Rationing of nursing care : associations with patient safety and quality of hospital care

On the basis of nurse reports indicating the occurrence of implicit rationing of nursing care in
Swiss hospitals, the Swiss Federal Office of Public Health asked the Institute of Nursing Science
of the University of Basel to conduct the Rationing of Nursing Care in Switzerland Study (RICH
Nursing Study). The resulting study is an extension of the International Hospital Outcomes
Study (IHOS), an international study of the organization of nursing care in hospitals and its
impact on patient outcomes [1-3]. The IHOS study is led by the Center for Health Outcomes and
Policy Research at the University of Pennsylvania (USA). The RICH Nursing study, and with it
the research program of this dissertation, extended the IHOS research protocol by developing a
new empirical measure of implicit rationing of nursing care.
This thesis is comprised of ten chapters. Chapters 3 and 5-9 have been published or submitted as
individual articles. Therefore, some repetition in the description of the background and methodology
could not be avoided.
The first three chapters describe the thesis’ background, its aims, and the available evidence on
effects of cost saving strategies and changes in staffing levels and skill mixes on patient and
nurse outcomes.
• Chapter 1 gives a literature based overview of relevant developments in the healthcare
system, including cost saving strategies, reductions of nursing resources, and their effects on
patient and nurse outcomes
• Chapter 2 describes the aims of this research program
• Chapter 3 is a literature review and analysis, examining the available evidence on the effects
of cost saving strategies and changes in staffing levels and skill mix in the inpatient care
setting on selected patient and nurse outcomes.
Chapters 4 and 5 explore the first two aims of this research program – to develop a conceptual
framework of implicit rationing of nursing care, as well as an instrument to measure it as an
empirical factor, and to evaluate the psychometric properties of the newly developed instrument.
• Chapter 4 presents the definition and conceptual framework of implicit rationing of nursing
care, upon which the proposed measurement tool was based.
• Chapter 5 explores the development of the Basel Extent of Rationing of Nursing Care
(BERNCA) instrument and its validity and reliability along lines of evidence suggested in
Standards for educational and psychological testing.
The central aim of this research program, ‘to explore the association between implicit rationing
of nursing care in Swiss acute care hospitals and patient outcomes, with consideration for major
organisational variables’, and the related aim, ‘to examine the levels of rationing in Swiss acute
care hospitals, identifying clinically meaningful rationing thresholds for selected patient
outcomes using a standardized rationing tool’ are explored in chapters 5 and 6.
• Chapter 6 explores the associations between implicit rationing of nursing care and its
relationships with patient outcomes as a new empirical factor, as well as with major organisational
system factors.
• Chapter 7 discusses the identified clinically meaningful rationing thresholds and their
implications for clinical nursing practice.
• Chapter 8 Discusses the mechanism of implicit rationing of nursing care, the occurrence of
rationing in Swiss acute care hospitals and its consequences.
• Chapter 9 explores the additional aim of this research program – ‘to compare sharp-device
injuries rates among hospital staff nurses across four Western countries’ using data from the
IHOS study.
• To conclude, Chapter 10 discusses the findings of the program as a whole, identifying
related methodological issues, implications for research and clinical practice, and possible
future steps to explore the causes, processes and effects of the rationing of nursing care.