Rationing of Nursing Care and its Relationship to Patient Outcomes: The Swiss Extension of the International Hospital Outcomes Study

Maria Schubert; Tracy R. Glass; Sean P. Clarke; Linda H. Aiken; Bianca Schaffert-Witvliet; Douglas M. Sloane; Sabina De Geest


Int J Qual Health Care. 2008;20(4):227-237. 

In This Article

Abstract and Introduction


Objectives: To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.
Design: Multi-hospital cross-sectional surveys of patients and nurses.
Setting: Eight Swiss acute care hospitals
Participants: Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units.
Main outcome measures: Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year.
Results: Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones.
Conclusion: As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.


Over the past decade, economic and demographic forces influencing both the supply of and demand for nurses have led to shortfalls in the number of nurses, particularly in hospitals. Concurrently, cost-cutting strategies to stem exploding health care costs have raised the thresholds for hospital admissions and shortened lengths of stay. This has increased the average acuity of hospital in-patients, along with the intensity of nursing services they require; however, budgetary concerns have typically limited nursing staff numbers.[1,2,3]

Nursing practice involves a wide range of daily tasks. When resources are limited, nurses are forced to ration their attention across their patients, using their clinical judgment to prioritize assessments and interventions.[4,5,6] On understaffed units, nurses are presumably forced to minimize or omit certain tasks, thereby increasing the risk of negative patient outcomes.

Worldwide, stakeholder groups consistently agree that many hospitals operate with suboptimal nursing staff levels,[3,7,8] while a growing evidence base connects nurse understaffing with negative patient outcomes. Internationally, studies have shown significant relationships between reduced nurse practice environment quality, nurse staffing levels/skill mixes, and increased numbers of adverse events or outcomes (medication errors, falls, nosocomial infections, pressure scores, ‘failure-to-rescue’ events, and mortality rates).[9,10,11,12,13,14] Furthermore, negative nurse practice environment features show significant associations with job dissatisfaction, burnout, work-related injuries and staff turnover.[10,15,16,17,18]

In fact, rationing of nursing care, defined as ‘the withholding or failure to carry out necessary nursing tasks due to inadequate time, staffing level, and/or skill mix,’ may be a directly observable consequence of low staffing levels and poor practice environments. To our knowledge, the association between this type of implicit rationing of care and patient outcomes in hospitals has never been directly investigated.

In 2003-04, in an extension of the International Hospital Outcomes Study (IHOS) led by the Center for Health Outcomes and Policy Research at the University of Pennsylvania (USA), the Rationing of Nursing Care in Switzerland study (RICH Nursing study) measured levels of implicit rationing of nursing care in Swiss acute care hospitals to explore its association with selected patient outcomes. The International Hospital Outcomes Study is an international study of the organization of nursing care in hospitals and its impact on patient outcomes.[6,15,19] The Swiss study extended the research protocol of the international study by developing a new empirical measure of implicit rationing of nursing care. Specifically, it involved surveys of patients and nurses and analyses adjusting for major organizational variables shown in prior research to correlate with outcomes, including the quality of the nurse work environment and staffing/workload. The study's guiding hypothesis was that higher levels of implicit rationing of nursing care would be associated both with lower patient satisfaction and more frequent nurse-reported adverse patient outcome rates (medication errors, falls, nosocomial infections, critical incidents and pressure sores).


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