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 Table of Contents  
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 308-312

Missed care and nurses' job satisfaction

Department of Nursing Foundation, Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission31-Aug-2019
Date of Decision18-Oct-2020
Date of Acceptance31-Dec-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Ms. Lata Mandal
Research Scholar, Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_130_19

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Background: Job satisfaction among nurses is a global concern for its crucial impact on nursing shortage and quality of care. Missed nursing care defined as nurses' decision to omit or delay aspects of patient care activities is hypothesized to influence nurses' job satisfaction. Aim: The aim of this study was to explore the relationship between missed nursing care and nurses' job satisfaction. Materials and Methods: The study used a cross-sectional design, and data were collected using the MISSCARE survey and Nurses' Work Satisfaction Scale from 205 randomly selected nurses working in the medical–surgical units of four tertiary care hospitals in India. Data were analyzed using IBM SPSS version 23. Results: Nurses' job satisfaction was significantly related to missed nursing care, hospital types, and education which together explained 27% of the variance in nurses' job satisfaction. Conclusion: Focused strategies to decrease missed nursing care can improve job satisfaction among nurses. Nurse leaders can use missed nursing care as a process indicator to assess and predict nurses' job satisfaction.

Keywords: Job satisfaction, missed nursing care, nurse, quality of care

How to cite this article:
Mandal L, Seethalakshmi A. Missed care and nurses' job satisfaction. J Datta Meghe Inst Med Sci Univ 2021;16:308-12

How to cite this URL:
Mandal L, Seethalakshmi A. Missed care and nurses' job satisfaction. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Dec 9];16:308-12. Available from: http://www.journaldmims.com/text.asp?2021/16/2/308/328446

  Introduction Top

Nurses' job satisfaction is a global and national concern because of its crucial impact on nursing retention and overall quality of patient care.[1] Job satisfaction of nurses has been mainly studied within the framework of the work environment, organizational policies, and job stress. However, researchers have given very little attention to the effect of nurses' work process on their job satisfaction. Missed nursing care, defined as nurses' decision to omit or delay aspects of patient care activities, is a component of nurses' work process.[2] In this study, missed nursing care was examined for its existence, pattern, and predictive ability to explain nurses' job satisfaction.


In India, the 1.32 million nursing workforces make for approximately 30% of the total human resource involved in the health care of the country.[3] In spite of this enormous number, shortage of trained nurses in India is an existing challenge and may worsen with the increase in the proportion of aged people and people living with chronic diseases.[4] Job satisfaction of nurses is, therefore, a central concern for the health-care organizations because of its contribution to nurses' intention to leave the profession.[5] In addition, low job satisfaction among nurses leads to increased absenteeism, turnover, and poor job performance.[5],[6],[7],[8] Studies suggest several factors to be associated with nurses' job satisfaction.[9] Nurses' overall perception of their work environment, organizational policies, autonomy, job stress, nurse–physician collaboration, and the effort–reward experience of nurses significantly contributed to the satisfaction with their jobs.[10],[11] However, these are not the only determinants of nurses' job satisfaction.

Herzberg et al., in their famous two-factor theory, suggested that positive ratings for factors such as organizational policies, salary, and the environment do not directly lead to job satisfaction but merely to the absence of dissatisfaction and called them hygiene factors. They argued that in contrast, the work content has a direct and positive influence on the person's satisfaction with the job and called it a motivational factor.[12] Research studies also reported that nurses felt more satisfied with their jobs when they could enrich their work with evidence based practice.[13],[14]

Missed nursing care defined as omission or delay of essential patient care tasks is considered a component of nurses' work process.[2],[15] Studies reported that missed nursing care is a global phenomenon and adversely influenced the quality of patient care.[2] In addition, nurses expressed feeling guilty, frustrated, robotic, and unethical while they missed essential patient care.[16] Thus, missed care when present in the work process of nurses is suggestive of influencing nurses' job satisfaction.

Conceptual framework

The study based its theoretical underpinning on the Job Characteristics Model proposed by Hackman and Oldham. The theory assumes that the characteristics of a job create a psychological state essential for satisfaction.[17] These characteristics are “task identity” defined as the degree to which a person views completeness of one's job and “task significance” defined as the degree to which a person perceives the impact of one's job in others' lives.[17] Nurses as trained individuals are bound to be conscious of the unfavorable effect of missed care and, at the same time, have difficulty in viewing the completeness of their work, thereby affecting both task identity and task significance of their job. Based on the proposition of the model, this study developed the working hypothesis that missed nursing care when existing will contribute to the overall job satisfaction of nurses. This study was taken up with the following aim:

  1. To assess whether missed nursing care exists and, if so, the pattern of missed nursing care
  2. To explore whether nurses' job satisfaction is related to nurse-reported level of missed nursing care
  3. To what extent missed nursing care predict nurses' job satisfaction.

  Materials and Methods Top

Design, settings, and sample

The quantitative cross-sectional study was carried out in four large tertiary care teaching hospitals managed by trusts in the southern and eastern regions of India. Each of the hospitals was having 1000–1500-bed capacities. Two of the hospitals (hospital A and B) were NABH (National accreditation Board for Hospitals and Healthcare providers)accredited centers serving patients from the upper middle class section of the society. The remaining two (referred to as hospital C and hospital D) were nonaccredited facilities catering to the economically marginalized patients.

Based on the global prevalence of missed nursing care between 55% and 98%,[2] a modest population proportion of Po (0.65) and a sample proportion of Pa (0.55) were considered. Using power (80%), level of significance (α = 0.05), and using a two-tailed test, the sample size was calculated as 183. Keeping in mind the chances of refusal, a randomly selected group of 220 registered nurses permanently employed in the hospitals and involved in direct patient care in the adult medical–surgical units of the hospitals were approached for the study. The final sample size was 205 as 15 of them refused to participate, indicating a refusal rate of 6.82%.


The nurses completed two instruments along with a demographic sheet. Job satisfaction was measured with the Nursing Workplace Satisfaction Questionnaire, which is a one-page standardized 15-item scale where the participants were to give their agreement to statements for each item.[18] The options in the questionnaire were strongly agree/agree/not sure/disagree/strongly disagree. A low score indicated low workplace satisfaction. The internal consistency (Cronbach's alpha) of the instrument in the present study was 0.88.

The MISSCARE survey instrument was used to measure the frequency of missed care.[19] The survey consisted of 23 nursing activities where the participants indicated the frequency of missing care activities on a scale with options of always/frequently/occasionally/rarely/never. A low score suggested less frequency of missed nursing care, indicative of a good work process. This tool has been extensively used and reported high psychometric properties.[2] The calculated Cronbach's alpha of 0.95 suggests a high internal consistency in the present study. As all the participants understood English, the questionnaires did not require translation. However, the scales were given to experts who were fluent in English to check whether cultural, idiomatic, and conceptual equivalence was maintained for clear understanding and acceptance by the participants. In addition, both the instruments were pilot tested on a group of nurses to check for ease of comprehension and the average time required (15 min) for filling up the questionnaires.


After choosing the hospitals by convenience sampling, permission and approval were sought and obtained from the institutional review boards of each hospital. The questionnaire was handed over to the participants in an envelope and requested to fill and return after 1 week. The questionnaires were collected from each of the hospitals within a 2 weeks' time frame between March and September 2018. Informed consent was obtained from each participant, ensuring confidentiality, anonymity, and their rights to refuse or withdraw at any time.

Data analysis

Data were analyzed with the help of IBM SPSS version 23 (IBM Corp., Armonk, NY). For job satisfaction and missed care, a composite score for each participant was calculated by dividing the total individual score by the number of items. The Kruskal–Wallis and Mann–Whitney tests were used to identifying differences in job satisfaction among hospitals and staff characteristics. The Spearman rank-order correlation coefficient was applied to determine the relationship between missed care and job satisfaction. Hierarchical multiple regression was used to calculate the predicting effect of variables on job satisfaction. The normality of the data was checked by the Shapiro–Wilk test for normality. As the variables were not normally distributed, square root transformation of both the variables was carried out before multiple regression analysis.

  Results Top

Descriptive statistics

Of the 205 nurses, the majority were female (88.29%). The range of age of the participating nurses was between 21 and 50 years, with a mean of 27.67 years (standard deviation [SD]: 5.52). Majority of the nurses were below 30 years of age. More than 50% of the nurses across all the sites held a general nursing and midwifery diploma. The total professional experience of the participants ranged from 6 months to 21 years, with more nurses having experience between 2 and 5 years. The detail of nurses' characteristics appears in [Table 1].
Table 1: Demographic and professional characteristics of nurse participants (n=205)

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Research question a: Existence of missed nursing care and its pattern

The mean score of missed care at the individual level was 2.41 (SD: 0.49), and the median score was 2.39 (interquartile range [IQR]: 0.61), indicating that when asked how often the nurses were unable to perform specific tasks, the nurses reported that it occurred between rarely and occasionally. Although there was a difference in the missed score (2.17–2.46) among the hospitals, it was not statistically significant (P = 0.410).

Percentage-wise distribution of self-reported data regarding missed care revealed that nurses accorded a different level of priority to the nursing tasks. Majority of the nurses reported that they rarely/never missed therapeutic and diagnostic functions such as administration of medicines and checking of bedside blood sugar (83.02%), documentation (56.10%), and assessment and monitoring of patients (67.02%). However, nurses reported frequently/always missing emotional support to patients (60.49%). Communicating information before tests and therapy and giving discharge advice were sometimes/frequently/always missed by the majority of the nurses (74.88). Moderate-to-low priority was also reported in assisting patients in meeting their hygiene needs such as bathing and oral hygiene (65.86%). Activities to meet the nutritional needs of patients such as setting trays or feeding when the food was still warm were given low-to-moderate priority (74.88%). [Table 2] presents the pattern of missed care for different nursing activities.
Table 2: Percentage-wise distribution of nurses as per pattern in Missed Nursing Care (n=205)

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Research question b: Relationship between job satisfaction and missed nursing care

At the individual level, the mean score of job satisfaction was 3.60 (SD: 0.34), and the median score was 3.60 (IQR: 0.40), indicating that nurses' work satisfaction was between the neutral option and satisfied. Overall, there was a significant difference in the level of job satisfaction among the hospitals (P = 0.002). The Mann–Whitney U-test for pairwise comparison of the four sites was carried out concerning nurses' job satisfaction, which showed that nurses of site D were statistically more satisfied than all other hospital sites. Hospital D was followed by hospital C, hospital B, and hospital A in the order of nurses' job satisfaction.

The other control characteristics of nurses that were significantly (P = 0.0001) related to their job satisfaction were the educational preparation of nurses, which indicated that the nurses who were holding bachelor's degree in nursing were on average less satisfied than the ones who were having a diploma. Spearman's rho coefficient (−0.464; P = 0.001) between the overall missed care and job satisfaction scores indicated a statistically significant moderate and negative correlation between the two variables.

Research question c: Prediction of nurses' job satisfaction

Missed nursing care scores and the significant controlling variables such as nurses' education and the type of hospital were included in the multivariate regression analysis [Table 3]. In Model 1, the type of hospitals and the education of nurses were added as predicting variables. In Model 2, the missed care score was added to the analysis. The following variables were coded as dummy variables: Hospitals (reference group=hospital D); Education (degree=0,diploma=1). Model 1 indicated that 10% of the variance in nurses' job satisfaction was predicted by the place of her work and her educational preparation (F (4,200) =6.844, P = 0.001). In Model 2, after the missed nursing care score was entered, the total variance in job satisfaction explained by the model was 27% (F (5,199) =15.841, P = 0.001). The Missed Nursing Care Scale thus explained the additional 17% of the variance in job satisfaction after controlling the hospital type and nurses' education. In Model 1, we observed that the hospital type was related to job satisfaction with the expected value of job satisfaction found least in hospital A than hospitals B and C. The expected job satisfaction hospital D was more than all other hospitals. After controlling for hospital type, expected job satisfaction for diploma-educated nurses was more than nurses with BSc degrees. With controlling other variables in the models, expected job satisfaction decreased with an increased level of missed nursing care.
Table 3: Multiple regression to determine predictors of job satisfaction

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  Discussion Top

Research studies that have been conducted on nurses' job satisfaction primarily included the hygiene factors of the job, and a very few dealt with the effect of nurses' work process on job satisfaction. Missed nursing care, considered as a component of nurses' work process, was examined for its existence, pattern, and predictive ability to explain nurses' job satisfaction.

The findings of the study revealed that missed nursing care exists among participating nurses, and the pattern of missed care revealed a tendency for nurses to give high priority to therapeutic, diagnostic, and monitoring activities in place of communication, teaching, hygiene care, and psychological care to patients. This finding is substantiated by studies across the globe that showed that activities lacking definite time effort estimate such as talking to patients, explaining procedures, or teaching before discharge were reported to be missed more often.[2],[20],[21],[22]

The findings of a moderate and significant negative correlation between missed care and job satisfaction supported the working hypothesis that missed nursing care when existing will play a part in the overall job satisfaction of nurses. These findings also revealed that missed nursing care could explain for 27% of the variance in job satisfaction along with nurses' education and hospital types. This finding confirms the results of the study by Kalisch et al., where missed nursing care along with the unit type and perception of staffing adequacy explained for 22.4% variance in nurses' job satisfaction.[14] In 2016, another study revealed that nurses' reporting higher rate of care omission was less satisfied with their job.[23]

The findings of a statistically significant regression coefficient between missed care and nurses' job satisfaction can be utilized by nursing administrators to measure and predict job satisfaction. Till date, human resource managers have emphasized structural indicators of job satisfaction such as resource availability, nurse–patient ratio, and working environment. Similarly, the focus on outcome indicators of job satisfaction such as the rate of turnover and absenteeism was also emphasized. However, missed nursing care, which is a real-time process indicator, can be adopted with the dual purpose of assessing nurses' job satisfaction as well as the quality of nursing care.

The study findings suggested that nurses working in the nonaccredited hospitals were significantly more satisfied than the reported level of satisfaction of nurses working in the NABH accredited hospitals. The apparent dichotomy can be explained by the findings of a qualitative study where nurses expressed feeling more stressed and less satisfied with their jobs because of increased accountability in work, despite working in hospitals which were having well-organized and high-quality health care.[24] The findings of significantly lower job satisfaction among nurses working in accredited hospitals require attention and deliberation. Nursing leaders need to focus on the additional accountability given to nurses in accredited health-care settings. Holding discussions with nurses and clarifying nurses' roles and responsibilities with other health-care workers may be a strategy to do so. Research studies may be taken up to explore this paradox of low job satisfaction among nurses in a high-quality organization.

In this study, the perception of job satisfaction among the diploma-trained nurses was significantly more than the satisfaction of nurses who held bachelors' degree in nursing. This finding supports the results of previous research done among nurses in England which found that graduate nurses enter the profession with higher expectation and reported lower job satisfaction and lower intention to remain in nursing.[25] The finding will pave the way for future research on nurses' job satisfaction within the framework of expectation-satisfaction theories.

Limitations of the study

The generalizability of this study is limited to tertiary care hospitals, and the self-report method of assessing the variables could have been vulnerable to the risk of reporting biases.

  Conclusion Top

Global and national health-care organizations are struggling with shortage of nurses and are looking for strategies to retain their nursing resource. Ensuring job satisfaction among nurses is an important strategy to do so. Missed nursing care was a significant predictor of nurses' job satisfaction in the study and can be used as a real-time process indicator to measure it. Nurse leaders should address the reasons for missed nursing care and develop strategies to reduce it and retain a satisfied group of the human resource vital for delivering quality health care.


We would like to thank Sri Ramachandra Institute of Higher Education and Research, Chennai, India.

Financial support and sponsorship

First author supported by Founder Chancellor Fellowship of Sri Ramachandra Institute of Higher Education and Research.

Conflicts of interest

There are no conflicts of interest.

  References Top

Alotaibi J, Paliadelis PS, Valenzuela FR. Factors that affect the job satisfaction of Saudi Arabian nurses. J Nurs Manag 2016;24:275-82.  Back to cited text no. 1
Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud 2015;52:1121-37.  Back to cited text no. 2
Karan A, Negandhi H, Nair R, Sharma A, Tiwari R, Zodpey S. Size, composition and distribution of human resource for health in India: New estimates using National Sample Survey and Registry data. BMJ Open 2019;9:e025979.  Back to cited text no. 3
CBHI. National Health Profile. Ministry of Health and Family Welfare, GOI; 2018. Available from: https://cdn.downtoearth.org.in/pdf/NHP-2018.pdf. [Last accessed on 2019 Aug 23].  Back to cited text no. 4
Lo WY, Chien LY, Hwang FM, Huang N, Chiou ST. From job stress to intention to leave among hospital nurses: A structural equation modelling approach. J Adv Nurs 2018;74:677-88.  Back to cited text no. 5
Roelen CA, Magerøy N, van Rhenen W, Groothoff JW, van der Klink JJ, Pallesen S, et al. Low job satisfaction does not identify nurses at risk of future sickness absence: Results from a Norwegian cohort study. Int J Nurs Stud 2013;50:366-73.3.  Back to cited text no. 6
Chen MF, Ho CH, Lin CF, Chung MH, Chao WC, Chou HL, et al. Organisation-based self-esteem mediates the effects of social support and job satisfaction on intention to stay in nurses. J Nurs Manag 2016;24:88-96.  Back to cited text no. 7
Saleh U, O'Connor T, Al-Subhi H, Alkattan R, Al-Harbi S, Patton D. The impact of nurse managers' leadership styles on ward staff. Br J Nurs 2018;27:197-203.  Back to cited text no. 8
Lu H, Zhao Y, While A. Job satisfaction among hospital nurses: A literature review. Int J Nurs Stud 2019;94:21-31.  Back to cited text no. 9
Zangaro GA, Soeken KL. A meta-analysis of studies of nurses' job satisfaction. Res Nurs Health 2007;30:445-58.  Back to cited text no. 10
Satoh M, Watanabe I, Asakura K. Occupational commitment and job satisfaction mediate effort-reward imbalance and the intention to continue nursing. Jpn J Nurs Sci 2017;14:49-60.  Back to cited text no. 11
Herzberg F, Mausner B, Snyderman BB. The Motivation to Work. London, New York: Routledge Taylor and Francis Group; 2017.  Back to cited text no. 12
Kang H. Evidence-based practice and job satisfaction of nurses in long-term care. OJN 2016;6:977-86.  Back to cited text no. 13
Kalisch B, Tschannen D, Lee H. Does missed nursing care predict job satisfaction? J Healthc Manag 2011;56:117-31.  Back to cited text no. 14
Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: A concept analysis. J Adv Nurs 2009;65:1509-17.  Back to cited text no. 15
Papastavrou E, Andreou P, Vryonides S. The hidden ethical element of nursing care rationing. Nurs Ethics 2014;21:583-93.  Back to cited text no. 16
Hackman JR, Oldham GR. otivation through the design of work: Test of a theory. Organizat Behav Hum Perf 1976;16:250-79.  Back to cited text no. 17
Fairbrother G, Jones A, Rivas K. Development and validation of the nursing workplace satisfaction questionnaire (NWSQ). Contemp Nurse 2009;34:10-8.  Back to cited text no. 18
Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm 2009;39:211-9.  Back to cited text no. 19
Jones TL. A descriptive analysis of implicit rationing of nursing care: frequency and patterns in texas. Nurs Econ 2015;33:144-54.  Back to cited text no. 20
Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P. 'Care left undone' during nursing shifts: Associations with workload and perceived quality of care. BMJ Qual Saf 2014;23:116-25.  Back to cited text no. 21
Halvorsen K, Slettebø A, Nortvedt P, Pedersen R, Kirkevold M, Nordhaug M, et al. Priority dilemmas in dialysis: The impact of old age. J Med Ethics 2008;34:585-9.  Back to cited text no. 22
Papastavrou E, Charalambous A, Vryonides S, Eleftheriou C, Merkouris A. To what extent are patients' needs met on oncology units? The phenomenon of care rationing. Eur J Oncol Nurs 2016;21:48-56.  Back to cited text no. 23
Hamid S, Malik AU, Kamran I, Ramzan M. Job satisfaction among nurses working in the private and public sectors: A qualitative study in tertiary care hospitals in Pakistan. J Multidiscip Healthc 2013;7:25-35.  Back to cited text no. 24
Robinson S, Murrells T, Clinton M. Highly qualified and highly ambitious: Implications for workforce retention of realising the career expectations of graduate nurses in England. Human Res Manag J 2006;16:287-312.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3]


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