Investigating the relationship between moral sensitivity, moral distress, and patient safety climate with missed nursing care in clinical nurses: a systematic review

Abstract

Background

In recent years, missed nursing care (MNC) has been a major concern for healthcare systems. Although existing literature highlights moral sensitivity (MS), moral distress (MD), and patient safety climate (PSCL), as important factors contributing to this issue, the precise relationship between these factors and MNC remains inadequately understood. This study aimed to explore the relationship between MS, MD, and PSCL with MNC in clinical nurses.

Methods

The systematic review used several international databases, including PubMed, Web of Science, Scopus, EMBASE, ProQuest as well as Google Scholar search engine. The search covered publications from January 1, 1995, to August 31, 2025; thirteen articles were included in this review. Quality was assessed using the 8-item Joanna Briggs Institute (JBI) critical appraisal tool for analytical cross-sectional studies.

Results

The findings showed varying links between MS and PSCL with MNC, spanning from no significant correlation to a significant negative one. Also, the findings revealed that the eligible included studies reported different relationships between MD and MNC, varying from no significant connection to a significant positive one.

Conclusion

The study identified MS, MD, and the PSCL as potentially influencing factors for clinical nurses’ MNC. Health policymakers and clinical nursing managers should focus on these specific factors to create initiatives that aim to minimize clinical nurse’ MNC and improve the quality of care provided.

Clinical trial number

Not applicable.

Supplementary information

The online version contains supplementary material available at 10.1186/s12912-026-04697-7.

Introduction

Patient safety is a fundamental dimension of quality care and has emerged as a global priority across healthcare systems [1]. Nurses, as frontline healthcare professionals, play a pivotal role in ensuring patient safety due to their continuous and direct contact with patients and their central involvement in care delivery. However, increasing pressures related to resource constraints, staffing shortages, and strained patient–provider relationships challenge their capacity to fully meet professional care standards and responsibilities. As a result, nurses concentrate on urgent duties, which causes them to delay or omit some care, leading to missed care [2, 3]. Kalisch defined “MNC” as any omitted or delayed aspect of needed patient care [4]. MNC, which can also be referred to as incomplete nursing care, unmet nursing care needs, care left undone, and implicit rationing of nursing care, reflects a failure to deliver required nursing interventions, often due to resource constraints and competing clinical demands [5]. It has been reported that 47.8% to 98% of nurses experienced unfinished nursing tasks [5–7], which may potentially compromise patient safety. Through the occurrence of errors, infections, and other complications, missed care can lead to reduced quality of care and an increased incidence of adverse outcomes [3, 8–10]. It also lowers nurses’ job satisfaction, increasing their desire to leave, which leads to higher turnover, therefore impacting nursing service quality [11, 12]. Previous studies have identified multiple structural and organizational factors influencing MNC, including material resources, staffing levels, communication quality, shift length, and caseload [2, 3, 13]. While these operational determinants have been extensively examined, growing attention has been directed toward ethical and contextual variables that may also shape nursing care delivery. In particular, MS, MD, and PSCL have emerged as critical ethical and environmental constructs within nursing practice [14–16].

For nurses, MS is fundamental, allowing them to make and act upon moral choices aligned with their profession [17–19]. Lützén says that MS requires nurses to understand patients’ vulnerabilities intuitively and to recognize the moral impact of their decisions [20]. According to research, nurses with heightened MS are better at recognizing moral issues, making ethical decisions, and acting morally [21, 22]. Therefore, they can not only provide patients with high-quality, human-centered care, leading to better patient outcomes, but also demonstrate greater respect for their colleagues, create a positive work environment, and boost professional identity and job satisfaction [23].

Nurses experience MD as a significant issue in patient care [24], originally described by Jameton (1984) as occurring “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” [25]. MD, potentially occurring with frustration, anger, and painful emotions, could compromise patient care, safety, and satisfaction if unnoticed and unresolved [26]. Nurses could unintentionally worsen patient care by overlooking suffering and avoiding requests, thus harming health [27]. Increased stress, fatigue, and impaired relationships from MD can lead to job burnout and decreased satisfaction, potentially causing nurses to leave the profession and reducing staffing [28, 29].

PSCL involves views on patient safety policies, norms, and procedures within a group, which is key to preventing patient harm in healthcare [30, 31]. A positive PSCL supports superior risk management, reduces the likelihood of negative events, and leads to improved patient outcomes, while a negative PSCL can impact professional practices, which in turn could compromise care quality and patient safety [32].

Some studies have examined factors associated with MNC. For example, in a systematic review and meta-analysis study, the findings revealed an inverse and significant relationship between patient safety culture (PSCU) and MNC. Also, the findings of this study highlighted the specific predictive roles of management support, organizational learning and unit-level safety culture, so that enhancing PSCU within healthcare organizations can be a strategic approach to mitigate MNC [33]. In addition, Breno et al. (2025), in their systematic review study, suggested a consistent association between MNC and adverse events, which their findings underscore the importance of addressing missed care as a patient safety concern [34].

Beyond structural and organizational determinants, emerging evidence highlights the importance of ethical and contextual factors that shape how nurses respond to competing demands and prioritize care under constrained conditions. Constructs such as MS and MD may influence clinical decision-making processes and care prioritization, thereby affecting the occurrence of MNC. However, despite growing scholarly attention, the interrelationship between MS, MD, and PSCL with MNC has not yet been comprehensively synthesized. This gap underscores the need for a systematic review to clarify the existing evidence and provide a more integrated understanding of these associations. This study aimed to investigate the relationship between MS, MD, and PSCL in relation to MNC in clinical nurses. A clearer understanding of these relationships may inform future research and guide the development of strategies to reduce MNC and improve health care outcomes.

Material and methods

This research adheres to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for reporting purposes [35]. The study protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251141525.

Review question

Is there a relationship between clinical nurses’ MS, MD, and PSCL with their MNC?

Search strategy

A comprehensive search of international databases such as PubMed/MEDLINE, Web of Science, Scopus, EMBASE, ProQuest as well as Google Scholar search engine was conducted from January 1, 1995, to August 31, 2025. We built search syntax in databases using keywords including “Moral Sensitivity,” “Moral Distress”, “Patient Safety Climate”, “Missed Nursing Care”, and “Nurses”. Because the existing literature [36, 37] considers the two concepts of PSCL and PSCU, as two separate concepts, this study only focused on PSCL and its synonyms and doesn’t consider PSCU and its synonyms as the study’s main keywords. The search was refined by combining keywords with “AND” and “OR” Boolean operators. The systematic search process was performed by two researchers (AM.N. and H.B.), separately. We considered the starting date of the databases search from 1995, because the concept of MS in clinical practice, as the oldest concept used, was introduced in 1995 by Lutzen et al. [20], and also covered a valid thirty-year time period for searching articles. We did not apply any language restrictions during the search of studies. We have also searched the gray literature (including theses and dissertations, research and committee reports, conference papers, and ongoing research) and consulted some experts. In addition, to avoid missing any studies, the reference lists and citation follow-ups of identified eligible articles were searched manually. The implemented search strategies in different databases are shown in Supplementary File 1.

Study selection

After the searches, all citations went into EndNote X8, and duplicates were removed. The titles and abstracts were screened independently by two authors (AM.N. and H.B.) to exclude publications. If the citation was potentially relevant, the full-text article was reviewed. The same two authors independently assessed the article based on inclusion and exclusion criteria. Any disagreements were resolved through discussion and consultation with a third author (F.B.).

Inclusion and exclusion criteria

In this systematic review, we employed the PCC framework (Population, Concept, Context) to define criteria.

Population

Included: Observational studies (cohort, cross sectional, and case-control studies) that have examined at least one of the variables of MS, MD, and PSCL with MNC in clinical nurses.

Excluded: Reviews, trials, qualitative studies, letters to editor, case reports, and case series

Concept

Included: Discussed the MS, MD, PSCL, and MNC in clinical nurses

Excluded: Discussed the PSCU in clinical nurses

Context

Included: Studies conducted on nurses working in different hospital departments (emergency departments, general departments, and critical care departments), which their results were reported in observational studies.

Excluded: Studies conducted on nursing students or other health care provides.

Quality assessment

The quality of the included studies was evaluated by two independent researchers (AM.N. and M.GH.) employing the 8-item JBI critical appraisal tool for analytical cross-sectional studies [38]. Any discrepancies between the reviewers were addressed by consulting a third reviewer (F.B.). The checklists assess several aspects, including clear inclusion criteria, sample and setting details, measurement tool validity, adherence to standards, confounding factor management, outcome assessment validity, and statistical analysis appropriateness. Appraisers use the checklist with answer choices: “yes = 1,” “no = 0,” “unclear = 0,” and “not applicable = not scored”. Total scores were converted to percentages relative to the maximum possible score and were categorized as high (≥75%), moderate (50–75%), or low (<50%) quality.

Data extraction

Key information from included studies was extracted by two researchers (AM.N. and H.B.). This included details such as author’s name, publication year, country, type of study, study population, sample size, average age, measurement tools, and key findings. The data charting was performed independently by the same both researchers, followed by an interpretation of the results.

Results

Literature search

Database searches yielded 1320 articles, duplicates were removed, and 965 articles were reviewed by title and abstract; then 25 articles were evaluated for full-text inclusion, and 13 articles were included. Figure 1 presents the PRISMA chart detailing the screening process.

Fig. 1.

PRISMA flow diagram of the study

Study characteristics

The systematic review considered 13 manuscripts, including 6699 participants from six countries. Seven studies explored MS and MNC [15, 39–44], three explored MD and MNC [16, 45, 46], and three explored PSCL and MNC [14, 47, 48]. These studies were conducted in various countries, including Iran (n = 5) [15, 39–41, 43], Turkey (n = 3) [44–46], China (n = 2) [16, 42], Brazil (n = 1) [47], Philippines (n = 1) [14], and the USA (n = 1) [48]. The reviewed studies all used a cross-sectional design (descriptive and analytical). The findings of these studies have been summarized in Table 1.

Table 1.

Characteristics of included studies in the systematic review

ID	Author, Year (ref)	Country	Type of study	Study population	Sample size	Mean age (years)	Measurement tools	Main findings
1	Ahansaz et al. [40], 2024	Iran	Cross-sectional	Nurses working in the medical and surgical departments	202	30.95 ± 6.03	1. MISSCARE1 2. MSQ2	Nurses’ mean moral sensitivity and total missed care scores were 149.07 ± 21.60 and 59.45 ± 4.87, respectively. Pearson correlation test showed no significant correlation between moral sensitivity scores and the total missed nursing care scores (r = 0.041, p = 0.152). However, in the regression analysis, moral sensitivity (p < 0.001), age (p < 0.001), working in rotating shifts (p < 0.001), monthly income (p = 0.004), work experience (p = 0.010), and monthly work hours (p = 0.010) influenced missed nursing care.
2	Jia et al. [42], 2025	China	Cross- Sectional	ICU nurses	182	NA	1. T-TPQ3 2. MSQ-R-CV4 3. MNC-CV5	The overall mean (± SD) score of moral sensitivity was 44.89 (±6.43) out of 54 and the score of missed nursing care was 37.49 (±20.78) out of 120. The findings of this study indicated that there was no correlation among missed nursing care and moral sensitivity (r = −0.087, p = 0.245).
3	Fouladi et al. [41], 2024	Iran	Cross-sectional	Nurses working in medical education centers	345	32.19 ± 3.98	1. MISSCARE 2. MSQ	The results of the study showed that nurses had an average level of moral sensitivity (70.75 ± 10.83). The mean and standard deviation of missed nursing care were (33.93 ± 10.35), which was less than the median of the questionnaire. There was a significant inverse relationship between moral sensitivity and missed nursing care (r = −0.253, p < 0.01).
4	Abdollahi et al. [39], 2025	Iran	Descriptive Correlational Study	Nurses working in the medical and surgical departments	120	34.50 ± 16.70	1. MISSCARE 2. MSQ	The mean score of moral sensitivity and missed nursing care were 76.45 ± 4.7 and 46.45 ± 5.5, respectively. A significant inverse correlation was observed between moral sensitivity and missed nursing care (r = −0.25, p < 0.05). Additionally, education level (p < 0.05) and work shift (p < 0.05) were significantly associated with missed nursing care.
5	Khoobi et al. [43], 2025	Iran	Cross- Sectional	Clinical nurses working in public and private hospitals	217	NA	1. MISSCARE 2. MSQ	The mean score of moral sensitivity among clinical nurses was 59.93 ± 10.28, indicating a moderate level of moral sensitivity. The mean missed nursing care score was 37.15 ± 10.66, indicating a relatively low level of missed nursing care. There was a significant and inverse relationship between moral sensitivity and missed nursing care (r = −0.248, p < 0.001).
6	Nobahar et al. [15], 2023	Iran	Cross- Sectional	ICU nurses	200	32.7 ± 5.65	1. T-TPQ 2. MISSCARE 3. MSQ	The mean and standard deviation of moral sensitivity and missed nursing care was 64.19 ± 13.43 and 55.04 ± 34.10, respectively. There was a significant and negative relationship between moral sensitivity and missed nursing care (r = −0.36, p < 0.001).
7	Taskiran Eskici et al. [44], 2025	Turkey	Descriptive Correlational Study	Nurses working in the inpatient units	640	NA	1. NPVS-R6 2. MISSCARE 3. MSQ	The total moral sensitivity score of nurses was 76.26 ± 28.94, which indicated that they had a high level of moral sensitivity. Also, the mean missed nursing care score of nurses was found to be 1.11 ± 0.71. Accordingly, nurses reported low levels of missed nursing care. In addition, a significant and negative correlation was found between the moral sensitivity score and the missed nursing care score of nurses (r = −0.521, p < 0.01).
8	Bakırlıoglu et al. [45], 2025	Turkey	Cross-sectional	NICU nurses	153	31.22 ± 7.6	1. MISSCARE7 2. MDS-R8	The results showed that subdimensions of the Missed Care including communication (p = 0.018) and labour resources (p = 0.021) were predictive factors that positively affected moral distress.
9	Xu et al. [16], 2025	China	Cross- Sectional	Newly graduated nurses	228	23.78 ± 2.07	1. MSQ-R-CV 2. MNC-CV 3. MDS-R-CV9	The mean scores for moral sensitivity, moral distress, and missed nursing care were 40.71 (0.39), 34.87 (2.41), and 9.82 (0.78), respectively. The results of the study showed a negative correlation between moral sensitivity and missed nursing care (r = −0.144, p < 0.05). Also, a significant positive correlation was observed between missed nursing care and moral distress (r = 0.325, p < 0.01).
10	Topal et al. [46], 2024	Turkey	Cross- Sectional	Pediatric nurses	140	NA	1. MDS-R (pediatric) 2. BMS10 3. MISSCARE- Ped11	The mean MDS-R score of the nurses participating in the study was 99.35 ± 57.74 (low moral distress) and the mean MISSCARE-Survey score was 2.85 ± 0.68 (high missed care). No statistically significant relationship was found between the mean scores of the MDS-R and its sub-dimensions and MISSCARE-Survey and its sub-dimensions (p > 0.05).
11	Dutra et al. [47], 2021	Brazil	Cross-sectional	Nursing professionals	219	37 ± 8.37	1. PES12 2.MISSCARE 3. SAQ13	The results of the study showed no statistically significant differences among the reasons for missed care and safety climate (p > 0.05).
12	Labrague et al. [14], 2022	Philippines	Cross- Sectional	Clinical nurses	624	29.80 ± 7.80	1. PES-NWI14 2. MNCS 3. SCS15 4. LQWQ16	The mean score of the missed nursing care was 1.210 ± 0.176 and the mean score of patient safety climate was 4.219 ± 0.666. The findings showed that patient safety climate (p = 0.001), decision authority (p = 0.018) and staffing/resource adequacy (p = 0.014) significantly predicted missed nursing care of nurses.
13	Zhong et al. [48], 2023	USA	Cross- Sectional	Labor registered nurses	3429	40.7 ± 11.8	1. SAQ 2. Perinatal Missed Nursing Care	The results of the mixed-effects linear regression models shown that in the unadjusted model, there was an estimated 2.6 unit decrease in missed care aspects for each unit increase in nurse-perceived safety climate scores (β = −2.60; 95% CI: −2.91, −2.29). This relationship was slightly larger in the adjusted model (β = −2.65; 95% CI: −2.97, −2.34). Perceptions of safety climate explained approximately 3.4% of the variance in missed care scores.

¹Kalisch’s missed care questionnaire

²Lutzen’s Moral Sensitivity

³Team STEPPS Teamwork Perceptions Questionnaire

⁴Moral Sensitivity Questionnaire–Revised Version into Chinese

⁵The Chinese version of the Missed Nursing Care Survey

⁶The Revised Nursing Professional Values Scale

⁷Missed Care Survey-pediatric form

⁸Moral Distress Scale-Revised for pediatric nurses

⁹The Chinese Moral Distress Scale- Revised Version

¹⁰Burnout measure-short version

¹¹MISSCARE survey- pediatric version

¹²Practice Environment Scale

¹³Safety Attitudes Questionnaire

¹⁴Practice Environment Scale of the Nursing Work Index

¹⁵Safety Climate Survey

¹⁶Leiden Quality of Work Questionnaire

Quality assessment

Regarding the quality assessment, the findings illustrated that the total scores of the final included studies was between 4 and 7, which 11 studies [14, 15, 39, 41–48] have moderate quality and only 2 studies [16, 40] have high quality. The results of studies’ quality assessment are presented in Table 2.

Table 2.

The quality assessment of the studies

ID	Study Name	1. Were the criteria for inclusion in the sample clearly defined?	2. Were the study subjects and the setting described in detail?	3. Was the exposure measured in a valid and reliable way?	4. Were objective, standard criteria used for measurement of the condition?	5. Were confounding factors identified?	6. Were strategies to deal with confounding factors stated?	7. Were the outcomes measured in a valid and reliable way?	8. Was appropriate statistical analysis used?	Total Score	Final Status
1	Ahansaz et al., 2024	Yes	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	7	High quality
2	Jia et al., 2025	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
3	Fouladi et al., 2024	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
4	Abdollahi et al., 2025	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
5	Khoobi et al., 2025	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
6	Nobahar et al., 2023	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
7	Taskiran Eskici et al., 2025	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
8	Bakırlıoglu et al., 2025	Unclear	Unclear	Yes	Yes	No	Unclear	Yes	Yes	4	Moderate quality
9	Xu et al., 2025	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	7	High quality
10	Topal et al., 2024	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
11	Dutra et al., 2021	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
12	Labrague et al., 2022	Yes	Yes	Yes	Yes	No	Unclear	Yes	Yes	6	Moderate quality
13	Zhong et al., 2023	Unclear	Unclear	Yes	Yes	Yes	Unclear	Yes	Yes	5	Moderate quality

MS

Literature offers various definitions of MS; for example, Gastman et al. (2002) defined MS as recognizing and responding to a situation’s moral implications [49]. Also, Weaver et al. (2007) viewed MS as encompassing behavioral concepts like actions, intentions, emotions, and perceptions [50]. Additional studies considered further definitions of MS, from “the capacity to recognize moral issues in real-world scenarios” to what they believe MS is, caring for the well-being of others, and is more than a cognitive ability [51, 52].

MD

MD is defined differently in the literature; Jameton et al. (1984) proposed that it occurs when one knows the correct course of action, but institutional obstacles make it nearly unachievable [53]. Moreover, Corley et al. (2002) believed that when a nurse learns what is best for a patient but cannot provide it, the nurse suffers MD [54]. A further study found that MD in healthcare is associated with ethical issues and difficulties in practicing while adhering to professional values [55].

PSCL

Safety climate, a psychological concept reflecting staff safety perceptions, is crucial for patient safety and quality [56]. It influences staff behavior and patient outcomes, thereby impacting patient safety [57]. Findings show fewer medication errors and lower readmissions for patients in units with a strong safety climate, defined by communication, support, and safety appreciation, which predicts nurse safety performance [58].

MNC

MNC, a new concept, includes any aspect of necessary patient care that’s left out or postponed [4, 59]. Organizational factors like staffing, work environment, teamwork, and safety can cause MNC, which affects nurse-reported care quality, job satisfaction, patient satisfaction, and increases adverse events, turnover, and intent to leave [3, 5].

The relationship between MS and MNC

Seven studies investigated the correlation between MS and MNC. Two studies reported no significant correlation between these variables. For example, the results of the study conducted by Ahansaz et al. (2024) showed no significant correlation between the total MS and MNC scores (r = 0.041, p = 0.152). Nevertheless, the findings of the regression analysis showed that several factors, including MS (β = 0.084, p < 0.001), monthly working hours (p < 0.010), rotating shift work (p < 0.001), age (p < 0.001), bachelor’s degree (p < 0.001), monthly income (p = 0.004), and work experience (p = 0.010) were significantly influenced the missed nursing among nurses working in the medical and surgical departments [40].

Furthermore, the study by Jia et al. (2025) indicated that there was no significant correlation between the overall MS and MNC scores (r = −0.087, p = 0.245). Also, the multiple linear regression analysis identified employment status (p < 0.010) and working time per shift (p < 0.010) as significant predictors for ICU nurses’ MNC, while MS (β = −0.039, p = 0.900) did not significantly predict its occurrence [42].

However, five studies reported a significant inverse correlation between MS and MNC. For example, the results of the study conducted by Fouladi et al. (2024) demonstrated a notable inverse correlation between total MS and MNC scores (r = −0.253, p < 0.01). Also, the findings of the regression analysis showed that various factors, such as respect for client independence (p = 0.027), professional knowledge (p < 0.001), the experiencing moral problems and conflicts (p < 0.001), and honesty and benevolence (p < 0.001) were negatively impacted MNC of clinical nurses. Conversely, factors like MS (β = 0.265, p < 0.001), human resources (p = 0.001), funds (p = 0.001), and connections (p = 0.01) were positively influenced their MNC [41].

Furthermore, in the study by Abdollahi et al. (2025), a significant inverse correlation was identified between the total MS and MNC scores (r = −0.25, p < 0.05). Additionally, the results of the multiple regression analysis indicated that both MS (β = 8.110, p < 0.001) and work shift (p < 0.001) were significant positive predictors of MNC among nurses working in the medical and surgical departments [39].

In addition, the results of the study conducted by Khoobi et al. (2025) reported a significant inverse correlation between the total MS and MNC scores among clinical nurses (r = −0.248, p < 0.001) [43]. In line with the previous studies, the findings of another study highlighted that there was a significant negative correlation between the total MS and MNC scores (r = −0.360, p < 0.001). Additionally, the results of the multiple regression analysis indicated that teamwork (p < 0.001), clinical experience (p = 0.001), and age (p = 0.008) were all negatively associated with MNC, suggesting that improved teamwork and greater clinical experience and age may decrease the likelihood of MNC among ICU nurses [15].

Moreover, in their study, Taskiran Eskici et al. (2025) found a significant negative correlation between the total MS and MNC scores (r = −0.521, p < 0.001). Also, the findings of the regression analysis indicated that both MS (β = −0.265, p < 0.001) and professional values (β = −0.193, p < 0.001) negatively predicted the incidence of MNC among clinical nurses [44].

The relationship between MD and MNC

The relationship between MD and MNC has been assessed in three studies. In their research, Bakırlıoglu et al. (2025) indicated that Missed Care survey aspects like communication (p = 0.018) and labour resources (p = 0.021) influenced NICU nurses’ MD [45]. Also, the study by Xu and colleagues (2025) discovered a negative link between the mean scores of MS and MNC in new nurses (r = −0.144, p < 0.05); their study also found a significant positive correlation between the mean scores of MD and MNC (r = 0.325, p < 0.01) [16]. However, the findings of the study conducted by Topal et al. (2024) showed no statistically significant relationship between the mean scores of the MD and its sub-dimensions with MNC and its sub-dimensions in pediatric nurses (p > 0.05) [46].

The relationship between PSCL and MNC

The association between PSCL and MNC also has been investigated in three studies. According to Dutra et al.’s study (2021), there were no statistically significant links between missed care reasons and safety climate (p > 0.05) [47]. However, in their research, Labrague et al. (2022) revealed that PSCL (β = −0.148, p = 0.001), decision authority (p = 0.018), and staffing/resource adequacy (p = 0.014) were significantly predicted MNC in frontline nurses during the COVID-19 pandemic [14]. Moreover, the study by Zhong et al. (2022) on labor and delivery registered nurses discovered that a better nurse-perceived safety climate was significantly linked to less MNC (β = −2.65, 95% CI : −2.97 to −2.34, p < 0.001) [48].

Discussion

This systematic review aimed to clarify the relationships between MS, MD, and PSCL with MNC in clinical nurses. The findings demonstrate heterogeneous associations across studies, suggesting that MNC is shaped by both ethical competencies and organizational conditions rather than a single determinant.

MS and MNC

The findings of this systematic review indicate varying levels of MS among nurses and inconsistent relationships with MNC. While some studies reported high MS [42, 44] and others moderate levels [15, 40, 41, 43], most studies demonstrated an inverse relationship between MS and MNC, although a few reported no significant association [40, 42].

Evidence from primary research suggests that higher MS is associated with fewer omissions in patient care, particularly among clinical nurses and newly graduated nurses, highlighting the role of ethical awareness in improving care quality. For instance, Xu et al. [16] found that lower MS was associated with higher MNC rates among newly employed nurses. Similarly, research examining the association between MS and missed care has emphasized that recognizing ethical implications in clinical situations can enhance patient-centered decision-making and reduce care omissions [40].

However, inconsistent findings observed across studies may reflect contextual influences. Structural constraints such as staffing shortages, workload pressure, and organizational environment have been repeatedly identified as major contributors to MNC independent of individual ethical competence [60]. Additionally, educational interventions appear to strengthen MS by improving ethical knowledge, communication, and awareness of professional responsibility, suggesting that ethical competence is modifiable and potentially relevant for reducing missed care [61].

Taken together, these findings suggest that although MS contributes to safer and more ethical nursing practice, its protective effect may be moderated by organizational and systemic factors.

MD and MNC

This review also revealed inconsistent relationships between MD and MNC. Some studies reported positive associations, suggesting that higher MD may increase care omissions, whereas others reported non-significant relationships. Previous literature indicates that MD arises when nurses cannot act according to ethical judgments due to institutional barriers, leading to emotional exhaustion, reduced engagement, and burnout [62, 63]. Burnout itself has been strongly linked to lower healthcare quality, reduced patient safety, and poorer patient satisfaction [64].

These mechanisms may explain why MD sometimes predicts MNC. However, contextual variability may account for inconsistent findings. Meta-analytic evidence suggests that MD levels vary significantly across countries and healthcare settings, often being higher in resource-limited contexts [65]. Furthermore, ethical dilemmas arising from organizational structure, collaboration challenges, and conflicting stakeholder expectations can intensify MD in clinical practice [66]. Therefore, MD should be understood not only as an individual psychological phenomenon but also as a systemic indicator of organizational ethical climate.

PSCL and MNC

Consistent with previous literature, this review identified mostly inverse relationships between PSCL and MNC. A findings of a study focusing on labor and delivery settings have shown that improved teamwork, communication, and leadership support within a positive PSCL can reduce MNC [67]. These findings are also supported by broader reviews indicating that MNC is associated with adverse patient outcomes such as infections, falls, mortality, and reduced patient satisfaction, underscoring its importance as a patient safety indicator [68]. However, PSCL alone does not fully explain MNC. Evidence suggests that workload, staffing adequacy, teamwork, and organizational environment remain critical determinants [60].

Integrated interpretation

Overall, the findings suggest that MNC arises from a dynamic interaction between ethical competence (moral sensitivity), emotional experience (moral distress), and organizational context (patient safety climate). Ethical awareness may promote high-quality care, whereas MD and weak PSCL may undermine nurses’ capacity to deliver complete care.

Importantly, improving only individual ethical competence without addressing organizational conditions may not effectively reduce MNC. Integrated interventions addressing ethics education, leadership support, staffing adequacy, and PSCL appear necessary.

Implications for practice and research

The findings of this systematic review have several important implications for clinical practice, healthcare management, and future research. First, the observed associations between MS and MNC suggest that strengthening nurses’ ethical competence through structured ethics education programs may enhance ethical awareness, clinical judgment, and patient-centered decision-making, thereby potentially reducing care omissions. Integrating ethics training into continuing professional development programs and undergraduate nursing curricula may therefore contribute to improved quality of care.

Second, the relationship between MD and MNC underscores the importance of organizational strategies aimed at mitigating MD among nurses. Supportive leadership, adequate staffing levels, open communication, and institutional policies that empower nurses to act according to their professional values may help reduce emotional exhaustion and burnout, ultimately improving patient care outcomes.

Third, the evidence highlighting the role of PSCL indicates that fostering a positive PSCL within healthcare organizations remains a critical priority. Enhancing teamwork, promoting non-punitive error reporting, ensuring sufficient resources, and strengthening managerial support may facilitate comprehensive nursing care and reduce the incidence of MNC and related adverse outcomes.

Future research directions

From a research perspective, future studies should prioritize longitudinal, experimental, and interventional designs to better clarify causal relationships between ethical factors and MNC. Additionally, cross-cultural comparative research is warranted, as variations in healthcare systems, organizational structures, and cultural expectations may significantly influence MS, MD, PSCL, and patterns of MNC.

Study limitations

Despite these contributions, several limitations should be acknowledged. First, most of the included studies employed cross-sectional designs, which limit causal inference between variables. Second, heterogeneity in measurement tools, study populations, and healthcare settings may affect comparability across studies and the generalizability of findings. Finally, variability in organizational contexts and healthcare infrastructures across countries may have influenced the observed relationships, warranting cautious interpretation of the findings.

Conclusion

This systematic review highlights the complex relationships between MS, MD, PSCL, and MNC. While higher MS and positive PSCL may be associated with fewer care omissions, findings remain inconsistent and appear strongly influenced by organizational and contextual factors. These results suggest that reducing MNC requires both strengthening ethical competence and improving workplace conditions. Further longitudinal and interventional research is needed to clarify causal relationships and guide effective interventions.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Conceptualization: AM.N., F.B.; Methodology: AM.N., H.B., M.GH., F.B.; Project administration: AM.N., H.B., M.GH., F.B.; Writing – original draft: AM.N., H.B., M.GH., F.B.; Writing – review & editing: AM.N., H.B., M.GH., F.B.; All authors read and approved the final manuscript.

Funding

This research was funded by Shahid Beheshti University of Medical Sciences to support its various stages.

Data availability

The datasets utilized and analyzed in this study will be made available by the corresponding authors upon request.

Declarations

Ethical approval

This study ethically evaluates the quality and relevance of evidence in primary research reports based on the review’s objective.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.