43.10 ± 15.87. The clinical nursing work environment was negatively correlated with missed nursing care (r = −0.502, P < 0.01), and positively correlated with both moral sensitivity (r = 0.241, P < 0.01) and humanistic care ability (r = 0.312, P < 0.01). Moral sensitivity was positively correlated with humanistic care ability (r = 0.228, P < 0.01) and negatively correlated with missed nursing care (r = −0.430, P < 0.01). Furthermore, humanistic care ability was negatively correlated with missed nursing care (r = −0.526, P < 0.01). Moral sensitivity and humanistic care ability served as a chain mediating pathway between the nursing work environment and missed nursing care (β = −0.015, P < 0.001), and the overall model demonstrated good fit indices.

Conclusion

The clinical nursing work environment is a key factor influencing missed nursing care. Moral sensitivity and humanistic care ability among nurses act as a mediating mechanism linking the nursing work environment to missed nursing care. Therefore, healthcare administrators may consider strengthening nurses’ moral sensitivity and humanistic care capacity as strategic entry points for developing targeted interventions to reduce missed nursing care.

What is known?

• •Missed nursing care is a common issue worldwide and negatively affects patient safety and care quality.
• •The nursing work environment has been identified as an external factor influencing missed nursing care.
• •Moral sensitivity and humanistic care ability are important individual nurse factors related to nursing behaviors and patient outcomes.

What is new?

• •Findings reveal that moral sensitivity and humanistic care ability function as a sequential mediating pathway between the nursing work environment and missed nursing care.
• •Results provide theoretical evidence for developing interventions that strengthen nurses’ moral sensitivity and humanistic care ability to reduce missed nursing care.

1. Introduction

In the Global Patient Safety Action Plan 2021–2030, the WHO emphasized that patient safety is a fundamental component of healthcare delivery. However, patient safety concerns remain a major global challenge [1]. The State of the World’s Nursing 2020 report further highlighted that strengthening the nursing workforce is critical to achieving the sustainable development goals and improving population health. Nurses play a pivotal role in advancing universal health coverage and sustainable development, and consistent delivery of high-quality, specialized nursing care can markedly improve clinical outcomes. However, variations in nursing care quality are frequently observed in clinical practice, with missed nursing care among the key underlying factors [2]. Missed nursing care refers to any required aspect of care that is omitted, delayed, or only partially completed due to various reasons [3]. This phenomenon is widespread, with approximately 55 %–98 % of clinical nurses reporting at least one missed or unfinished task during their previous shift [4]. Nelson et al. [5] surveyed 4,086 nurses across ten hospitals and found common areas of missed care, including patient mobilization, participation in nursing meetings, and oral hygiene. Palese et al. [6] reported that in Italian medical wards, the most frequently missed care tasks were assistance with mobility (91.4 %), patient turning every two hours (74.2 %), and timely medication administration (64.6 %). Similarly, Labrague et al. [7] identified engaging with patients and assisting with position changes as the most commonly missed tasks in the Philippines. The omission of essential nursing interventions has become routine in many settings, making missed nursing care an escalating global concern [8]. Evidence indicates that missed nursing care is a critical factor affecting both care quality and patient safety [2]. It increases the likelihood of adverse events, such as falls, and is strongly associated with overall care outcomes [2]. Hospitals with higher rates of missed nursing care also demonstrate higher patient mortality [9]. Thus, identifying effective strategies to reduce missed nursing care is essential for improving care quality and patient prognosis.

Missed nursing care results from the combined effects of multiple factors. According to Social Cognitive Theory, individual behavior is jointly influenced by external environmental factors and personal cognitive factors [10]. In the nursing context, the nursing work environment is an external factor that significantly shapes nurses’ behaviors. At the same time, moral sensitivity and humanistic care ability are key cognitive and affective factors that influence nurses’ clinical judgment and behavioral performance. Based on this theoretical framework, the present study explores the relationships among the nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care from an interactive perspective of environmental and individual factors.

The nursing work environment refers to a comprehensive system of elements that directly or indirectly affect nursing practice, including staffing, resource availability, leadership support, teamwork, and organizational culture [11]. Teamwork, leadership, and adequate human and material resources—key components of the work environment—have profound impacts on nursing outcomes [12]. The nursing work environment is an important external factor affecting missed nursing care [13]. For instance, Dutra et al. [14] found that a positive work environment not only enhances nurses’ job satisfaction and safety climate, but also significantly reduces the incidence of missed nursing care. The phenomenon of missed nursing care is more prevalent in busy clinical settings with frequent emergencies [15]. Therefore, Hypothesis 1 was proposed: the nursing work environment is negatively correlated with missed nursing care.

Moral sensitivity is the core cognitive ability that enables nurses to recognize, understand, and respond to ethical issues, and it is considered an essential psychological attribute for ensuring nursing quality [16]. Nurses with higher moral sensitivity are better equipped to identify and manage ethical dilemmas in clinical practice. They are more likely to prioritize patients’ needs, thereby minimizing omissions in nursing tasks [17]. For example, Xu et al. [18] found that moral sensitivity was significantly negatively correlated with missed nursing care among newly employed nurses. In addition, the nursing work environment can influence nurses’ moral sensitivity through supportive culture and ethical climate [19]. Specifically, an organization that values ethics and provides managerial support can enhance nurses’ ethical awareness and decision-making ability [20]. One study has further demonstrated a positive association among environmental resource richness, cultural support, and moral sensitivity [19]. Therefore, Hypothesis 2 was proposed: moral sensitivity may mediate the relationship between the nursing work environment and missed nursing care.

Humanistic care ability, a core value of nursing, emphasizes patient-centeredness, respect for dignity, and the protection of patient rights [21]. It not only affects patients’ care experiences and treatment outcomes, but also serves as an important indicator of nurses’ professional development [22]. The formation and enhancement of this ability depend on a supportive work environment and continuous humanistic education [23]. Conversely, an unfavorable nursing work environment may compromise nurses’ psychological well-being and job satisfaction, thereby reducing their capacity for humanistic care [24]. According to Social Cognitive Theory, environmental factors can influence individual behavior not only directly but also indirectly by shaping cognitive and emotional capacities [25]. Hence, a positive nursing work environment can foster nurses’ humanistic care abilities, which, in turn, may help reduce the occurrence of missed nursing care [26]. Accordingly, Hypothesis 3 was proposed: humanistic care ability mediates the relationship between the nursing work environment and missed nursing care.

In nursing practice, nurses’ moral sensitivity is crucial to their humanistic caring behaviors. Nurses with higher moral sensitivity tend to exhibit stronger empathy and responsibility, enabling them to better perceive and respond to patients’ needs and thereby demonstrate higher levels of humanistic care [18]. However, existing research has mainly focused on single mediation mechanisms and rarely examined their sequential effects. In fact, moral sensitivity, by enhancing nurses’ ethical responsibility and empathy, may further promote humanistic caring behaviors, thereby indirectly influencing missed nursing care. Therefore, Hypothesis 4 was proposed: humanistic care ability mediates the relationship between moral sensitivity and missed nursing care; that is, the nursing work environment influences missed nursing care through a chain-mediation pathway of “moral sensitivity–humanistic care ability.”

Although previous studies using cross-sectional designs have examined the relationships among some of these variables—such as the nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care—few have explored the dynamic evolution of their interrelationships over time or the underlying mediating mechanisms. Compared with cross-sectional studies, longitudinal research can provide deeper insights into the causal pathways among variables over time. On the one hand, longitudinal design allows for the verification of causal order through temporal sequencing, thereby enhancing the validity of causal inference; on the other hand, multiple time-point measurements can effectively reduce common method bias and improve internal validity. Moreover, as the nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care are all dynamic constructs, a longitudinal design can more accurately capture their temporal variations. Therefore, adopting a longitudinal design not only strengthens the scientific rigor and theoretical contribution of this study but also provides a more robust empirical foundation for understanding the mechanisms underlying missed nursing care.

2. Methods

2.1. Study design

This longitudinal study adheres to the STROBE guidelines to ensure transparency and rigor in reporting.

2.2. Study participants

Participants were clinical nurses recruited from three tertiary hospitals in Henan Province, China. To enhance representativeness, a stratified convenience sampling approach was used within each hospital. Specifically, departments were stratified by specialty (internal medicine, surgery, obstetrics and gynecology, pediatrics, intensive care, and emergency). With the Nursing Department’s coordination, eligible departments were selected based on feasibility, and all eligible nurses in those departments were invited to participate.

Inclusion criteria were registered clinical nurses. Exclusion criteria were: a) nurses not directly engaged in patient care, b) nurses enrolled in advanced training programs, and c) nurses on leave during the study period.

Before data collection, the sample size was estimated to ensure adequate model fit and statistical reliability. According to the empirical rules of structural equation modeling (SEM), the required sample size should be 10–20 times the number of observed or latent variables. This study included four latent variables—nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care—with 11 dimensions regarded as observed indicators. Thus, the estimated minimum sample size ranged from 110 to 220. Following the recommendations of Kline [27] and Hair et al. [28], approximately 60–80 participants per latent variable are required for stable parameter estimation and model fit, yielding a preliminary sample size of 660–880. Considering a potential attrition rate of 10 %–15 % in longitudinal studies, the final required sample size was estimated at 730–1,010 participants.

2.3. Measurements

2.3.1. Sociodemographic characteristics

A self-designed questionnaire was used to collect demographic information, including age, gender, marital status, hospital type, department, education level, professional title, years of experience, average monthly income, monthly night shift frequency, and average daily working hours.

2.3.2. Nursing work environment

The nursing work environment was assessed using the scale developed initially by Lake [29], and adapted into Chinese by Wang et al. [30]. The scale contains 5 dimensions and 31 items, rated on a 4-point Likert scale (1–4), with total scores ranging from 31 to 124. Higher scores indicate a more favorable work environment. The Cronbach’s α coefficient of the total scale was 0.91, and the Cronbach’s α coefficient of this study was 0.98.

2.3.3. Moral sensitivity

Moral sensitivity was measured using the Moral Sensitivity Questionnaire developed by Lützén et al. [31], and translated and culturally adapted into Chinese by Huang et al. [32]. The scale includes two dimensions—moral responsibility and strength (5 items) and moral burden (4 items)—for a total of 9 items. It adopts a 6-point Likert scale (1 = strongly disagree to 6 = strongly agree), with scores ranging from 9 to 54. Higher scores indicate stronger moral sensitivity. The Cronbach’s α coefficient of the total scale was 0.82, and the Cronbach’s α coefficient of this study was 0.98.

2.3.4. Humanistic Care ability

Humanistic Care ability was assessed using the Caring Ability Inventory (CAI) developed by Nkongho et al. [33], and translated and culturally adapted by Xu [34], which is currently one of the most widely used instruments in China for measuring nurses’ humanistic caring ability. The scale comprises three dimensions—cognition, patience, and courage—with 37 items rated on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree). Higher scores indicate stronger caring ability. The Cronbach’s α coefficient of the total scale was 0.84, and the Cronbach’s α coefficient of this study was 0.99.

2.3.5. Missed nursing care

Missed nursing care was measured using the scale developed by Kalisch and Williams [35] and translated into Chinese by Si et al. [36]. The scale has one dimension with 24 items and uses a 5-point Likert scale. Higher scores indicate more frequent omissions of nursing activities. The Cronbach’s α coefficient of the total scale was 0.92, and the Cronbach’s α coefficient of this study was 0.96.

2.4. Data collection

With the approval of the hospital’s Nursing Department and relevant departments, a three-phase questionnaire survey was conducted from October 2024 to April 2025 among nurses meeting the inclusion and exclusion criteria.

Prior to the formal survey, the research team provided standardized training to investigators to ensure they were familiar with the study objectives, questionnaire content, and distribution procedures, and to ensure they strictly adhered to informed consent and confidentiality principles. All surveys employed uniform instructions, with trained researchers providing on-site guidance to participants during questionnaire completion. Participants completed the questionnaires anonymously, and the research team assigned each nurse a unique identification number (ID) for tracking and matching across the subsequent three surveys.

During Phase T1 (October 2024), 989 nurses were invited to participate, yielding 989 returned questionnaires. Of these, 962 were valid (27 invalid questionnaires were excluded due to missing information or logical inconsistencies). This phase primarily collected demographic variables and data on the nursing work environment. At T2 (January 2025), the 962 valid samples from T1 underwent follow-up to assess ethical sensitivity and caring ability. Due to nurse attrition (n = 13) from resignation, job transfer, or departure from clinical frontline roles, as well as incomplete or illogical responses (n = 8), 941 valid questionnaires were ultimately obtained. At T3 (April 2025), the 941 valid participants were tracked for missed nursing care. During this phase, additional nurses were excluded due to resignation or absence (n = 15), missing key variables (n = 12), inconsistent responses or mismatched information (n = 12), resulting in 902 valid questionnaires.

In summary, of the 989 questionnaires initially distributed, 902 were deemed complete and valid for inclusion in the final statistical analysis. Throughout the data collection process, the research team rigorously applied logical verification and data consistency analysis to ensure data accuracy and reliability.

2.5. Data analysis

Data were analyzed using SPSS 25.0 and AMOS 26.0. Descriptive statistics (frequency, percentage, mean, standard deviation) were used to summarize participants’ characteristics and scores for nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care. Harman’s single-factor test was employed to assess common method bias, and Skewness and Kurtosis tests were used to confirm the normality of continuous variables. Pearson’s correlation analysis was conducted to examine relationships among the four variables. Structural equation modeling using AMOS 26.0 was performed to test the chain mediation model, with nursing work environment as the independent variable, missed nursing care as the dependent variable, and moral sensitivity and humanistic care ability as mediators. Monthly income was included as a covariate. To test the indirect effects, bias-corrected percentile bootstrapping was conducted with 5,000 samples to generate 95 % confidence intervals. The adequacy of model fit was evaluated using several indices, including a Chi-square to degrees of freedom ratio (χ²/df) of ≤5.00, Incremental Fit Index (IFI), Goodness-of-Fit Index (GFI), Comparative Fit Index (CFI), and Tucker–Lewis Index (TLI) values ≥ 0.90, as well as a Root Mean Square Error of Approximation (RMSEA) value ≤ 0.08 [37]. A two-tailed P-value of <0.05 was considered statistically significant.

2.6. Ethical considerations

Prior to participation, all participants were informed about the purpose, procedures, and confidentiality of the study, and provided written informed consent. This study was approved by the Ethics Committee of Henan University (Ethics Review No.: HUSOM2024-532).

3. Results

3.1. Sociodemographic characteristics of participants

A total of 902 clinical nurses were included in this study. The majority of participants were aged 26-35 years (54.5 %), followed by those aged 36–45 years (36.0 %). Most participants were female (70.7 %) and married (78.4 %). In terms of departments, 34.7 % worked in internal medicine, 30.2 % in surgery, and the remainder were distributed across gynecology, pediatrics, emergency, ICU, operating theatre, and other departments. Regarding educational background, 92.6 % of nurses held a bachelor’s degree, and only 2.2 % had a master’s degree or above. Further details are provided in Table 1.

Table 1.

Demographic characteristics (n = 902).

Variables		n	%
Age (years)	≤25	47	5.20
	26-35	492	54.50
	36-45	325	36.00
	≥46	38	4.20
Gender	Male	264	29.30
	Female	638	70.70
Married status	Single	169	18.70
	Married	707	78.40
	Divorced or widowed	26	2.90
Departments	Internal Medicine	313	34.70
	Surgery	272	30.20
	Gynaecology	23	2.50
	Paediatrics	61	6.80
	Emergency	55	6.10
	ICU	52	5.80
	Operating room	60	6.70
	Others	66	7.30
Educational background	Junior college or below	47	5.20
	Bachelor’s	815	92.60
	Master’s or above	40	2.20
Professional title	Nurse	157	17.40
	Senior nurse	480	53.20
	Nurse-in-charge	242	26.80
	Deputy chief nurse or above	23	2.50
Working duration (years)	≤1	22	2.40
	2-5	143	15.90
	6-10	197	21.80
	≥11	540	59.90
Monthly income (RMB)	≤4,000	108	12.00
	4,001-7,000	616	68.30
	7,001-10,000	165	18.30
	≥10,001	13	1.40
Average number of night shifts per month (times)	0	119	13.20
	1–4	164	29.30
	5–8	400	44.30
	≥9	119	13.20
Average daily working hours (hours)	≤7	75	8.30
	8-10	709	78.60
	≥11	118	13.10

3.2. Descriptive statistical and correlation analysis

The means, standard deviations, and Pearson correlation coefficients for all variables in this study are presented in Table 2. The scores for nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care were 99.05 ± 20.23, 39.50 ± 12.20, 161.23 ± 57.53, and 43.10 ± 15.87, respectively. As all variables were self-reported, Harman’s single-factor test was used to assess common method bias. The results indicated that eight factors had eigenvalues greater than 1, with the first factor explaining 28.04 % of the total variance, which is below the critical threshold of 40 %, suggesting no significant standard method bias in this study.

Table 2.

Correlation of variables.

Variable	NWE	MS	HCA	MNC	Mean	SD
NWE	1				99.05	20.23
MS	0.241∗	1			39.50	12.20
HCA	0.312∗	0.228∗	1		161.23	57.53
MNC	−0.502∗	−0.430∗	−0.526∗∗	1	43.10	15.87

Note: NWE = Nursing Work Environment; MNC = Missed Nursing Care; MS = Moral Sensitivity; HCA = Humanistic Caring Ability. ∗P<0.01 (Two-tailed).

Pearson’s correlation analysis revealed that the nursing work environment was significantly positively correlated with moral sensitivity (r = 0.241, P < 0.01) and humanistic care ability (r = 0.312, P < 0.01), and significantly negatively correlated with missed nursing care (r = −0.502, P < 0.01). Moral sensitivity was significantly positively correlated with humanistic care ability (r = 0.228, P < 0.01) and significantly negatively correlated with missed nursing care (r = −0.430, P < 0.01). In addition, humanistic care ability was significantly negatively correlated with missed nursing care (r = −0.526, P < 0.01).

3.3. Mediation analysis and hypothesis testing

As illustrated in Fig. 1, the nursing work environment significantly predicted moral sensitivity (β = 0.51, P < 0.001), humanistic care ability (β = 0.75, P < 0.001), and missed nursing care (β = −0.33, P < 0.001), supporting Hypothesis 1. Moral sensitivity was a significant predictor of both humanistic care ability (β = 0.21, P < 0.001) and missed nursing care (β = −0.14, P < 0.001). Additionally, humanistic care ability significantly and negatively predicted missed nursing care (β = −0.14, P < 0.001).

Fig. 1.

Path analysis chart of nursing work environment, ethical sensitivity, humanistic caring ability and missed nursing care

Note: NWE: Nursing Work Environment; MNC: Missed Nursing Care; MS: Moral Sensitivity; HCA: Humanistic Caring Ability. P<0.01 (Two-tailed).

To examine the mediating roles of moral sensitivity and humanistic care ability in the relationship between nursing work environment and missed nursing care, we employed a percentile bias-corrected bootstrap method. As shown in Table 3, the results indicated significant mediating effects of moral sensitivity and humanistic care ability, with a total indirect effect of −0.330. Specifically, three indirect pathways were identified:

• (1)The nursing work environment exerted an indirect effect on missed nursing care via moral sensitivity (indirect effect = −0.069; bootstrap 95 % CI: 0.100 to −0.045; P < 0.001), supporting Hypothesis 2.
• (2)The nursing work environment exerted an indirect effect on missed nursing care via humanistic care ability (indirect effect = −0.105; bootstrap 95 % CI: 0.135 to −0.079; P < 0.001), supporting Hypothesis 3.
• (3)A chained mediation effect was observed through both moral sensitivity and humanistic care ability (indirect effect = −0.015; bootstrap 95 % CI: 0.025 to −0.008; P < 0.001), supporting Hypothesis 4.

Table 3.

Overall, direct and indirect effects of nursing work environment on missed nursing care(n = 902).

Effect	Path relationship	Effect	Bootstrap SE	Bootstrap 95 % CI
Direction effect	NWE→MNC	−0.330	0.032	−0.394 — −0.269
Indirect effect	NWE→MS→MNC	−0.069	0.014	−0.100 — −0.045
	NWE→CA→MNC	−0.105	0.015	−0.135 — −0.079
	NWE→MS→CA→MNC	−0.015	0.004	−0.025 — −0.008
Total mediating effect	NWE→MNC	−0.190	0.021	−0.238 — −0.146
Total effect	Total indirect effect	−0.519	0.032	−0.588 — −0.448

Note: NWE = Nursing Work Environment; MNC = Missed Nursing Care; MS = Moral Sensitivity; CA = Humanistic Caring Ability; all P < 0.001.

3.4. Model fit analysis

The model showed good fit: χ²/df = 3.239 ( < 5.0), GFI = 0.977 ( > 0.90), CFI = 0.989 ( > 0.90), AGFI = 0.962 ( > 0.90), TLI = 0.985 ( > 0.90), IFI = 0.989 ( > 0.90), and RMSEA = 0.046 ( < 0.08), indicating an acceptable model fit.

4. Discussions

The present study found that the average score of missed nursing care among clinical nurses was 43.10 ± 15.87, slightly lower than the scale’s preset average of 47.00, suggesting a moderate level of omissions. Nevertheless, missed nursing care remains a common and often under-recognized issue in clinical practice [11]. These findings highlight the importance of nursing administrators paying greater attention to the prevalence of missed nursing care in clinical settings. Notably, a significant strength and innovation of this study is the three-wave longitudinal design with individual-level matching, which provides more robust evidence than cross-sectional research. This time-lagged measurement also helps mitigate concerns about common-method bias in single-occasion self-report studies. It enhances the credibility of the mediation pathways as a process unfolding over time rather than a static association. In addition, standardized investigator training, uniform instructions, and rigorous logical verification and data consistency checks across waves strengthened the reliability of the matched data.

Our results further demonstrated that the nursing work environment negatively predicted missed nursing care, supporting Hypothesis 1. This aligns with prior research [13], which showed that better work environments are associated with fewer missed nursing activities. From a social cognitive theory perspective, missed nursing care may be influenced by the broader work environment. A positive environment with adequate resources energizes nurses and promotes greater work engagement, thereby reducing the likelihood of care omissions. One study found that the probability of missed nursing care was 63.3 % lower in units with favorable environments than in units with poor environments [38]. These findings provide practical implications for nursing managers. Interventions may include improving resource allocation [9], ensuring the availability of essential equipment and medications, and minimizing care omissions due to material shortages. Optimizing the physical work environment, such as creating quiet and comfortable workspaces, may also reduce distractions. Additionally, maintaining a reasonable nurse-to-patient ratio is crucial to prevent work overload and mitigate the risk of missed nursing care [39].

This study also revealed that moral sensitivity mediated the relationship between the nursing work environment and missed nursing care, supporting Hypothesis 2. A supportive work environment can enhance nurses’ moral sensitivity, thereby reducing missed nursing care. This finding demonstrated that positive work environments—characterized by supportive leadership, effective communication, and adequate resources—can reduce burnout and enhance moral sensitivity. Nurses in ethically supportive settings are more likely to engage in ethical discussions and reflective practice, which heightens their awareness of patient needs and ethical dilemmas. Moral sensitivity was found to negatively predict missed nursing care [18], supporting ethical decision-making models that view moral sensitivity as a foundation for ethical action. Nursing is inherently a moral practice, where every decision carries ethical implications—not only in life-and-death situations but also in routine care. Strengthening moral sensitivity enables nurses to recognize patient needs, anticipate the ethical consequences of missed care, and take proactive measures to prevent adverse outcomes. To this end, nursing administrators should incorporate ethics education into training programs, using strategies such as scenario simulation and reflective practice to improve ethical judgment and responsibility [40]. Establishing ethics committees or consultation services can also provide timely support to nurses facing complex moral dilemmas, thereby reducing missed nursing care due to ethical distress.

Moreover, the study confirmed that humanistic care ability mediated the relationship between the nursing work environment and missed nursing care, supporting Hypothesis 3. According to social cognitive theory, individual behavior is shaped by both environmental and personal factors. In this case, the work environment functions as a macro-level determinant that influences nurses’ psychological state and professional competence, indirectly affecting nursing behaviors. Within our time-lagged design, the work environment was associated with humanistic care ability assessed, which subsequently predicted missed nursing care, providing longitudinal support for the interpretation that an enabling environment can cultivate caring-related competencies and thereby reduce later care omissions. A supportive environment provides opportunities for professional growth, thereby enhancing nurses’ sensitivity and empathy toward patients, which helps reduce missed nursing care. In particular, strengthening humanistic caring competencies—especially among less experienced nurses—may foster caring awareness and a service-oriented mindset, helping prevent care omissions. These findings suggest a dual strategy for nursing managers: improving the work environment through enhanced staffing, leadership, and communication, while simultaneously strengthening nurses’ care abilities through targeted training programs [9,40].

Finally, this study demonstrated a chained mediation effect of moral sensitivity and humanistic care ability on the relationship between the nursing work environment and missed nursing care, supporting Hypothesis 4. Zhai et al. [40] reported that moral sensitivity is a key predictor of patient-centered care, as nurses with high moral sensitivity tend to demonstrate greater empathy and responsibility—qualities that contribute to stronger care ability. According to Watson’s Theory of Human Caring, nurses with well-developed care ability are more attuned to patients’ holistic needs. They are less likely to commit care omissions due to negligence or misallocation of resources. The chained mediation model validated in this study illustrates the sequential mechanism through which the work environment influences missed nursing care via “moral sensitivity → humanistic care ability”. This model not only deepens understanding of the underlying causes of missed care but also provides a novel theoretical framework to guide nursing management and education. Practically, the findings suggest that hospitals should adopt multifaceted approaches to reduce missed nursing care. Integrating ethics education and humanistic care training—such as role-playing and scenario-based simulations—may strengthen nurses’ ability to respond effectively in complex clinical situations. Additionally, managers can improve incentive structures through recognition programs and reward systems, which enhance nurses’ sense of mission and responsibility, thereby improving care ability, reducing missed nursing care, and elevating overall quality of care.

5. Limitations

Several limitations should be acknowledged in this study. First, due to resource constraints, the follow-up period in this study was relatively short. It may not have been sufficient to fully reveal the long-term relationship between the nursing work environment, ethical sensitivity, caring ability, and missed nursing care. Future research could adopt a longitudinal tracking design with a longer time span, combined with data collection at multiple time points, to explore the dynamic evolution and long-term trajectories of these variables. Second, this study employed self-reported questionnaires to measure variables. Although we minimized bias through anonymous completion, standardized instructions, and logical consistency checks, self-reporting bias may still exist. Future research could incorporate multi-source data collection methods—such as peer evaluations, patient and family feedback, or even on-site observations and qualitative interviews—to establish triangulation and enhance the reliability and validity of findings. Finally, this study’s sample originates from healthcare institutions in central China. Differences exist across countries and regions in nurse training models, human resource allocation, division of nursing responsibilities, and professional values. Consequently, the proposed chained mediating pathway may vary across cultures and healthcare systems. Future research could expand its scope to conduct cross-cultural validation across diverse countries and regions, thereby assessing the model's universality.

6. Conclusion

This study examined the relationships among the nursing work environment, moral sensitivity, humanistic care ability, and missed nursing care, and developed a chain mediation model. The findings revealed that the nursing work environment not only directly influences missed nursing care but also indirectly affects it through sequential effects on nurses’ moral sensitivity and humanistic care ability. The establishment of this model provides a novel theoretical perspective on the mechanisms underlying missed nursing care and enriches the existing framework regarding the interplay among the work environment, individual cognition, and nursing behaviors. Based on these findings, hospital managers should prioritize optimizing the nursing work environment and enhancing nurses’ perceptiveness and caring competence through ethics education and humanistic care training, thereby effectively reducing missed nursing care and improving the overall quality of nursing services.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Yifan Lu: Conceptualization, Data Curation, Software, Methodology, Investigation, Formal Analysis, Writing – original draft, Writing – Review & Editing. Qinqin Liu: Data Curation, Validation, Software, Investigation, Formal Analysis, Writing – review & editing. Congcong Dai: Software, Investigation, Formal Analysis. Shuqi Zhai: Investigation, Formal Analysis. Huanhuan Zhang: Methodology. Jie Liu: Visualization, Formal Analysis. Chaoran Chen: Supervision, Writing – review & editing.

Funding

Medical Science and Technology Tackling Program Project of Henan Province [RKX202402028].

Declaration of competing interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article: