Missed nursing care: Testing the moderation-mediation energetic and motivational pathways via a nested design

Aims: To examine: (1) a motivational pathway where head nurse proactive leadership and nurse vigour are linked, which in turn correlates to missed nursing care, and might be moderated by workload; and (2) an energetic pathway where workload and nurse exhaustion are linked, which in turn correlates to missed nursing care, and might be moderated by head nurse proactive leadership. Design: A cross-sectional design, with nurses nested in wards. Methods: During 2018, 196 nurses from 37 wards completed questionnaires that included the 22-item MISSCARE survey; the 6-item Work Demand subscale; the 10-item Proactivity Personality scale; the 5-item Exhaustion subscale of the Maslach Burnout Inventory; the 5-item Vigour subscale of the Work Engagement scale; and nurse's and head nurse's sociodemographic characteristics. Moderation-mediation models were performed using mixed-linear model analyses. Results: A moderation-mediation motivational pathway was supported. Specifically, nurse vigour was higher under low workload when head nurse proactive leadership was high (β = −.09, p =.050), which in turn was associated with lower missed nursing care (β = −.10, p =.045). Yet, a moderation-mediation energetic pathway was not supported. Specifically, nurse exhaustion was lower under low workload when head nurse proactive leadership was high (β =.14, p =.032), but no association was found between exhaustion and missed nursing care. Conclusions: This study shows that there is a significant role for nurse agency and nurse ability to cope with scarce resources. Impact: To date, research has focused mainly on the assumption that missed nursing care is a result of scarce resources. Findings indicate that even under scarce resources, nurses can be motivated to reduce missed nursing care. Emphasis should be placed on promoting and maximizing nurse motivation. This can be achieved by developing and implementing interventions of proactive leadership of head nurses.