Ethical performance predicts missed nursing care in critical and general care settings

Missed nursing care, the omission or delay of essential care, is a silent threat to patient safety, driven by systemic pressures such as understaffing and workload intensity. While organizational factors dominate MNC research, nurses’ ethical performance (observable adherence to professional ethical principles in practice) remains underexplored as a modifiable, protective factor. To examine the association between ethical performance and MNC across high-acuity (intensive care units, ICUs) and general inpatient settings, and to identify setting-specific patterns informing targeted interventions. A multicenter, cross-sectional study was conducted across 41 academic medical centers. A total of 342 registered nurses (171 ICU; 171 general ward) participated via a multistage sampling method where the sample size was allocated proportionally based on the number of eligible hospitals in each city (Tehran: 114 participants from 15 hospitals; Mashhad: 114 participants from 14 hospitals; Isfahan: 114 participants from 12 hospitals). Participants completed validated measures: the MISSCARE Survey and the Nurses’ Ethical Performance Instrument. Analyses included independent t-tests, Pearson correlation, and multilevel linear regression (accounting for ward clustering), with effect sizes and 95% confidence intervals reported. ICU nurses demonstrated significantly higher ethical performance (M = 91.07 vs. 85.69, d = 0.37, p = 0.001) and lower missed nursing care (M = 38.47 vs. 40.33, d = − 0.30, p = 0.007) than general ward nurses. Ethical performance showed a strong inverse correlation with missed care (r = − 0.703, p < 0.001), accounting for 49.4% of variance. In multilevel regression controlling for demographics and ward clustering, ethical performance remained significantly associated with missed care (β = −0.299, p < 0.001), with the model explaining 50.1% of total variance (Conditional R² = 0.501).