Iran Journal of Nursing

Introduction
Job burnout is a serious challenge for healthcare providers, which can affect their performance. This multidimensional phenomenon encompasses emotional exhaustion, depersonalization, and reduced personal accomplishment. Emotional exhaustion refers to the physical and mental drain resulting from job-related pressures, leading to emotional depletion. Depersonalization involves negative and callous responses to or emotional detachment from various aspects of the job. Reduced personal accomplishment manifests as diminished feelings of competence and success in one’s job.
Nurses experience high levels of job burnout due to factors such as heavy workloads, emotional stress, fatigue, workplace stressors, and the multifaceted challenges of patient care. It has negative consequences for their personal and professional lives. Previous studies have shown that job is inversely related to mental health and can lead to disorders such as depression and anxiety. Furthermore, job burnout is directly associated with cardiovascular, musculoskeletal, and gastrointestinal disorders, reducing overall quality of life. It can lead to a noticeable decline in nurses’ job performance, resulting in decreased quality of patient care, increased medication errors, higher rates of hospital-acquired infections, patient safety threats, increased occurrence of adverse events, patient dissatisfaction, and a greater likelihood of patients leaving the hospital.
Previous studies have shown a negative association between job burnout and the quality of nursing care. One concept relevant to nursing care quality is missed nursing care. Missed nursing care refers to the care that is forgotten, such as attention to oral hygiene, emotional support, and education of patients. This phenomenon is associated with decreased patient satisfaction, worsened patient outcomes, increased side effects (such as infections), and longer hospital stays. Kalisch and Williams categorized the reasons for missed nursing care into three domains: communication, material resources, and human resources. Based on previous research, human resources play the most significant role in missed nursing care. 
Studies in various countries have explored the relationship between missed nursing care and job burnout, but there are limited studies in Iran, creating a research gap in this area. The prevalence of job burnout and missed nursing care are different in different countries, necessitating further examination. Therefore, this study aims to explore the association between job burnout and missed nursing care among nurses in selected hospitals in Tehran, Iran.

Material and Methods
This descriptive-analytical study was conducted on 194 nurses working at Imam Khomeini and Shariati hospitals affiliated with Tehran University of Medical Sciences in 2024. The inclusion criteria were consent to participate in research, at least a bachelor’s degree in nursing, and at least 6 months of work experience. Exclusion criteria were non-response to more than 10% of the questions. Sampling was performed using the convenience sampling method. Data were collected using electronic and printed questionnaires including (a) Demographic form which surveys age, work experience, gender, marital status, educational level, and the type of department, (b) the Maslach burnout inventory (MBI) with 22 items rated on a seven-point Likert scale from 0 (never) to 6 (always), and three subscales: Emotional Exhaustion (9 items), Depersonalization (5 items), and Personal Accomplishment (8 items), (c) Kalisch’s missed nursing care scale with 24 items rated on a four-point Likert scale as 1=Rarely missed, 2=Occasionally missed, 3=Frequently missed, and 4=Always missed (The total score ranges from 24 to 96, with higher scores indicating more missed nursing care). Data were analyzed in SPSS software, version 26. Descriptive statistics (mean, standard deviation, Percentage, and frequency) and inferential statistics (Independent T-test, Pearson correlation test, ANOVA, and multiple linear regression analysis) were used for data analysis. The significance level was set at 0.05.

Results
The mean scores for the subscales of MBI, including emotional exhaustion, depersonalization, and personal accomplishment, were 32.44±10.70, 18.76±4.14, and 29.91±7.10, respectively. The mean score of missed nursing care was 35.78±2.67. The results showed no significant difference in job burnout and missed nursing care scores based on demographic variables (P>0.05). No significant relationship was found between job burnout and age or work experience (P>0.05). 
Pearson correlation test results revealed a significant direct relationship between the subscales of MBI and missed nursing care (P<0.001). The highest and lowest correlations were for the MBI subscales of emotional exhaustion (r=0.608, P<0.001) and depersonalization (r=0.301, P<0.001), respectively.
The results of regression analysis showed that emotional exhaustion (β=0.62), depersonalization (β=0.30), and personal accomplishment (β=0.34) were significant predictors of missed nursing care (P<0.001). They predicted 58% of the variance in missed nursing care.

Conclusion
There is no significant relationship between nurses’ job burnout and their age or work experience.  There is no significant difference in nurses’ job burnout based on demographic variables, including gender, marital status, educational level, and type of department. Based on these demographic variables, there is no significant difference in nurses’ missed nursing care, either.  There is a significant positive correlation between nurses’ job burnout and missed nursing care. Job burnout domains, including emotional exhaustion, depersonalization, and personal accomplishment, are the predictors of missed nursing care, where the emotional exhaustion domain is the strongest predictor. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of the Tehran University of Medical Sciences (Code: IR.TUMS.FNM.REC.1402.219). After explaining the study objectives to the participants and ensuring their confidentiality, their informed consent was obtained.

Funding
This study was funded by Tehran University of Medical Sciences.

Authors' contributions
Data Collection: Mehdi Jafari; Data Analysis: Mohammad Mehdi Rajabi; Conceptualization and final Approval: All Authors.

Conflict of interest
According to the authors, there were no conflicts of interest.

Acknowledgments
The authors would like to thank the Deputy for Research of the Faculty of Nursing and Midwifery at Tehran University of Medical Sciences for the financial support and all nurses who participated in this study.


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