Introduction

Nursing quality, defined as excellence in care whereby nurses provide patients with individualized and appropriate attention (Liu, 2014), is crucial in healthcare. It directly impacts patient outcomes and safety indicators, such as mortality, patient satisfaction falls, hospital-acquired infections, and medication administration errors, which collectively serve as important markers of a hospital’s performance (McHugh and Stimpfel, 2012; Tvedt et al. 2014; Yu et al. 2021). In addition, improving nursing quality not only enhances professionalism (Kim et al. 2003) but also builds trust in the nursing profession among patients, healthcare managers, and medical staff (Shin et al. 2017).

Several factors influence nursing quality, including the individual capabilities of organizational members, the physical environment, nursing organizational culture, and hospital policies (Klopper et al. 2012). Among these, nursing organizational culture stands out as a key factor, enabling efficient organizational management through shared values and behaviours among nurses to achieve the organization’s goals (Shin et al. 2017; Srimulyani and Hermanto, 2022). A positive nursing organizational culture, characterized by behaviour patterns, norms, and expectations that positively shape members’ thoughts and actions (Kim and Kim, 2021), enhances job satisfaction, self-development, and proactive job performance at the individual level, while at the organizational level it leads to more effective delivery of high-level medical services (Yom et al. 2014).

Care is fundamental to nursing (Coates, 2002). The Quality Caring Model by Duffy and Hoskins (2003) provides a comprehensive framework that encompasses four caring relationships—self, patients and families, each other, and communities—along with various caring factors like encouraging manners, mutual problem solving, affiliation needs, a healing environment, and human respect (Edmundson, 2012). Understanding the relationship between care and nursing practice, and its impact on nursing outcomes, is critical for expanding knowledge in the field and demonstrating the significance and value of care (Kim et al. 2016). Caring behaviours among nurses are crucial, as they directly influence the quality of patient care (Labrague, 2021). Moreover, caring and helping behaviours within the organization foster interdisciplinary collaboration and facilitate conflict resolution, convey positive energy, and promote personal growth and self-realization, which in turn enhances patient recovery and satisfaction (Kong, 2007; Jeong, 2023). These caring behaviours can contribute to improving the quality of nursing care by encouraging job satisfaction and the retention of experienced nurses who are capable of providing high-quality care (Boykin and Schoenhofer, 2013; Kim, 2006; Longo, 2009).

In a hospital setting, organizational health reflects effective functioning and adaptability (Lee and Jung, 2017). A healthy organization fosters emotional bonds among its members, facilitates adaptation to the environment, and encourages active engagement in tasks (Han and Jung, 2017). Managing organizational health is a powerful strategy for enhancing personnel management efficiency, particularly in healthcare organizations where it plays a vital role for nurses (Lee, 2015). Studies suggest that nurses who perceive their hospital as healthy are more engaged in their duties, which in turn improves patient safety and the quality of nursing care provided (Han and Jung, 2017). Positive interactions within the organization, such as a nursing organizational culture that promotes cooperation and satisfaction, along with caring and supportive behaviours, contribute to the improvement of organizational health (Lee, 2015). Thus, it follows that a supportive work environment is a critical factor influencing the provision of quality nursing care (Lake et al. 2016; Luxford et al. 2011).

Given the integral role of organizational health in enhancing nursing quality, it is anticipated to mediate the relationship between positive nursing organizational culture, caring behaviours, and nursing care quality. Through previous research, the quality of nursing care has been associated with various factors, such as nurses’ work engagement (Wei et al. 2023), nurse staffing, missed care and adverse events (Nantsupawat et al. 2022), workload and job satisfaction (Maghsoud et al. 2022; Yu et al. 2021; Khan and Muhammad, 2022), occupational fatigue and individualized nursing care (Cho et al. 2022), nurses’ turnover intentions and job satisfaction (Al Sabei et al. 2020; Yu et al. 2021), workplace incivility and patient safety outcomes (Cho et al. 2020), and nursing work environment as well as job burnout (Al Sabei et al. 2020; Khan and Muhammad, 2022). Despite the identified associations between various factors and nursing care quality, there has been limited exploration of the specific relationships between positive nursing organizational culture, caring behaviours, and nursing care quality. Additionally, studies on the mediating effects of hospital organizational health in these relationships are scarce.

Literature review for the framework development

Positive nursing organisational culture

A positive organizational culture, specifically within nursing organizations, is characterized by an environment that prioritizes employee recognition, fosters development, and empowers nurses to perform at their highest capabilities (Parent and Lovelace, 2015). This culture promotes learning, inclusion, and well-being among employees, aligning with the organization’s core values and goals. In nursing, a positive organizational culture is reflected in the behavioural patterns, norms, and expectations that positively influence nurses’ thinking and actions, creating a healthy work environment conducive to professional autonomy and collaborative relationships with other healthcare professionals (Mrayyan, 2019; Yom et al. 2014). Positive interactions within the organization, such as a nursing organizational culture that promotes cooperation and satisfaction, along with caring and supportive behaviours, contribute to improving organizational health (Lee, 2015). This positive culture is not just a supportive backdrop but is crucial for improving healthcare quality. Flexible organizational cultures that adapt to changing conditions and support nursing management practices have been shown to enhance the quality of nursing care (Bernardes et al. 2020). Studies have demonstrated a close relationship between positive nursing organizational culture and outcomes such as productivity, job satisfaction, and reduced turnover intentions among nurses (Aiken et al. 2002; Choi et al. 2014). Moreover, fostering a positive nursing organizational culture has been linked to maintaining high-quality nursing performance and sustainability in nursing tasks (Park et al. 2014). Therefore, positive nursing organizational culture is closely related to hospital organizational health and caring behaviour among colleagues, ultimately enabling the provision of high-quality nursing care.

Caring behaviour

Caring behaviour in nursing is the technical act of assisting individuals through protective actions that demonstrate concern for their needs, well-being, and survival (Leininger, 1985). This behaviour is vital in nursing as it forms the basis of the nurse-patient relationship and contributes to the overall quality of care provided. Caring behaviour extends beyond interactions with patients; it includes relationships with other nurses, nursing managers, and colleagues (Kong and Kim, 2017). Acts of caring within a nursing team can enhance patient care competencies, reduce stress, and alleviate conflicts among nurses (Longo, 2011). Therefore, caring behaviour is expected to play a role in creating a healthy organization.

Caring behaviour also plays a significant role in determining the quality of nursing care, which is a standard measure of the value and effectiveness of nursing practice (Kim and Park, 2014). Research indicates that caring behaviours, particularly from first-line nurse managers, promote professional growth and job satisfaction among nurses, ultimately leading to improved patient care (Peng et al. 2015; Putra et al. 2021). Peer support and caring behaviours among nursing staff have been shown to reduce job stress and increase job commitment, thereby mitigating the negative impacts of high turnover rates on organizational efficiency and nursing care quality (AbuAlRub, 2004; Longo, 2009; Kong and Kim, 2017). Thus, strategies that promote caring behaviour are essential for maintaining a high quality of nursing care.

Hospital organisational health

Hospital organizational health refers to the overall well-being and functionality of a hospital as perceived by its members, particularly nurses. This concept is similar to the health of an individual, encompassing both physical and mental aspects (Quick et al. 2007). A healthy organization is characterized by high productivity, performance, and the ability to maintain competitiveness (Keller and Price, 2011). In a hospital setting, organizational health involves creating a conducive environment that supports adaptation to work and fosters positive, collaborative relationships among staff (Kim and Yu, 2011). Therefore, it can be understood that hospital organizational health is closely related to a positive nursing organizational culture and caring behaviours among colleagues.

The health of a hospital organization is crucial for achieving its goals, particularly in providing high-quality nursing care. Healthy hospital organizations are more likely to engage in open cultural changes that enhance patient safety, reduce nursing errors, and improve overall healthcare quality (Brittain and Carrington, 2021). Moreover, hospital organizational health is significantly influenced by the quality of relationships within the organization. Strong teamwork and supportive relationships between managers and colleagues are essential for maintaining organizational health, particularly in rapidly changing hospital environments (Hadian et al. 2023; Hussein, 2014). These supportive relationships contribute to better organizational performance, patient safety, and nursing quality.

Relationships between the three concepts

The literature indicates that there are interrelated and potentially overlapping relationships between positive nursing organizational culture, caring behaviour, and hospital organizational health. A positive nursing organizational culture sets the foundation for caring behaviours by creating an environment that supports and values these behaviours. In turn, these caring behaviours contribute to the overall health of the hospital organization by promoting job satisfaction, reducing stress, and enhancing the quality of care provided. The health of the hospital organization, as perceived by its members, acts as a mediating factor that can amplify or diminish the effects of the nursing culture and caring behaviours on the quality of nursing care. Understanding the overlapping nature of these concepts is crucial for the development of a persuasive mediation model. The positive organizational culture and caring behaviours within nursing do not operate in isolation; they collectively contribute to the health of the hospital organization, which in turn influences the quality of nursing care. This integrative approach provides a more comprehensive understanding of how these factors interact to impact nursing outcomes.

The objectives of the current study were to explore the relationship between positive nursing organizational culture, caring behaviour, and quality of nursing care, and to examine the mediating role of hospital organizational health between the positive nursing organizational culture, caring behaviour, and nursing care quality. Based on the proposed pathways, along with the results of previous studies, it was hypothesized that (Fig. 1):

  1. 1.

    Positive nursing organisational culture and caring behaviour would be associated with hospital organisational health;

  2. 2.

    Positive nursing organisational culture and caring behaviour, and hospital organisational health would be associated with quality of nursing care; and

  3. 3.

    Hospital organisational health could serve as a mediating factor between a positive nursing organisational culture, caring behaviour, and the quality of nursing care.

Fig. 1: Research framework of positive nursing organizational culture, caring behaviour towards quality of nursing care.
figure 1

Positive nursing organizational culture, caring behaviour influence quality of nursing care through hospital organizational health plays a moderating role.

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Methods

Participants

Nurses who worked at a tertiary general hospital in City C, South Korea, were targeted. The sample size was determined via the software G-Power version 3.1.9.4 (Faul et al. 2009). A multiple regression analysis was employed with a medium effect size (f2) of 0.15 (Cho, 2022), significance level (α) of 0.05, and power (1-β) of 0.80. Based on 28 input explanatory variables (general characteristics including dummy variables, positive nursing organisational culture, caring behaviours, and hospital organisational health), the minimum sample size was 181. We considered a potential dropout rate of approximately 5–10% during data collection. Hence, 200 participants were randomly selected and surveyed via questionnaires. Collected data comprised 196 responses (recovery rate: 98%). After six unreliable responses were excluded, 190 responses were analysed. Data were collected via self-administered questionnaires between 2022 and 2023. The researcher distributed the questionnaires directly and explained the study’s purpose, data collection procedures, participants’ anonymity and confidentiality, voluntary nature of participation, and right to withdraw consent. Completed questionnaires were sealed in individual envelopes to maintain anonymity and collected directly by the researcher.

Measurements

General characteristics

We obtained data on 15 variables that reflected nurses’ demographic and sociological characteristics, such as gender, age, educational level, and clinical career.

Positive nursing organisational culture

The Positive Nursing Organizational Culture (PNOC) scale, created by Kim and Kim (2021), included four factors and 26 items: pursuit of common values (seven items), formation of organisational relationships based on trust (eight items), a fair management system (four items), and positive leadership of the nursing unit manager (seven items). PNOC refers to the behaviours, norms, and expectations that positively influence the thoughts and actions of nursing organization members (Kim and Kim, 2021). Each item was rated on a 5-point Likert scale that ranged from ‘Strongly Agree (5)’, ‘Agree (4)’, ‘Neutral (3)’, ‘Disagree (2)’, to ‘Strongly Disagree (1 point)’. A higher score indicated a stronger positive perception of the nursing organisational culture. Cronbach’s alphas (reliability) were α = 0.95 in the original study describing the scale (Kim and Kim, 2021) and 0.97 in the current study.

Caring behaviour

The modified and validated Korean versions of the Organizational Climate of Caring Questionnaire (OCCQ) (Longo, 2009) and Peer Group Caring Interaction Scale (PGCIS) (Hughes, 1998) known as the Organizational Climate of Caring Scale (OCCS) and PGCIS-K (Peer Group Caring Interaction Scale-Korean), respectively, were used. These have been validated by Kong and Kim (2017).

The OCCS, a tool to measure nursing managers’ caring behaviours within a nursing unit organisation, was structured into four factors with 17 items: modelling (seven items), dialogue (three items), practice (four items), and confirmation (three items). Each item was rated on a 6-point Likert scale that ranged from ‘Always True (6)’, ‘Often True (5)’, ‘Usually True (4)’, ‘Sometimes True (3)’, ‘Rarely True (2)’, to ‘Never True (1 point)’. A higher score indicated a more positive perception by nurses of nursing managers’ caring behaviours. Cronbach’s alphas were 0.98 (Longo, 2009) and 0.98, (Kong and Kim, 2017) in previous studies, and 0.98 in the current study.

The PGCIS-K, a tool to measure caring behaviours among peer nurses within a nursing organisation unit, was structured into two factors with 16 items: modelling (nine items) and providing assistance (seven items). Each item was rated on a 6-point Likert scale that ranged from ‘Always True (6)’, ‘Often True (5)’, ‘Usually True (4)’, ‘Sometimes True (3)’, ‘Rarely True (2)’, to ‘Never True (1 point)’. Higher scores indicated a more positive perception of caring behaviours among peer nurses. Cronbach’s alphas were 0.94 at the time of development (Hughes, 1998), 0.95 in a more recent study (Kong and Kim, 2017), and 0.98 in the current study.

Hospital organisational health

We utilised the Hospital Organizational Health (HOH) measurement tool, developed by Kim and Yu (2014). It was modified and complemented by Lee and Jung (2017) for nursing organisations.

Hospital organizational health refers to the perceived suitability and well-being of the organization as experienced by clinical nurses within the hospital (Lee and Jung, 2017).

The tool comprised four factors with 31 items: environmental fit (eight items), workflow fit (nine items), vitality (eight items), and community orientation (six items). Each item was rated on a 5-point Likert scale that ranged from ‘Strongly Agree (5)’, ‘Agree (4)’, ‘Neutral (3)’, ‘Disagree (2)’, to ‘Strongly Disagree (1 point)’. A higher score indicated a higher perception of organisational health by the hospital. Cronbach’s alphas were 0.96 in the original study describing the tool (Kim and Yu, 2014), 0.94 for the modified version (Lee and Jung, 2017), and 0.97 in the current study.

Quality of nursing care

We utilised the nurse-reported Quality of Care (QNC) measurement tool developed by Havaei et al. (2019), which was translated into Korean by the researcher and a nursing professor. Following the translation, the items’ meaning and understanding were validated by three registered nurses with over 20 years of experience and master’s degrees or higher qualifications. The QNC refers to the extent to which nurses provide appropriate care that meets the patient’s needs, leading to the achievement of the patient’s health goals and excellence in the level of care provided. The tool comprised 4 items. Each item was rated on a 4-point Likert scale that ranged from ‘Very High Level (4)’, ‘High Level (3)’, ‘Low Level (2)’, to ‘Very Low Level (1 point)’. Higher scores indicated a higher perception of nursing quality. Cronbach’s alphas were 0.80 in the original study describing the tool (Havaei et al. 2019) and 0.87 in the current study.

Data analysis

Data were analysed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive analyses, which included frequency, percentage, mean, and standard deviation, were performed for the participants’ general characteristics, PNOC, CB, HOH, and QNC results. Differences were analysed via independent samples t-tests and one-way analysis of variance (ANOVA), with Scheffé’s post-hoc tests conducted where applicable. Pearson’s correlation coefficients were calculated to examine the correlations among variables. A hierarchical linear regression was used to analyse the factors that influenced the quality of nursing care. Multiple regression analysis, based on Baron and Kenney’s (1986) three-step technique, was conducted to examine the mediating effect of hospital organisational health on the relationship between positive nursing organisational culture, caring behaviour, and nursing quality. The significance of the mediation effect was assessed using a 95% bootstrapped confidence interval (CI) with 5000 bootstrap replications. The indirect effect is considered as significant if the zero is not included in the 95%CI.

Results

Nurses’ general characteristics and differences in quality of nursing care according to participants’ characteristics

Table 1 presents the nurses’ general characteristics and differences in quality of nursing care according to the participants’ general characteristics. Before differences in quality of nursing care according to the participants’ characteristics were analysed, a normality check confirmed that data were normally distributed. Characteristics that showed differences in the QNC scores were age (F = 3.71, p = 0.013), department of work (F = 6.07, p < 0.001), current hospital work experience (F = 3.50, p = 0.017), total clinical experience (F = 4.83, p = 0.003), nursing job satisfaction (F = 11.19, p < 0.001), department satisfaction (F = 33.07, p < 0.001), intention to leave (t = −2.53, p = 0.012), and the level of job stress (F = 8.35, p < 0.001). Regarding age, those under 25 years showed higher nursing quality than those aged 25–29 and 30–34 years. Regarding the department of work, nursing quality was higher in the neonatal intensive care unit (NICU) and nursery compared to the intensive care unit (ICU) and emergency room. Current hospital work experience revealed that those with less than two years of experience had higher nursing quality than those with 5–10 years. Total clinical experience indicated higher nursing quality for those with less than two years of experience than those with 2–5 years, 5–10 years, or over 10 years of experience. Nursing job and department satisfaction showed higher nursing quality as ‘satisfied’, neutral’, and ‘dissatisfied’ sequentially. No intention of leaving resulted in higher nursing quality than intention to leave. Level of job stress indicated a higher nursing quality for those who reported ‘low’ stress than those who reported ‘high’ stress (Table 1).

Table 1 General characteristics and differences in quality of nursing care according to the participants’ characteristics (N = 190).
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Scores of variables and correlations among the variables

The scores for the QNC, positive nursing organisational culture, caring behaviours, and hospital organisational health were 2.92 ± 0.45 (out of 4 points), 3.60 ± 0.59 (out of 5 points), 4.23 ± 0.73 (out of 6 points), and 3.40 ± 0.57 (out of 5 points), respectively. The QNC was significantly correlated with the PNOC (r = 0.61, p < 0.001), caring behaviour (CB) (r = 0.59, p < 0.001), and HOH (r = 0.67, p < 0.001; Table 2).

Table 2 Scores and correlations between positive nursing organizational culture, caring behaviour, hospital organizational health, and quality of nursing care (N = 190).
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Influence of participants’ characteristics, positive nursing organisational culture, caring behaviour, and hospital organisational health on quality of nursing care

To investigate the impact of participants’ general characteristics, PNOC, CB, and HOH scores on QNC scores, a hierarchical linear regression analysis was calculated. Model 1 included the general characteristic variables identified as affecting QNC scores. Model 2 added PNOC and CB scores to Model 1, whereas Model 3 added the HOH scores to Model 2.

Before analysis, we checked for autocorrelation among the error terms via the Durbin-Watson statistic, which resulted in a value close to 2 (1.849). This indicated that there was no autocorrelation. Furthermore, we examined the distribution of the residuals through standardised residuals to assess the assumption of normal distribution. All values, except for one case, fell within ±3 standard deviations of the mean. Even the one exception was close to this threshold, with a value of −3.177, suggesting that the assumption of a normal distribution for the error terms was valid.

We examined the presence of multicollinearity among the input-independent variables via tolerance and variance inflation factors (VIF). Tolerance ranged from 0.176–0.732, which exceeded 0.10, and VIF ranged from 1.366 to 5.671, all below 10 (Kutner et al. 2004). These results indicated the absence of multicollinearity.

In Model 1, the variables that significantly influenced the quality of nursing care were the surgical ward (β = 0.21, p = 0.004) and other (outpatient) departments (β = 0.16, p = 0.027) for work, satisfaction (β = 0.57, p < 0.001) and average satisfaction (β = 0.32, p = 0.006) for department satisfaction, and average stress level (β = 0.15, p = 0.026) for job stress. Therefore, nursing care quality tended to be higher in the surgical and other (outpatient) departments compared to intensive care units and emergency rooms regarding work department. Regarding department satisfaction, nursing care quality was higher in satisfied and moderately satisfied conditions compared to dissatisfied conditions. Additionally, nursing care quality was higher when the level of job stress was average compared to high stress. The explanatory power of Model 1 was 38.0% (F = 5.83, p < 0.001, R2 = 0.380, Adj R2 = 0.315).

In Model 2, among the additional variables, a positive nursing organisational culture had a significant impact on quality of nursing care (β = 0.33, p = 0.001). Meanwhile, caring behaviour (β = 0.15, p = 0.140) did not show a significant influence. Hence, higher levels of positive nursing organisational culture were associated with higher quality of nursing care. The proportion of additional explanatory power in Model 2 was 10.4%, and the total explanatory power was 48.4% (F = 7.92, p < 0.001, R2 = 0.484, Adj R2 = 0.423).

In Model 3, the added variable, hospital organisational health, showed a significant impact on quality of nursing care (β = 0.47, p < 0.001). Thus, higher levels of hospital organisational health were associated with higher quality of nursing care. The proportion of additional explanatory power in Model 3 was 8.8%, and the total explanatory power was 57.2% (F = 10.70, p < 0.001, R2 = 0.572, Adj R2 = 0.519; see Table 3).

Table 3 Factors affect quality of care according to hierarchical regression analysis (N = 190).
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Mediating effect of hospital organisational health

To examine the mediating effect of hospital organisational health on the relationship between positive nursing organisational culture, caring behaviours, and quality of nursing care, a regression analysis was conducted using Baron and Kenny’s three-step procedure (Baron and Kenny, 1986) after controlling for general characteristic variables that showed significant differences in association with the quality of nursing care. Additionally, significance of the indirect effects of the mediating variable was assessed via bootstrapping. Before the analysis, the absence of autocorrelation among the error terms was confirmed via the Durbin-Watson statistic, which ranged from 1.885–1.944 and indicated no autocorrelation. Examination of the standardised residuals suggested normal distribution assumptions, and all cases fell within ± 3 standard deviations of the mean, except for one, which implied that the assumption of normal distribution for the error terms was reasonable. We assessed multicollinearity among the independent input variables, performed via tolerance and VIF, and revealed tolerance and VIF values between 0.181–0.821 (above 0.10) and 1.218–5.538 (below 10), respectively, which indicated the absence of multicollinearity.

Mediating effect of hospital organisational health on the relationship between positive nursing organisational culture and quality of nursing care

In the first step, the PNOC scores had significant direct effect on HOH scores (β = 0.73, p < 0.001). In the second step, PNOC scores had a significant impact on QNC scores (β = 0.45, p < 0.001). In the final third step, HOH scores significantly influenced QNC scores (β = 0.48, p < 0.001), while the PNOC scores demonstrated no significant effect on QNC scores (β = 0.08, p = 0.380). Therefore, HOH scores fully mediated the relationship between PNOC and QNC scores. The test for the significance of the indirect effect of HOH scores on the relationship between PNOC and QNC scores showed that the mediating effect was significant, as the 95% confidence interval did not include zero (B = 0.27, 95% CI = 0.18–0.37; Table 4, Fig. 2).

Table 4 Mediating effect of hospital organizational health in relationship between positive nursing organizational culture and quality of nursing care, and test for significance of mediating effect (N = 190).
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Fig. 2
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Mediating effect of hospital organizational health in relationship between positive nursing organizational culture, caring behaviours, and quality of nursing care.

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Mediating effect of hospital organisational health on the relationship between caring behaviour and quality of nursing care

In the first step, CB had a significant direct effect on HOH scores (β = 0.66, p < 0.001). In the second step, CB scores had a significant impact on QNC scores (β = 0.38, p < 0.001). In the final third step, HOH scores significantly influenced QNC scores (β = 0.50, p < 0.001), while CB scores had no significant effect on QNC scores (β = 0.04, p = 0.649). Therefore, HOH scores fully mediated the relationship between CB and QNC scores. The result for the indirect effect of HOH scores on the relationship between CB and QNC scores was significant (B = 0.21, 95% CI = 0.14–0.28; Table 5, Fig. 2).

Table 5 Mediating effect of hospital organizational health in relationship between caring behaviour and quality of nursing care, and test for significance of mediating effect (N = 190).
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Discussion

This study aimed to examine the relationships among positive nursing organisational culture, caring behaviour, and quality of nursing care among clinical nurses. Additionally, this study also investigated the mediating effect of hospital organisational health on the relationship between positive nursing organisational culture, caring behaviour, and the quality of nursing care. We aimed to provide foundational data for exploring strategies for establishing an appropriate nursing culture that could enhance the quality of nursing care.

Our results indicated that the QNC scores for the study participants averaged 11.67 points out of 16 (mean rating of 2.92 out of 4). In Havaei et al.’s (2019) study, which used the same instrument and focused on surgical ward nurses, the average score was 10.7. Additionally, in Ji’s (2017) study, which targeted ICU nurses albeit with a different instrument to assessed nursing quality, the mean rating was 2.47 out of 4. Thus, compared to previous studies, our results indicated higher quality of nursing care.

Ji’s (2017) study found that as nurses’ competence increased or their working environment improved, the quality of nursing care also increased. Furthermore, Yu et al.’s (2021) study targeted neonatal ICU nurses in three tertiary general hospitals and reported that 47.5% responded that the quality of nursing care was either average or low. They emphasised the need for appropriate staffing, improved nursing work environment, and establishment of measures to enhance job satisfaction to improve nursing care quality. Aiken et al.‘s (2011) research focused on Asian countries and revealed that 68%, 60%, and 30% of nurses in Korea, China, and Japan, respectively, responded that the quality of nursing care was deteriorating. Among Asian countries, Korea was reported as having a particularly low quality of nursing care compared with other nations. Labrague’s (2021) study on Filipino nurses revealed that nursing managers’ toxic leadership behaviours influenced deteriorations in nursing care quality. Additionally, Van Bogaert et al.’s (2017) study on Belgian nurses indicated differences in patient conditions and quality of nursing care based on high job demands. Hence, the quality of nursing care was influenced by both nurses’ individual competence and various other factors, such as nursing staff, work environment, job demands, nursing organisational culture, and hospital organisational policies. Our results focused on the general characteristics and organisational factors that influenced the quality of nursing.

In this study, the most significant factor that influenced the quality of nursing care was hospital organisational health. If the hospital organisation was perceived to be healthy, the quality of nursing care tended to be higher. A healthy hospital organisation was associated with increased autonomy among members, enhanced morale, and maximized effectiveness, which contributed to goal achievement (Ha, 2013). Direct comparisons were limited due to a scarcity of studies on the relationship between hospital organisational health and the quality of nursing care. However, Han and Jung (2017) examined the relationship between hospital organisational health and patient safety nursing activities, suggesting that a higher level of organisational health could enhance patient safety nursing activities.

Patient safety nursing activities encompass the overall realm of nursing activities, including patient safety and nursing-specific tasks, and can be considered a driving force for improving the quality of healthcare services (Han and Jung, 2017). This study identified enhancement of hospital organisational health as a means of improving the quality of nursing care. However, lack of direct research on the relationship between hospital organisational health and the quality of nursing care made it challenging to create a clear comparison. To this end, further studies are required.

Second, among participants’ characteristics, department satisfaction was identified as a factor that influenced the quality of nursing care. The higher the satisfaction with the current department, the higher the quality of nursing care. Kim (2021) focused on novice nurses and revealed that those placed in their preferred department had higher job satisfaction compared to those who were not placed in their preferred department. Additionally, Bang and Kim (2014) examined the relationship between job stress and job performance among novice nurses and found that nurses placed in their preferred department exhibited better job performance than those in other departments. Hence, satisfaction with the current department could be associated with increased job satisfaction and job performance. Furthermore, department satisfaction could positively influence improvement in nursing care quality. Therefore, in hospital organisations, efforts should be made to consider nurses’ individual preferences, such as deploying personnel to their desired departments whenever possible. This efficient workforce management approach could assist nurses in adapting to their roles and contribute to enhancing the quality of patient care. The working department was also a factor that influenced nursing care quality. Participants perceived that nursing care quality was higher when they worked in surgical wards, operating rooms/delivery rooms, neonatal ICUs, and outpatient departments compared to in critical care/emergency rooms. Previous studies indicated that nurses who worked in urgent care settings, such as emergency rooms, experienced higher levels of stress due to the need for constant alertness (Oh et al. 2011; Lee and Ahn, 2015). Nurses in intensive care units, who require advanced skills and deal with critically unwell patients, experience higher job stress (Sung, 2006; Oh et al. 2016; Ha et al. 2016). Nurses in outpatient departments with irregular shift schedules have been shown to experience higher job stress than those in departments with regular shifts (Sung et al. 2007). We observed that the quality of nursing care was lower in association with high job stress. Elevated job stress has been associated with decreased job satisfaction and increased burnout (Kwon et al. 2021), which makes effective and efficient task performance challenging and ultimately leads to a decline in the quality of patient care (Kim and Yu, 2014; Kim and Lee, 2006). Therefore, development of a differentiated compensation system based on departments or work types and exploration of various programs to manage nurses’ job stress and enhance the quality of nursing care are essential. Furthermore, since this study was conducted in a tertiary hospital, the observed results may be attributed to the higher acuity and complexity of tasks compared with smaller hospitals or medical centres. Therefore, additional research in hospitals of different sizes is necessary to validate and extend our findings.

In this study, positive nursing organizational culture and caregiving behaviour did not directly impact the quality of nursing care. However, our analysis revealed that HOH scores completely mediated the relationship between positive nursing organizational culture and nursing care quality. This indicates that while a positive nursing organizational culture may not have a direct effect on nursing care quality, it exerts its influence through the mediation of hospital organizational health. The quality of nursing care is a multifaceted outcome influenced by various factors. The direct impact of positive nursing organizational culture and caring behaviours may be overshadowed when more immediate or stronger factors are present. Instead, these influences on nursing care quality primarily occur through intermediary processes, such as improving job satisfaction, reducing stress, or enhancing teamwork. These indirect pathways, as highlighted by the mediating role of hospital organizational health, suggest that while the direct effects may be less visible, they remain crucial to the overall quality of care. Lee (2015) examined organizational culture and health among nurses in university hospitals and found that a human-centred organizational culture based on mutual trust established healthy relationships and made the organization healthier. This, in turn, enhanced job performance and satisfaction. Similarly, improved hospital organizational health can enhance nurses’ job satisfaction and organizational commitment (Lee and Jung, 2017). These factors—job satisfaction and organizational commitment—are critical to providing high-quality nursing care (Lake et al. 2016). Therefore, improving hospital organizational health through positive enhancements in nursing culture could lead to better nursing care quality. Consequently, cultivating a positive organizational culture, such as fostering a sense of community among members and creating a culture of mutual support, should be prioritized to promote hospital organizational health.

Furthermore, when analysing the mediating effect of hospital organisational health in the relationship between caring behaviour and nursing quality, hospital organisational health completely mediated the relationship between caring behaviour and nursing quality. Mutual care and respect exhibited among organisational members positively impact patient safety and enhance healthcare quality (Kim, 2012). Through caring and considerate behaviours, nurses’ nursing performance and caregiving capabilities can be increased (Shin et al. 2020), which facilitates the growth of nurses’ caregiving skills resulting in improved proficiency in patient caregiving practices (Longo, 2011). Ultimately, highly skilled nurses contribute to hospital organisational health, enable effective task performance, and enhance the quality of nursing (Lee and Jung, 2017). Therefore, the promotion of caregiving and considerate behaviour among nurses should raise awareness of hospital organisational health and positively influence the quality of nursing care. However, it was challenging to directly compare the relationship between caring behaviour, hospital organisational health, and nursing quality in the current study, as prior research on these associations was scarce. Thus, further studies are warranted. Although this study found that caring behaviour did not directly impact nursing quality, it did influence nursing quality indirectly through the mediating variable of hospital organisational health. Therefore, efforts promoting caring behaviours at the nursing organisational level, encouraging nurse participation, and fostering a culture that normalises caring behaviour among members are essential for enhancing the awareness of hospital organisational health.

This study’s scope was limited to tertiary hospitals, which may restrict the generalisability of the results. Additionally, the data collection relied on self-reported surveys, which included the assessment of nursing quality, which could pose limitations regarding objectivity. Caution is advised when interpreting the results. In addition, data collected during a specific timeframe may not capture long-term changes or trends. However, our results indicated that hospital organisational health was a crucial direct factor that influenced nursing quality and a significant mediating factor between positive nursing organisational culture, caring behaviour, and nursing care quality. Additionally, hospital organisational health was influenced by a positive nursing organisational culture and caring behaviour. By providing insights into the significant predictors of QNC, these findings can contribute to improving the quality of care in Korean hospitals.

Conclusion

The following practical suggestions are provided based on the findings of the current study: 1) There should be a focus on improving hospital organizational health, which significantly influences nursing care quality. This can be achieved by promoting teamwork, fostering supportive relationships among staff, and creating a positive work environment. Regular assessments and targeted interventions to address weaknesses could be beneficial. 2) Hospitals should emphasize mutual trust, collaboration, and shared values. Leadership training for nurse managers can promote positive cultural practices, thereby enhancing overall organizational health. 3) Programs that encourage caring behaviours, such as peer support systems and regular team-building activities, should be implemented to help maintain a healthy work environment. Recognizing and rewarding caring behaviours among staff can reinforce these practices. 4) Work and environmental conditions should be improved at the organizational level to further support nursing quality. This includes fostering a positive nursing organizational culture and managing stress effectively.

Going forward, the scope of the current study should be broadened to include a wider range of healthcare institutions and regions. Future studies should also confirm the relationship between hospital organizational health and nursing quality, and investigate whether raising awareness of organizational health through interventions based on caring behaviour leads to improvements in nursing quality.