The Association Between the Nursing Work Environment and Missed Nursing Care: A Systematic Review and Meta-Analysis.

Abstract

Background/Objectives: Missed nursing care threatens care quality and patient safety and may reflect modifiable organizational conditions. This systematic review and meta-analysis quantified the association between the nursing work environment and missed nursing care. Methods: PubMed, Scopus, Web of Science, and APA PsycInfo via EBSCOhost were searched from inception; searches were updated and finalized on 13 July 2026. Quantitative studies examining nursing work, professional, or practice environments in relation to missed, incomplete, unfinished, omitted, or implicitly rationed nursing care were eligible. The eligibility criteria, primary total-score Pearson correlation analysis, random-effects model with restricted maximum likelihood (REML) estimation, and direction harmonization were specified before inspection of the pooled results. Additional robustness and exploratory analyses were conducted post hoc, including Hartung-Knapp adjustment, leave-one-out and influence analyses, risk-of-bias and instrument-family sensitivity analyses, alternative correlation-metric analyses, meta-regression, and small-study-effect assessments. The review was retrospectively registered in the Open Science Framework on 25 August 2026 (DOI: 10.17605/OSF.IO/J62D3); no prospective protocol was available. Results: Forty studies were included. The primary meta-analysis comprised 15 studies and 7100 participants. A more favorable nursing work environment was associated on average with less missed nursing care (r = -0.301; 95% CI -0.402 to -0.192; p < 0.001; model-based I² = 95.7%). The 95% prediction interval ranged from -0.641 to 0.139 and crossed the null, indicating substantial uncertainty about the magnitude and potentially the direction of the association in a new setting. The association remained statistically significant with Hartung-Knapp adjustment (95% CI -0.411 to -0.182; p < 0.001), and no leave-one-out model changed its direction or statistical significance. Conclusions: On average, a more supportive nursing work environment was associated with less missed nursing care. However, the very high heterogeneity and a prediction interval crossing the null indicate substantial variation across settings. The pooled coefficient therefore represents an average association rather than a universal effect, and the predominantly observational evidence does not establish that modifying the work environment will causally reduce missed nursing care.