Rationing of nursing care and its relationship to patient outcomes : the Swiss extension of the International Hospital Outcomes Study

OBJECTIVE: 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.