6th Edition of World Nursing Science Conference 2026

Abstract

Background: Ethical nursing practice is commonly conceptualized as an individual professional attribute; however, the extent to which ethical commitments can be translated into completed bedside care may depend substantially on the clinical environment. Care omissions therefore provide an important lens through which to examine whether ethical agency operates similarly across high-acuity and general inpatient settings. This study examined contextual patterns underlying the relationship between nurses' ethical enactment and omitted nursing care, with particular attention to ward type, geographical consistency, and the relative contribution of individual nurse characteristics.
Methods: Data were obtained from a multicenter cross-sectional study involving 342 registered nurses from 41 university-affiliated hospitals in three metropolitan regions. The sample was equally distributed between intensive care units and general medical-surgical wards. Ethical enactment was assessed using the Nurses' Ethical Performance Questionnaire, while omitted or delayed essential nursing activities were measured using the Persian-adapted MISSCARE Survey. Clinical-setting comparisons were undertaken alongside correlation analysis and multilevel linear regression accounting for ward-level clustering and demographic and professional characteristics.
Results: A distinctive setting-related pattern emerged. Nurses working in intensive care units demonstrated higher ethical performance than those in general wards (91.07 vs 85.69; mean difference 5.38; p=0.001; Cohen's d=0.37), while simultaneously reporting lower missed nursing care (38.47 vs 40.33; mean difference -1.86; p=0.007; d=-0.30). In contrast, ethical performance and missed care showed negligible variation across the three participating cities, suggesting that the observed patterns were not primarily geographically driven. Ethical performance was strongly inversely correlated with missed care (r=-0.703, p<0.001) and remained the only significant individual-level predictor in the adjusted multilevel model (beta=-0.299, p<0.001). Age, work experience, sex, educational attainment, work shift, and city were not independently associated with omission frequency. The model explained approximately half of the observed variance, while 49.9% remained unexplained, indicating substantial influence from factors not captured by individual characteristics alone.
Conclusion: The findings suggest that ethical nursing practice should not be interpreted solely as an individual competency. The coexistence of stronger ethical enactment and fewer omissions in intensive care settings, together with the absence of meaningful demographic or geographical effects, raises the possibility that organizational conditions influence nurses' capacity to convert ethical commitments into completed care. Rather than relying exclusively on ethics education directed at individual nurses, future research should test integrated approaches that combine ethical-development interventions with modifiable structural supports, including appropriate staffing, protected time for essential care, supportive leadership, and psychologically safe clinical environments.
Keywords: ethical agency; missed nursing care; care omission; nursing ethics; organizational context; patient safety; intensive care nursing