Structural Modeling of Patient Safety Culture Based on the Professional Nursing Practice Environment: The Mediating Role of Missed Nursing Care Among Inpatient Nurses

Abstract

Purpose: This study aimed to examine a structural model of patient safety culture based on the professional nursing practice environment, with missed nursing care as a mediating variable among nurses working in inpatient hospital wards.

Methods and Materials: This cross-sectional analytical study was conducted in 2026 among 392 registered nurses working in inpatient wards of Imam Khomeini Hospital Complex, Tehran, Iran. Participants were selected using proportionate stratified random sampling. Data were collected using the Hospital Survey on Patient Safety Culture, the Practice Environment Scale of the Nursing Work Index, the Persian MISSCARE Survey, and a demographic-professional characteristics form. The proposed measurement and structural models were tested using covariance-based structural equation modeling. Model fit was evaluated using χ²/df, CFI, TLI, RMSEA, and SRMR. The indirect effect was examined using bias-corrected bootstrapping with 5,000 resamples.

Findings: The professional nursing practice environment was significantly and negatively associated with missed nursing care (β = −.47, p < .001) and positively associated with patient safety culture (β = .41, p < .001). Missed nursing care was negatively associated with patient safety culture (β = −.34, p < .001). The indirect association between the professional nursing practice environment and patient safety culture through missed nursing care was statistically significant (β = .16, 95% bootstrap CI [.11, .22], p < .001), indicating partial mediation. The structural model demonstrated acceptable fit (χ²/df = 2.22, CFI = .948, TLI = .941, RMSEA = .056, SRMR = .049) and explained 46% of the variance in patient safety culture.

Conclusion: A more favorable professional nursing practice environment was associated with stronger patient safety culture both directly and indirectly through lower levels of missed nursing care. Improving staffing and resource adequacy, nursing leadership, interdisciplinary collaboration, and nurses’ participation in organizational decision-making may reduce missed nursing care and strengthen patient safety culture. Longitudinal and multicenter studies are recommended to further examine the temporal and causal relationships among these variables.