In February 2024, in response to government plans to expand medical school admissions in South Korea, physician-led collective actions resulted in widespread surgical cancellations and outpatient service delays at tertiary hospitals [1], as well as disruptions to the emergency department operations [2]. The government subsequently sought to mitigate disruptions in healthcare delivery by directing patients with mild or non-emergency conditions to general hospitals [3]. As tertiary hospitals reduced their elective services and capacity, general hospitals were increasingly required to absorb a broader range of patients, thereby contributing to the congestion in outpatient and inpatient care. These measures shifted a substantial volume of patient care to hospitals where staffing and resources were relatively limited. In 2024, inpatient bed utilization in these hospitals increased by 4.9% year-over-year, whereas the nursing workforce grew by only 0.6% compared to the previous quarter [4,5]. Nurse staffing is largely determined by the licensed bed capacity, which limits rapid workforce expansion during this period. This imbalance between patient demand and staffing capacity exacerbates nursing shortages and places an additional burden on nurses. Staffing shortages pose a significant threat to patient safety and the quality of nursing care [6], further underscoring the importance of systematically examining and managing missed nursing care (MNC).

MNC is defined as an essential nursing activity that is delayed, partially completed, or omitted owing to resource constraints, which are sensitive indicators of patient safety risk [6]. In Kalisch's MNC model, MNC occur when care demands exceed available resources or when relationship and communication problems constrain care delivery and nurses' internal processes, including team norms, priority decision making, internal values and beliefs, and habits in which care is delayed or omitted [7]. Previous studies have demonstrated that MNC are influenced by a combination of organizational factors, such as the nursing work environment, levels of staffing and material resources, teamwork, and communication, as well as nurses' psychosocial characteristics, including self-efficacy [7-9]. Additionally, the nursing work environment has been identified as a key structural factor influencing how nurses prioritize nursing activities under constrained conditions [10]. When this environment is suboptimal, nurses are more likely to selectively omit or delay certain nursing activities owing to time constraints and excessive workload, thereby increasing the likelihood of MNC [8].

Beyond structural factors, nurses' psychosocial attributes, including communication competencies, have been recognized as internal mechanisms that mitigate the effects of MNC. Patient-centered communication—regarded as a core element of high-quality nursing care—refers to an interactive process that respects patients' values and preferences, clearly conveys treatment-related information, and facilitates shared decision-making [11]. Nurses with high patient-centered communication competence are more likely to establish trusting relationships with patients and accurately identify patient needs, thereby streamlining care processes and reducing unnecessary delays [12]. Occupational coping self-efficacy (OCSE) refers to an individual's belief in their ability to manage job-related stressors effectively. For nurses, this includes confidence in managing both occupational burden and relational difficulties encountered in clinical practice [13]. Nurses with greater self-efficacy may be better able to mitigate stress and actively engage in behaviors that promote patient safety, even under demanding workloads [9].

Nurses with a robust professional identity are more likely to internalize the core values of nursing and recognize the essence of care. Professional identity reflects nurses' perceptions of their professional roles, responsibilities, and ethical standards, and serves as a value-based framework guiding prioritization in practice [14]. This value-based framework allows them to engage in patient care more actively and prioritize safety-critical activities, even under constrained clinical conditions [14,15]. Accordingly, professional identity may be considered as a factor that reduces the likelihood of MNC.

While previous studies have primarily focused on structural factors, such as staffing levels, workload, time pressure, material resources, and the nursing work environment, research that integrates psychosocial factors, including patient-centered communication, OCSE, and professional identity, remains scarce [8]. In general hospital settings, where task complexity increases amid limited staffing, these psychosocial factors may function as critical internal mechanisms [7]. However, empirical research examining these relationships among nurses in general hospitals is limited. Accordingly, this study comprehensively examined the associations of the nursing work environment, patient-centered communication, OCSE, and professional identity with MNC among nurses working in general hospitals. Understanding the combined influence of structural and psychosocial factors in MNC may support the development of evidence-based nursing education and quality improvement initiatives.

We investigated the level of MNC among nurses in general hospitals within the unique context of the 2024 physician collective action and explored the associations of the nursing work environment, patient-centered communication, occupational coping self-efficacy, and professional identity with MNC. Our findings offer a foundation for the development of educational interventions aimed at preventing MNC.

The levels of MNC and patient-centered communication were comparable to those in previous reports [22,23], whereas perceptions of the nursing work environment and professional identity were relatively low [24,25]. In the context of an increased workload and deteriorating work conditions, nurses' professional values that prioritize patient safety and essential care help explain the variations in MNC [7,26]. Meanwhile, patient-centered communication may remain relatively stable because it is driven more by internal attitudes than by fluctuating environmental factors [11]. The nursing work environment score fell below the 2.5 cutoff, which indicates an "unfavorable" status [27], likely due to the surge in patient volume during the medical crisis and chronic staffing shortages. Consistent with this, our nursing work environment score (2.26±0.67) was lower than that reported among general-hospital nurses before the 2024 physician collective action (2.56±0.55) [28], suggesting that the crisis context may have amplified negative perceptions of the work environment. Lower professional identity may be linked to the participants' younger average age and shorter clinical experience compared to previous reports [25]. Conversely, occupational coping self-efficacy is relatively high, suggesting that nurses employ adaptive strategies such as enhancing collegial communication to maintain efficiency under pressure [8].

MNC was significantly higher among unmarried and staff nurses, further aligning with previous research in general hospitals [29]. However, as unmarried nurses are generally younger, this may reflect age-related factors. Consistent with a previous study [30], staff nurses reported more missed care than charge nurses, likely because those in higher positions had more prioritization experience. Given the small married and charged nurse subsample, marital status- and position-related differences should be interpreted cautiously. MNC were positively and negatively correlated with overtime hours and total clinical experience, respectively. The negative association with clinical experience suggests that less experienced nurses struggle with multitasking and complex prioritization [29].

Multiple regression analysis identified overtime hours, nursing work environment, patient-centered communication, and professional identity as predictors of the MNC. This finding is consistent with reports indicating that working hours increased and overtime normalized during the 2024 medical workforce shortage compared with prior periods [31]. The link between overtime and MNC corroborates systematic reviews [10] as prolonged hours deplete the cognitive energy required for effective task prioritization. Consistent with previous research [22], the nursing work environment was identified as a significant factor influencing the MNC. During the 2024 medical crisis, general hospitals absorbed a surge of patients redirected from tertiary hospitals, whereas nurse staffing levels remained constrained by licensed bed capacity standards. Such structural strain may also weaken nurse manager leadership and coordination in complex clinical situations [32], further intensifying time pressure and increasing the likelihood of delays or omissions in nursing care [7,33]. Therefore, a poor environment directly undermines nurses' abilities to fulfill their essential care duties.

Patient-centered communication has emerged as a significant factor that influences MNC. While few studies have directly tested this factor, communication skills are consistently linked to overall nursing performance [24]. Through active listening, open-ended questions, and empathy, nurses can accurately identify patients' priorities and emotional needs [12], thereby reducing redundant tasks, enhancing patient cooperation, and minimizing missed nursing care [32]. For example, attentive listening can help nurses detect unspoken concerns and clarify patients' understanding, which supports the timely delivery of care that is frequently missed under time pressure, such as emotional support, discharge teaching, and the assessment of medication effects.

Professional identity has been identified as a significant predictor of MNC. Although direct evidence is scarce, previous research has demonstrated that professional identity is positively associated with patient safety attitudes and caring behaviors [34]. Weak identity may diminish intrinsic motivation and the sense of responsibility required to complete essential nursing activities, rendering it more challenging for nurses to prioritize tasks and fulfill caring roles [15,26]. Furthermore, professional commitment, as a core component of professional identity, has been associated with lower levels of missed care [14,35]. However, considering this study's cross-sectional design, MNC are unlikely to be explained by intrinsic motivation alone, and instead likely reflect the combined influence of individual and work-related factors.

Occupational coping self-efficacy was significantly correlated with MNC but did not emerge as a significant predictor in the regression analysis. Considering its strong correlation with patient-centered communication (r=.58) and moderate association with professional identity (r=.33) and nursing work environment (r=.35), its explanatory power was likely attenuated after adjustment for these related factors. These findings suggest that occupational coping self-efficacy is more likely to influence missed nursing care indirectly through communication behaviors and professional values, rather than exerting an independent effect. Occupational coping self-efficacy is associated with the ability to cope with relational difficulties involving colleagues and other healthcare workers [13], which enhances communication and collaboration in clinical interactions [11]. The relatively strong correlation with the nursing work environment also indicates a conceptual overlap with teamwork-related aspects [20]. However, the actual completion of nursing tasks was more directly influenced by structural conditions and internalized professional values, which may account for the lack of significance in the final model.

During the 2024 medical crisis, patient volumes decreased in tertiary hospitals but increased in general hospitals, shifting the care burden to settings with relatively limited staff. Although limited emergency support measures were introduced at the government level, corresponding compensation or institutional support, such as overtime pay or professional development opportunities, were not sufficiently available in the present study setting. Considering the established association between inadequate staffing, increased workload, and missed nursing care [7,33], government-level support and compensation systems for nurses in general hospitals are likely essential for mitigating missed nursing care during future healthcare disruptions. This study had several limitations. First, the participants were recruited through convenience sampling from a single general hospital in one region, thereby limiting the generalizability of the findings. Second, the limited empirical evidence on the relationship between MNC and occupational coping self-efficacy restricts the interpretation of its role as an influencing factor. Accordingly, future research should include nurses from diverse general hospital settings and examine a broader range of variables to better elucidate the factors associated with MNCs. Third, because backward stepwise regression is data-driven, the final model may not fully reflect the theoretical assumptions and may be susceptible to overfitting. Therefore, these findings should be interpreted with caution, and future studies using theory-driven or confirmatory approaches are warranted.

Despite these limitations, overtime hours, the nursing work environment, patient-centered communication, and professional identity were identified as significant factors, accounting for 47.4% of the variance in MNC among general hospital nurses. These findings add to the literature by highlighting the roles of professional identity and patient-centered communication in MNC. Interventions targeting these factors may help reduce MNC and maintain the quality of nursing care in general hospital settings, where workforce expansion is limited.

This study examined the factors associated with MNC among general hospital nurses. Increased overtime, an unfavorable work environment, and lower levels of patient-centered communication and professional identity were associated with higher levels of missed nursing care. Although clinical experience and occupational coping self-efficacy were negatively correlated with MNC, these were not associated with MNC in the multiple regression analysis. Based on these results, structural improvements should be made to reduce overtime and enhance the work environment, along with organizational strategies to bolster nurses' professional identities and patient-centered communication competencies.