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. 2023 May 20;10(8):5589–5596. doi: 10.1002/nop2.1802

Inadequate number of staff and other reasons for implicit rationing of nursing care across hospital types and units

Renáta Zeleníková 1,✉, Darja Jarošová 1, Eva Mynaříková 2, Eva Janíková 1,2, Ilona Plevová 1
PMCID: PMC10333843  PMID: 37209016

Abstract

Aim

The aim of the study was to find differences in perceived reasons for implicit rationing of nursing care across hospital types and units.

Design

A descriptive multicentre study.

Methods

The study in 14 Czech acute care hospitals was conducted from September 2019 to October 2020. The sample consisted of 8316 nurses working in medical and surgical units. Items for rating the reasons for implicit rationing of nursing care were selected from the MISSCARE Survey. Nurses were asked to rate each item on a scale from 0 (a not significant reason) to 10 (the most significant reason).

Results

The most significant reasons for implicit rationing of nursing care were ‘Inadequate number of staff’, ‘Inadequate number of assistive personnel’ and ‘Unexpected patient admission and discharge’. Most reasons were rated as more significant by nurses from non‐university hospitals. Nurses from medical units perceived all reasons for implicit rationing of nursing care as more significant.

Keywords: hospital, implicit rationing of nursing care, nurse shortage, reasons

1. INTRODUCTION

A significant feature of 21st‐century nursing research is the impact of the global nursing shortage on the quality of care provided. In 2012, the International Council of Nurses (ICN) expressed concern about patient safety and quality of care being at serious risk due to inadequate qualified staff. The current global nursing shortage represents such a threat (ICN, 2012). Even before the COVID‐19 pandemic, the World Health Organization estimated that by 2030, there will be a global shortage of 15 million physicians, nurses and other health workers (Liu et al., 2017). The pandemic has made the global problems resulting from nursing shortage worse. Nurses are traumatized and exhausted, leaving their profession. In their new report, the ICN estimates that due to the current shortage and increasing average age of nurses, as well as the mounting effects of COVID‐19, as many as 13 million nurses will be needed in the future to compensate for the global shortage (ICN, 2021). Adequate nurse staffing is essential for patient safety and care quality (ICN, 2018). Due to a lack of necessary resources, situations may occur when nurses cannot provide care to all patients looked after by them. Thus, nursing staff shortages are an important factor contributing to rationing of nursing care (Campbell et al., 2020; Zhao et al., 2020). The term implicit rationing of nursing care refers to the fact that nurses, mostly as a consequence of a lack of time, are unable to complete all nursing care activities planned (Schubert et al., 2008).

2. BACKGROUND

Numerous research studies and reviews have concluded that rationed nursing care negatively affects both nurse and patient outcomes: quality of care, adverse events, healthcare‐associated infections, in‐hospital mortality, medication errors, patient falls, patient satisfaction, nurses' job satisfaction, nurse turnover and intention to leave the profession (Alsubhi et al., 2020; Jones, 2016; Smith et al., 2020).

The latest studies (Bragadóttir et al., 2017; Campbell et al., 2020) and systematic reviews (Griffiths et al., 2018; Zhao et al., 2020) have confirmed that inadequate staffing is an important predictor for implicitly rationed care. Research studies focusing on the prevalence, predictors or consequences of rationed care in various clinical and geographical have been published in the last two decades. However, studies on the reasons for rationing of care are rare, or the reasons are only reported as part of results of selected studies. This also stems from the fact that even though several instruments are available for assessing rationed nursing care, only few of them assess, in addition to missed nursing care activities, also the reasons for doing so. One of them is the MISSCARE Survey, of which Part B allows nurses to comment on reasons that, in their opinion, caused omission of necessary activities. Part B consists of 17 items – reasons for missed nursing care (Kalisch & Williams, 2009). In this study, we used an adapted short version – modified for the Czech context which contains 10 items. The first modified version with 11 items was used in a pilot study in a sample of 100 Czech nurses (Jarošová & Zeleníková, 2019).

3. METHODS

3.1. Aim

The main aim of the study was to find differences in perceived reasons for implicit rationing of nursing care across hospital types and units.

3.2. Design

A descriptive multicentre study.

3.3. Sample

The study's target group was nurses working in medical and surgical units in the Czech Republic. The medical unit is a hospital ward in which patients are treated with drugs rather than surgery. The medical units included internal medicine, neurology, rehabilitation, oncology, haemato‐oncology, pneumology, dermatology, and infectious diseases. The surgical unit is a hospital ward in which patients are treated mostly by surgery. The surgical units included surgery, neurosurgery, traumatology, orthopaedics, cardiac surgery, urology, plastic surgery, otorhinolaryngology and gynaecology.

Although their exact numbers are not available, we know that 48,329 general nurses and 5264 practical nurses were employed by Czech acute care facilities in 2020 (Institute of Health Information and Statistics, 2021a). General nurses (equivalent to registered nurses, having a 3‐year bachelor's degree from a university or a higher vocational school diploma) as well as practical nurses (with 4‐year training at a secondary nursing school) work as bedside nurses, providing direct care to patients. Their working activities differ as practical nurses are not allowed to perform certain nursing procedures that general nurses do, like administer medication via intravenous route or insert peripheral venous and urinary catheters.

Only nurses providing direct care to hospitalized patients were invited to participate. Nurse managers not involved in direct care were excluded from the sample. To set the sample size, the online sample size calculator was used. It was set that the sample of minimum 3817 nurses gives the study a margin of error of ±2% (confidence interval 97%). A total of 8486 questionnaires were completed by nurses working in medical and surgical units. Due to high numbers of missing items, 170 of them were excluded. Thus, the final sample consisted of 8316 general and practical nurses working in medical and surgical units.

3.4. Data collection

Data collection was from September 2019 to October 2020 in 14 Czech acute care hospitals. All regions were represented by at least one hospital. The original intention was to collect data continuously for 12 months. But due to the COVID‐19 pandemic and lockdown, the data collection was interrupted between April 2020 and June 2020. Four university (with more than 1000 beds each) and 10 non‐university hospitals (between 300 and 1000 beds) were included in the study. Approximately 10 surgical and medical units were selected in each hospital, making up a total of 168 hospital units. There, bedside nurses (mostly general and practical nurses) were asked to fill in a questionnaire containing three parts: demographic information (gender, age, education, work position, usual working hours), the PIRNCA (Jones, 2014) and reasons for implicitly rationed nursing care. The PIRNCA is a self‐reported questionnaire containing a list of 31 frequent nursing activities. Originally questionnaire was developed for nurses caring for hospitalized medical‐surgical patients. Nurses reflected on the latest seven shifts and specified how often they were not able to finish each nursing activity because of a lack of personnel or time resources. Nurses rated each item on the following scale: 0 – never, 1 – rarely, 2 – sometimes, 3 – often. The Czech version of the PIRNCA (Jarošová & Zeleníková, 2019; Zeleníková et al., 2020) was used in this study. Because the PIRNCA instrument does not contain items for rating the reasons for implicit rationing of nursing care, adapted scale for reasons of rationing of nurse care were developed based on the MISSCARE Survey 17‐item Part B (Kalisch & Williams, 2009). Ten items were selected, adapted and modified from the MISSCARE Survey as a result of consensus by a group of seven experts (nurse researchers, nurse manager and bedside nurse). Participants rated each item on a scale from 0 (a not significant reason) to 10 (the most significant reason). The reliability and validity of the scale was evaluated using Cronbach's alpha coefficient and the exploratory factor analysis.

3.5. Data analysis

For the purpose of this study, only the total PIRNCA score (calculated as sum of means of all 31 PIRNCA items) was used. The variable work position was grouped in two bedside nurse categories: general nurses, practical nurses, nurse specialists (n = 7853; 95.66%) and head nurses of units involving in direct patient care (n = 356; 4.34%). The normality of data distribution was tested by the Shapiro–Wilk test. Because data were not normally distributed non‐parametric tests were used. The two‐sample Wilcoxon rank‐sum (Mann–Whitney) test was used to calculate differences between ratings of reasons for missed nursing care according to several parameters. Spearman's correlation coefficient was used to find associations between the total PIRNCA score and reasons for rationing of nursing care. The total PIRNCA score (a mean composite score) was measured as the arithmetic mean score across all inventory items.

Data were analysed using the statistical program Stata 14. The significance level was set at 5%.

3.6. Ethical consideration

Ethics committee approval was obtained prior to study initiation (no. 603/2017 Ethics Committee, University Hospital Ostrava, Czech Republic and no. 19/2017 Ethics Committee, Faculty of Medicine, University of Ostrava, Czech Republic). All participants were fully informed about the purpose of the study. Confidentiality of the participants was fully respected. The study was also approved by the nursing care management office in each participating hospital.

3.7. Validity, reliability and rigour

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was followed to report this cross‐sectional study. The Czech version of PIRNCA reached a reliability of 0.86 (Zeleníková et al., 2020). The Cronbach alpha of the 10‐item scale that rated the reasons for implicit rationing of nursing care was 0.908. The exploratory factor analysis revealed two factors (communication and material resources; labour resources). To guarantee rigour during period of data collection, the main investigator was in touch by email with nurse researchers in each hospital.

4. RESULTS

The mean age of nurses in our sample was 39.06 years (SD = 11.56). The mean amount of time spent working overtime was 19.51 h (SD = 21.35). The majority of the sample were females (96.71%) and those who had completed secondary nursing school (63.08%). A bachelor's degree was reported by 19.29% of the nurses. Most participants worked as general nurses (75.34%), followed by practical nurses (13.06%). Working for 30 or more hours/week was reported by 89.56% of our sample (Table 1).

TABLE 1.

Sample characteristics (n = 8316).

Characteristics n %
Gender (n = 8258)
Female 7986 96.71
Male 272 3.29
Education level in nursing (n = 8206)
Secondary nursing school 5176 63.08
Higher school 1447 17.63
Bachelor's degree in nursing 1583 19.29
Work position (n = 8316)
General nurse (equivalent to Registered Nurse) 6265 75.34
Nurse specialist 502 6.04
Practical nurse 1086 13.06
Head nurse of a unit 356 4.28
Other 107 1.29
Usual working hours per week (n = 8189)
Less than 30 855 10.44
30 or more 7334 89.56
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The most significant reason for rationing of nursing care was ‘inadequate number of staff’, followed by ‘inadequate number of assistive personnel’ and ‘unexpected patient admission and discharge’. The least significant reason for rationing of nursing care was ‘lack of cooperation and/or help from team members’ and ‘communication problems within the nursing team’ (Table 2). The majority of the reasons are labour resources.

TABLE 2.

Perception of reasons for rationing of nursing care.

Reasons for rationing of nursing care Median Mean a SD Min Max
Inadequate number of staff 5 5.13 3.20 0 10
Inadequate number of assistive personnel 5 4.96 3.14 0 10
Unexpected patient admission and discharge 5 4.69 2.90 0 10
Deterioration of the condition of a patient 4 4.09 2.68 0 10
Communication problems with doctors in the department 2 2.96 2.58 0 10
Supplies/equipment not available when needed, or not functioning properly 2 2.59 2.40 0 10
Inadequate hand‐off from previous shift or from other department 2 2.51 2.25 0 10
Nursing assistant did not communicate that planned activities of nursing care were not provided 2 2.38 2.38 0 10
Lack of cooperation and/or help from team members 2 2.25 2.23 0 10
Communication problems within the nursing team 2 2.17 2.18 0 10
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a

0 – a not significant reason; 10 – the most significant reason.

Nurses in medical units perceived all reasons for rationing of nursing care as more significant, except ‘communication problems with doctors in the department’. This reason for the rationing of nursing care was rated as more significant by surgical nurses. Differences in the rating of perceived reasons for the rationing of nursing care were statistically significant (Table 3). The lack of staff and the worsening of health status of patients in both types of units led to missed nursing care.

TABLE 3.

Differences in perception of reasons for rationing of nursing care by unit type.

Reasons for rationing of nursing care Unit Median Mean a SD Min Max p b
Inadequate number of staff Surgical 5 4.85 3.21 0 10 <0.001
Medical 5 5.32 3.17 0 10
Inadequate number of assistive personnel Surgical 5 4.67 3.15 0 10 <0.001
Medical 5 5.15 3.11 0 10
Unexpected patient admission and discharge Surgical 4 4.41 2.78 0 10 <0.001
Medical 5 4.88 2.96 0 10
Deterioration of the condition of a patient Surgical 3 3.61 2.53 0 10 <0.001
Medical 4 4.41 2.73 0 10
Communication problems with doctors in the department Surgical 3 3.00 2.50 0 10 0.0165
Medical 2 2.93 2.63 0 10
Supplies/equipment not available when needed, or not functioning properly Surgical 2 2.39 2.29 0 10 <0.001
Medical 2 2.72 2.47 0 10
Inadequate hand‐off from previous shift or from other department Surgical 2 2.23 2.05 0 10 <0.001
Medical 2 2.70 2.35 0 10
Nursing assistant did not communicate that planned activities of nursing care were not provided Surgical 1 2.11 2.23 0 10 <0.001
Medical 2 2.56 2.46 0 10
Lack of cooperation and/or help from team members Surgical 1 2.01 2.03 0 10 <0.001
Medical 2 2.40 2.33 0 10
Communication problems within the nursing team Surgical 1 1.93 1.97 0 10 <0.001
Medical 2 2.33 2.29 0 10
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Note: Bold values are the most significant reasons.

a

0 – a not significant reason; 10 – the most significant reason.

b

Mann–Whitney test.

Except for the first two (‘inadequate number of staff’ and ‘inadequate number of assistive personnel’), all reasons were rated as more significant by nurses from non‐university hospitals (Table 4). By contrast, ‘inadequate number of staff’ and ‘inadequate number of assistive personnel’ were perceived as more significant reasons for rationing of nursing care by nurses from university hospitals.

TABLE 4.

Differences in perception of reasons for rationing of nursing care by hospital type.

Reasons for rationing of nursing care Hospital Median Mean a SD Min Max p b
Inadequate number of staff University 5 5.24 3.36 0 10 <0.001
Non‐university 5 5.09 3.14 0 10
Inadequate number of assistive personnel University 5 5.10 3.32 0 10 0.0275
Non‐university 5 4.90 3.07 0 10
Unexpected patient admission and discharge University 4 4.35 2.95 0 10 <0.001
Non‐university 5 4.82 2.87 0 10
Deterioration of the condition of a patient University 3 3.90 2.82 0 10 0.0997
Non‐university 4 4.16 2.63 0 10
Communication problems with doctors in the department University 2 2.76 2.63 0 10 0.0165
Non‐university 2 3.03 2.56 0 10
Supplies/equipment not available when needed, or not functioning properly University 2 2.40 2.42 0 10 <0.001
Non‐university 2 2.66 2.39 0 10
Inadequate hand‐off from previous shift or from other department University 2 2.30 2.29 0 10 <0.001
Non‐university 2 2.59 2.23 0 10
Nursing assistant did not communicate that planned activities of nursing care were not provided University 1 2.20 2.49 0 10 <0.001
Non‐university 2 2.44 2.34 0 10
Lack of cooperation and/or help from team members University 1 2.08 2.30 0 10 <0.001
Non‐university 2 2.31 2.20 0 10
Communication problems within the nursing team University 1 2.01 2.24 0 10 <0.001
Non‐university 2 2.23 2.16 0 10
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a

0 – a not significant reason; 10 – the most significant reason.

b

Mann–Whitney test.

The strongest association was found between the total PIRNCA score and the ‘inadequate number of staff’ and between the total PIRNCA score ‘inadequate number of assistive personnel’. Nurses who reported more rationed nursing care also more often stated the ‘inadequate number of staff’ and the ‘inadequate number of assistive personnel’ as the significant reasons for rationing of nursing care (Table 5).

TABLE 5.

Correlation between reasons for rationing of nursing care and the total score of rationing of nursing care (PIRNCA).

Reasons for rationing of nursing care PIRNCA
Inadequate number of staff 0.4910*
Inadequate number of assistive personnel 0.4803*
Unexpected patient admission and discharge 0.3953*
Deterioration of the condition of a patient 0.3786*
Inadequate hand‐off from previous shift or from other department 0.3583*
Communication problems with doctors in the department 0.3522*
Lack of cooperation and/or help from team members 0.3464*
Supplies/equipment not available when needed, or not functioning properly 0.3457*
Nursing assistant did not communicate that planned activities of nursing care were not provided 0.3350*
Communication problems within the nursing team 0.3257*
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*

p < 0.05 (Spearman's correlation coefficient).

All correlations between the total PIRNCA score and reasons for rationing of nursing care were statistically significant.

5. DISCUSSION

The study aimed to find differences in perceived reasons for implicit rationing of nursing care across hospital types and units. The most significant reasons were ‘inadequate number of staff’, followed by ‘inadequate number of assistive personnel’ and ‘unexpected patient admission and discharge’. The least significant reasons were communication problems within the nursing team and lack of cooperation and/or help from team members.

The first Czech study (Zeleníková et al., 2019) using the MISSCARE Survey and a sample of Czech and Slovak nurses found that (i) Czech nurses reported that the most significant reasons for missed care were ‘unexpected rise in patient volume and/or acuity on the unit’, ‘inadequate number of staff’, ‘urgent patient situations (a patient's condition worsening)’ and ‘heavy admission and discharge activity’; (ii) the items most frequently reported by Slovak nurses were ‘inadequate number of assistive and/or clerical personnel’, ‘inadequate number of staff’, ‘urgent patient situations (a patient's condition worsening)’ and ‘heavy admission and discharge activity’. In another survey conducted among Czech nurses, the most important reasons for rationing of care were identical, that is ‘inadequate number of staff’, ‘unexpected rise in patient volume and/or acuity on the unit’, ‘urgent patient situations’ and ‘heavy admission and discharge activity (Jarošová et al., 2021). Similarly, a US study identified the most frequent reasons for missed nursing care identical activities (Gravlin & Phoenix Bittner, 2010). Studies from Spain (Juvé‐Udina et al., 2020), Michigan, USA (Kalisch et al., 2009), Brazil (Siqueira et al., 2013), Greece (Kiekkas et al., 2021), California, USA (Orique et al., 2016), or Jordan (Al‐Faouri et al., 2021) also found that the most frequent reasons for rationing of nursing care were labour resources, namely ‘urgent patient situations’, ‘unexpected rise in patient volume and/or acuity on the unit’, ‘heavy admission and discharge activity’ or ‘inadequate number of staff’. Even though the locations are geographically diverse, the reasons for missed nursing care are the same.

Inadequate staffing and considerable workload may lead to missing, not completing or delaying tasks. If there is a lack of nurses, nursing care is mainly oriented towards completing tasks and less time is devoted to the so‐called human side of patient care (Al‐Kandari & Thomas, 2009). A systematic review confirmed that inadequate staffing is associated with rationed nursing care (Griffiths et al., 2018). In a survey, as many as 48.8% of nurses reported routinely staying after shifts without claiming for overtime, most frequently to enter data into patients' medical records (Harvey et al., 2018). In another study, nurses reported spending 39% of their time performing tasks that only they could perform, 12% of time performing activities that nursing assistants could do unsupervised and 49% of time completing tasks suitable for both nurses and assistants (Gran‐Moravec & Hughes, 2005).

Better staffing is correlated with better teamwork (Ausserhofer et al., 2021) and also associated with improved patient outcomes (Kane et al., 2007). Results from several studies (Kalisch & Lee, 2010) and a systematic review (Zhao et al., 2021) confirm that effective teamwork may reduce implicitly rationed care. In the present study, reasons for rationing of care were perceived differently depending on unit and hospital types. Nurses working in medical units rated reasons for rationing of care as more significant.

In a recent Czech study (Jarošová et al., 2021), nurses working in medical units rated four reasons as more significant (‘inadequate number of assistive personnel’, ‘unbalanced patient assignments’, ‘urgent patient situations’, and ‘communication with nursing assistants’). In the same study, nurses from medical units identified rationing of nursing care significantly more often than did nurses from surgical units. Comparably nurses in Poland rated significantly higher rationing of nursing care in medical units than in surgical or intensive care units (Witczak et al., 2021). In 2019, similar to previous years, most hospital stays in the Czech Republic (16%) were in medical units, namely 378.1 thousand stays lasting for a mean of 5.9 days. An average of 6.1 thousand (15.7%) patients a day stayed in medical units in 2019. The second most occupied units in 2019 were surgical ones, with 355.5 thousand (15%) stays of a mean of 4.3 days (Institute of Health Information and Statistics, 2021b). A Czech study conducted during the COVID‐19 pandemic found no statistically significant differences in perception of reasons for rationing of care between nurses from medical and surgical units (Gurková et al., 2021), even though medical nurses rated the reasons as more important.

In the present study, reasons for rationing of care were rated as more serious by nurses working in non‐university hospitals, with only two reasons being rated as more serious by their university hospital counterparts, namely inadequate numbers of staff and assistive personnel. At the time of the pandemic, labour resources were considered statistically more significant by nurses in Czech non‐university hospitals (Gurková et al., 2021). According to Gurková et al. (2021), smaller, or non‐university hospitals, face more staffing problems. In four central European countries (Czechia, Slovakia, Poland and Croatia), unfinished nursing care was predicted by perceived adequacy of staffing, intention to leave workplace, type of hospital, type of unit, quality of care and job satisfaction (Zeleníková et al., 2020).

Identifying reasons for rationing of care may aid in selecting intervention to reduce the prevalence of implicitly rationed care. In the case of unexpected rise in patient volume or acuity on a unit, for example, a special team of nurses may be available in the healthcare facility to be deployed to the overloaded unit (Kalisch et al., 2009). Some hospitals employ special assistants to help patients with ambulation or oral care. Their role is to merely go around the unit performing these activities throughout their shift (Kalisch & Xie, 2014). In addition, optimizing work processes, using information technology, electronic health records, wearable devices and telehealth services may partially help to solve the nursing shortage. Finally, increasing investment in nursing education is necessary as the nursing workforce is ageing in many countries and the baby‐boom generation of nurses approaches retirement (OECD, 2022).

5.1. Limitation of the study

There are several limitations of the study. One of the limitations is using non‐randomized sample study. In addition, the sample was not homogeneous as general nurses and practical nurses were included. Another limitation is interruption in the data collection period due to COVID‐19 pandemic. However, the sample is large enough to give reliable data.

6. CONCLUSION

Inadequate number of staff and unexpected patient admission and discharge were perceived as the most significant reasons for not providing adequate nursing care to patients in surgical and medical units. Understanding reasons contributing to implicit rationing of nursing care may help to choose the appropriate intervention to reduce this phenomenon.

7. IMPACT TO NURSING SCIENCE, PRACTICE OR DISCIPLINARY KNOWLEDGE

Findings from this study contribute to our understanding of implicit rationing of nursing care and its reasons as perceived by nurses. The results showed nursing shortage to have the major impact on nurse care rationing. Strategies to limit implicit rationing of nursing care should take into account the most important reasons reported by nurses.

AUTHOR CONTRIBUTIONS

DJ, RZ: designed the study. DJ, IP, EM: collected the data. RZ, DJ: analysed the data. DJ, RZ, IP, EM: prepared the manuscript. All authors approved the final version for submission.

FUNDING INFORMATION

This study was supported by Ministry of Health of the Czech Republic, grant no. NV18‐09‐00420. All rights reserved.

CONFLICT OF INTEREST STATEMENT

No conflict of interest has been declared by the authors.

ACKNOWLEDGEMENTS

We would like to thank all nurses participated in our study.

Zeleníková, R. , Jarošová, D. , Mynaříková, E. , Janíková, E. , & Plevová, I. (2023). Inadequate number of staff and other reasons for implicit rationing of nursing care across hospital types and units. Nursing Open, 10, 5589–5596. 10.1002/nop2.1802

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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