Depressive symptoms in nurses have been leading to problems, impacting not only nurses’ well-being, but also quality of care and patient safety by diminishing their neurocognitive function [1,2]. The prevalence of depressive symptoms is higher in nurses than in other job groups [3,4] and depressive symptoms are more common among shift-working nurses [5,6], who generally provide direct patient care. Missed nursing care, which is defined as the omission of required nursing care [7] is applied in nursing research as a proxy measurement of direct patient care. In order to examine the impact of depressive symptoms in nurses on direct patient care, a practical step forward would be to examine the differences in missed nursing care based on nurses’ depressive symptoms.

Nurse performance includes patient outcomes affected by the quality of nursing care [8]. Missed nursing care is associated with adverse events in patients [9], and with an increased risk of death post-surgery [10]. Therefore, the causes of missed nursing tasks must be examined and managed carefully.

Researchers have primarily focused on analyzing hospital and unit characteristics associated with missed nursing care [11-13]. Missed nursing care is influenced by structural factors such as nurse staffing [11,14,15], teamwork within nursing [12], and other characteristics of nurses’ practice environment [16]. However, nurses’ personal characteristics are also likely to influence missed nursing care because cognitive factors (e.g., thought processes and decision-making) affect nursing performance [8]. Previous studies have shown that perceived burnout and job dissatisfaction have positive associations with missed nursing care [17,18]. However, because burnout is closely related to the work environment, and results have been reported regarding the relationship between burnout and depression [19,20], it remains necessary to conduct additional research to elucidate the relationship between depressive symptoms and missed nursing care. In previous studies, nurses’ depressive symptoms were negatively correlated with health-promoting behaviors [6] and positively related to sleep disturbance, fatigue, anxiety [21], and occupational stress [3]. Those studies presented the effects of depression on various outcomes in nurses. Of note, employees with depressive symptoms generally take more time off from work [22], whereas only 6.0% of employees working with depressive symptoms had positive results for their performance [22]. Skinner and Scott [4] already assumed that depression would lead to declines in nursing performance because of poor concentration, lowered energy levels, and dysphoric mood, and it was also reported that the depressive symptoms most frequently reported by registered nurses included continual fatigue and trouble concentrating [23]. As depressive symptoms among Korean nurses, job stress, emotional labor, fatigue, anxiety, and anger were reported [21], and globally, diminished energy, decreased concentration, fatigue, and indecision were included [24]. Therefore, nurses with depressive symptoms may have poor function at work due to impairments in cognitive and biological function, which may lead to omissions in nursing practice. Therefore, the aims of this study were to analyze nurses’ depressive symptoms and the degree of missed nursing care, identify nurses’ missed care according to their depressive symptoms, and investigate the causes of nurses’ missed nursing care according to nurses’ depressive symptoms. Through this, it will be possible to identify differences in the nursing care items that are missed between nurses with and without depressive symptoms.

Sample characteristics are presented in Table 1. In total, 184 nurses participated in the study, of whom 39.1% (n=72) had depressive symptoms and 60.9% (n=112) did not. Most of the nurses were women (94.6%). The mean age of participants was 26.54±3.58 years and most of them were unmarried (88.6%). In addition, most of the nurses had a bachelor's degree (88.0%). Fewer nurses with depressive symptoms had a bachelor's or higher degree, but this difference was not statistically significant. Most of the participants worked in the general ward (45.7%) or intensive care unit (25.5%). The BDI-II score showed a statistically significant difference between the depressive symptoms (20.35±5.77) and no-depressive symptom groups (6.71±3.99, p=.004). Furthermore, 21.7% of nurses showed mild depressive symptoms, 13.0% of them showed moderate symptoms, and 4.4% of them showed severe symptoms.

Table 2 presents between-group comparisons of the overall scores and the scores for the 24 items of missed nursing care. Nurses in the depressive symptom group had higher scores, indicating that they missed more nursing care (33.79±9.90) than those in the no-depressive symptom group (30.57±5.83, p=.019). In both groups, the most frequently missed nursing care items were monitoring intake/output, assessing the effectiveness of medications, bathing and skin care, and hand washing, in descending order. The order of missed nursing care items was similar between the depressive-symptom and no-depressive-symptom groups, but there were statistically significant differences between the two groups in the mean scores for vital signs, bedside glucose monitoring, turning patients every 2 hours, emotional support to patients and/or family, skin/wound care, patient discharge planning and teaching, response to call light, and pro re nata (PRN) medication requests acted on. Specifically, the nurses with depressive symptoms tended to report missing some nursing care items more frequently than the nurses without depressive symptoms.

Table 3 presents between-group comparisons of the scores for the 16 items on reasons for missed nursing care. No significant differences were found between the two groups, although the overall scores of labor resources and communication were higher in the depressive-symptom group. The order of the reasons for omitting nursing care was similar between two groups. Specifically, nurses thought that issues involving labor resources were important factors related to missed nursing care.

This study aimed to determine whether differences in nursing practice and associated factors related to missed nursing care existed between nurses with and without depressive symptoms.

The prevalence of depressive symptoms among nurses was 39.1% in this study, which was higher than has been reported for the general population in South Korea using national data (6.1% in the 19∼29 age group) [29]. However, our study showed a lower prevalence of depressive symptoms than was found in a nationwide study of Korean nurses, where 64.8% of nurses reported mild to severe depressive symptoms and most participants were 29 years of age or younger [30]. The prevalence of depressive symptoms reported herein is also higher than the rate of 18% of hospital-employed nurses in the United States [30]. Between-study differences in the prevalence of depressive symptoms might be due to age differences in nurses, as the mean age of our participants was 26.3, whereas it was 44.7 in the United States’ study [30]. Age has consistently been reported as a significant contributor to depression in nurses, with depression being more likely in younger nurses [23]. It is quite plausible that younger nurses, with less work experience, would be more vulnerable to depressive symptoms due to work environment factors such as job-related stress or role overload [31].

Our findings provide further evidence that missed nursing care is common. In previous studies, ambulation, bathing/skin care, turning position, mouth care [11], emotional support, and teaching [32] were the most commonly missed nursing care items. Instead, in our study, monitoring intake/output was the most commonly reported item, followed by assessing the effectiveness of medications and bathing/skin care. Monitoring intake/output and assessing the effectiveness of medications require more cognitive competence than ambulation, bathing, turning, and mouth care. Thus, we can say that the participants in this study omitted tasks requiring higher levels of mental ability, but no significant difference between the depressive symptom and no-depressive symptom groups was found. The discrepancy between our results and those of other studies may be related to differences in the participants, as this study included nurses working in special care units (e.g., the emergency room, intensive care unit, and recovery room), whereas previous studies [11,32] conducted in South Korea only included nurses working in general wards. The tasks required from nurses-and therefore, the tasks they omit-vary across settings, as supported by the findings of Kalisch and Williams [7], who reported that the ranking of missed nursing care items differed depending on the study sample. The priority of nursing tasks in each nursing unit should be investigated in further research. In addition, differences likely exist among nurses depending on the country, culture, hospital policy, patient characteristics, and unit characteristics in terms of perceptions of the scope of work, which could affect nurses’ perceptions of whether they are missing their work. However, this study could not address these potential differences in perceptions. Therefore, future studies should analyze the work environment and characteristics of nurses in greater depth to analyze factors that can affect missed care.

Nurses with depressive symptoms were more likely to miss nursing care than nurses without depressive symptoms. More specifically, nurses with depressive symptoms more frequently missed items related to emotional support, turning positions, skin/wound care, administering PRN medications on time, discharge planning and teaching, responding to the call light, assessment of vital signs, and glucose monitoring. In the depressive symptom group, it is noteworthy that aspects of nursing practice that require extensive conversations with patients were often omitted. The nurses with depressive symptoms were also more likely to omit basic routine nursing tasks, as well as nursing practices requiring critical judgment and quick performance. A study reported that nurses’ depression and the frequency of medication errors was positively correlated [33]. Our findings do not provide information on the direct effects of nurses’ depressive symptoms on patient outcomes; however, they do indicate that missed nursing care might be influenced by nurses’ mental health status. Further studies are needed to explore the direct link between nurses’ depressive symptoms and patient outcomes. The causes of depressive symptoms in clinical nurses and their effect on work performance also require in-depth consideration using various research methods, including nurses in various working environments.

Nurses with depressive symptoms showed higher scores for 10 of the 16 items on reasons for missed nursing care, but the differences were not significant. The depressive symptom group had higher overall scores for two factors (labor resources and communication). The mean score for labor resources was higher than was reported for nurses in the United States, but the scores for material resources and communication were lower [15]. Compared with a previous study conducted in Korea [11], the mean score for labor resources was higher than for high-staffing units and lower than for low-staffing units, while the scores for material resources and communication were lower overall. These findings indicate that nurses with depressive symptoms were more likely to experience inadequate staffing levels and to be unsatisfied with the communication in their units than nurses without depressive symptoms. However, further investigation and interpretation are needed to determine whether these nurses became more depressed while suffering from a lack of adequate nursing staff and communication difficulties at work, or whether nurses with depressive symptoms were more aware of in-sufficient staffing and communication problems. The possibility cannot be excluded that nurses feel lethargy or experience depressive symptoms when they are constantly in an inadequate work environment. Therefore, the results of this study do not enable an explanation of the predecessor and causal relationship between the causes of missed nursing care and depressive symptoms of nurses, for which additional research would be necessary. In addition, considering the results of a previous study [19] that showed an association between higher job stress and burnout among nurses with higher levels of depression, rather than simply approaching nurses’ depressive symptoms as an individual mental problem, it is necessary to approach and manage the accumulated work-related stress and burnout at the organizational and institutional level. As burnout, job stress [20], and inappropriate nurse staffing [9] have been revealed to be factors associated with more frequent missed nursing care, it is necessary to analyze in detail whether personal factors (e.g., depressive symptoms) or institutional factors (e.g., nursing work environment) have a greater impact on missed nursing care.

Since communication involves interaction, it is difficult to find reasons only from the perspective of nurses with depressive symptoms. However, because it was demonstrated that nurses with depressive symptoms missed more nursing practices requiring communication with patients and co-workers, strategies are needed to prevent depressive symptoms of nurses by targeting factors associated with communication failures and missed nursing care. A recent study has demonstrated that social support from colleagues lowers nurses’ depressive symptoms, even in an environment where work demands are high [34]. It is important to focus on the depressive symptoms of nurses themselves and to provide appropriate treatment and prevention.

Short-term and long-term strategies are needed to manage nurses’ depressive symptoms, and these strategies should include mental health promotion programs such as a mental health first aid course, mental health promotion interventions including stress coping, mental health literacy improvement courses, and educational programs to reduce stigmatizing attitudes [35]. It is necessary to recognize the depressive symptoms of nurses as a problem that needs to be managed not at the individual level, but at the organizational, institutional, and even governmental levels. This is because previous studies have already reported that nurses’ accurate job performance is an important factor influencing patients’ health and safety. In particular, the results of this study are significant for nursing research and practice because missed care includes basic nursing (i.e., primary nursing care items mainly performed by clinical nurses). Failure to perform primary care items may not have an impact on patients’ immediate treatment outcomes, but it is necessary to further examine how this will affect nursing performance and patient outcomes in the long term if missing care items accumulate. In this respect, this study was intended to emphasize that nurses’ mental health, in addition to their physical health, is a highly influential factor that constitutes an essential asset for protecting patients’ safety and health.

This study has a few limitations. First, it was conducted among nurses at a single general hospital, the participants were relatively young, and a cross-sectional design was used; therefore, the generalizability of the findings may be limited. Second, since there is a cultural expectation in South Korea for families to participate in basic nursing care for hospitalized patients, South Korean nurses’ perceptions of missed nursing care might be different from those of nurses in other countries. Third, the study data were obtained from a cross-sectional survey, so the relationships among depressive symptoms and missed nursing care do not reflect causal relationships. Fourth, since we used self-report data, the results might not accurately reflect nurses’ true behaviors. Fifth, we tried to control for individual health problems and working environments that might affect depressive symptoms and missed nursing care, but we recommend further studies to conduct a comparative analysis considering more factors that could affect this relationship.

The findings of this study provide further evidence that missed nursing care is common and that nurses with depressive symptoms tend to miss nursing care more often than nurses without depressive symptoms. In addition, differences were found in missed nursing care items between nurses with and without depressive symptoms. As nurses provide health care services to patients close to 24 hours a day, their mental health condition may have implications for patient safety. Therefore, preventing and managing depressive symptoms in nurses is very important, regarding their personal health and job performance. As follow-up research in the future, studies that deal in depth with the causes and experiences of depressive symptoms among nurses are needed. In particular, we suggest conducting qualitative studies that examine the nature of the phenomenon from the perspective of nurses.