Levels and correlates of implicit rationing of nursing care in Swiss acute care hospitals--a cross sectional study

Objectives: (1) To describe the levels of implicit rationing of nursing care in Swiss acute care hospitals; (2) to explore the associations between nine selected potential rationing predictors and implicit rationing of nursing care.

Design: Cross sectional multi-center study.

Settings: A quota sample of 35 acute care hospitals from the German, French and Italian speaking regions of Switzerland participating in RN4CAST (Registered Nurse Forecasting) study.

Participants: 1633 registered nurses working in randomly selected medical, surgical or medical-surgical units.

Methods: Implicit rationing of nursing care, i.e., the withholding of any of 32 necessary nursing measures due to a lack of nursing resources, was measured using the revised Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Nine potential rationing predictors, e.g., staffing and resource adequacy, patient-to-nurse ratio, nurse education, and confounding variables, e.g., nurse gender and age, hospital typology, were assessed with validated instruments or single items of the RN4CAST study. Descriptive statistical procedures were used as appropriate. Three level regression models were used to investigate the effect of the selected nine predictors on rationing at the nurse, unit and hospital levels.

Results: Ninety-eight percent of the participating nurses reported that, in their last seven working days, they had to ration at least one of the 32 nursing tasks listed in the BERNCA. The mean rationing level of 1.69 (SD=0.571) indicates that on average the nurses reported 'rarely' being unable to perform the nursing tasks listed in the BERNCA. Multilevel regression analysis confirmed two of the nine tested predictors: better unit level staff resource adequacy and a more favorable hospital level safety climate were both consistently significantly associated with lower rationing levels. Counter to our assumptions, the other two nurse practice environment dimensions, the three workload measures, nurse experience and nurse education were not associated with rationing.

Conclusions: Rationing frequency varied among the 32 BERNCA items, indicating differing prioritizations of necessary nursing tasks. The identified rationing predictors, staff resource adequacy and safety climate, can determine starting points for interventions, i.e., proactive changes to improve staff resource adequacy when rationing exceeds predefined thresholds, increasing the risk of negative effects on patient outcomes.