Operating Room Nurses’ Experiences of Missed Nursing Care: A Qualitative Study

Background Missed nursing care (MNC) is recognized as a critical threat to patient safety in the operating room (OR), where the clinical environment is high-risk and error tolerance is low. However, there have been few studies that explore the lived experiences of operating room nurses in China who are facing missed nursing care. Methods This qualitative study recruited 15 OR nurses from a tertiary hospital in Anhui Province, China, between February and May 2025, using purposive sampling. Semi-structured interviews were conducted, and data were analyzed with Colaizzi’s seven-step method. Results Contributing factors to MNC included human and material resource shortages, workflow interruptions, patient-related issues, nurse burnout, inadequate collaboration, and OR-specific challenges. Coping strategies were characterized by low reporting willingness, defensive concealment, and reflective thinking. Desired improvements emphasized system optimization, enhanced team collaboration, and targeted training. Nurses highlighted a hierarchical demand for improvements at operational, team, and system levels. Conclusion MNC in the OR results from systemic and contextual interplay, reflecting both individual and organizational challenges. Interventions should focus on strengthening staffing, optimizing workflows, promoting interprofessional collaboration, and establishing a supportive reporting culture. Future multicenter, mixed-method studies are warranted to validate these findings and guide systemic strategies for improving perioperative nursing safety.