Identifying thresholds for relationships between impacts of rationing of nursing care and nurse- and patient-reported outcomes in Swiss hospitals: a correlational study.
ABSTRACT In the Rationing of Nursing Care in Switzerland Study, implicit rationing of care was the only factor consistently significantly associated with all six studied patient outcomes. These results highlight the importance of rationing as a new system factor regarding patient safety and quality of care. Since at least some rationing of care appears inevitable, it is important to identify the thresholds of its influences in order to minimize its negative effects on patient outcomes.
To describe the levels of implicit rationing of nursing care in a sample of Swiss acute care hospitals and to identify clinically meaningful thresholds of rationing.
Descriptive cross-sectional multi-center study.
Five Swiss-German and three Swiss-French acute care hospitals.
1338 nurses and 779 patients.
Implicit rationing of nursing care was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Other variables were measured using survey items from the International Hospital Outcomes Study battery. Data were summarized using appropriate descriptive measures, and logistic regression models were used to define a clinically meaningful rationing threshold level.
For the studied patient outcomes, identified rationing threshold levels varied from 0.5 (i.e., between 0 ('never') and 1 ('rarely') to 2 ('sometimes')). Three of the identified patient outcomes (nosocomial infections, pressure ulcers, and patient satisfaction) were particularly sensitive to rationing, showing negative consequences anywhere it was consistently reported (i.e., average BERNCA scores of 0.5 or above). In other cases, increases in negative outcomes were first observed from the level of 1 (average ratings of rarely).
Rationing scores generated using the BERNCA instrument provide a clinically meaningful method for tracking the correlates of low resources or difficulties in resource allocation on patient outcomes. Thresholds identified here provide parameters for administrators to respond to whenever rationing reports exceed the determined level of '0.5' or '1'. Since even very low levels of rationing had negative consequences on three of the six studied outcomes, it is advisable to treat consistent evidence of any rationing as a significant threat to patient safety and quality of care.
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ABSTRACT: This article reports on observation of 18 nurses in urban and rural based critical care settings. The purpose of the study was to observe and describe the decision-making activities of critical care nurses within natural clinical settings. During the 2-hour observation, the researcher dictated a detailed commentary on to audio-tape of each nurse's actions. Tapes were transcribed and subjected to content analysis. Findings indicated three main categories of decisions. Decision frequencies were linked to nurses' critical care experience, appointment level, and location, as well as nursing shifts. The findings are discussed in relation to previous empirical evidence and the implications for practice. The author concludes that future research should be directed towards measuring the contextual influences on nurses' decision-making on the outcome of patient care.Journal of Clinical Nursing 02/2000; 9(1):25-35. · 1.12 Impact Factor