The relationship of staffing and work environment with implicit rationing of nursing care in Swiss nursing homes - A cross-sectional study

Franziska Zuniga, Dietmar Ausserhofer, Jan P. H. Hamers, Sandra Engberg, Michael Simon, Rene Schwendimann*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background: Implicit rationing of nursing care refers to the withdrawal of or failure to carry out necessary nursing care activities due to lack of resources, in the literature also described as missed care, omitted care, or nursing care left undone. Under time constraints, nurses give priority to activities related to vital medical needs and the safety of the patient, leaving out documentation, rehabilitation, or emotional support of patients. In nursing homes, little is known about the occurrence of implicit rationing of nursing care and possible contributing factors. Objectives: The purpose of this study was (1) to describe levels and patterns of self-reported implicit rationing of nursing care in Swiss nursing homes and (2) to explore the relationship between staffing level, turnover, and work environment factors and implicit rationing of nursing care. Design: Cross-sectional, multi-center sub-study of the Swiss Nursing Home Human Resources Project (SHURP). Settings: Nursing homes from all three language regions of Switzerland. Participants: A random selection of 156 facilities with 402 units and 4307 direct care workers from all educational levels (including 25% registered nurses). Methods: We utilized data from established scales to measure implicit rationing of nursing care (Basel Extent of Rationing of Nursing Care), perceptions of leadership ability and staffing resources (Practice Environment Scale of the Nursing Work Index), teamwork and safety climate (Safety Attitudes Questionnaire), and work stressors (Health Professions Stress Inventory). Staffing level and turnover at the unit level were measured with self-developed questions. Multilevel linear regression models were used to explore the proposed relationships. Results: Implicit rationing of nursing care does not occur frequently in Swiss nursing homes. Care workers ration support in activities of daily living, such as eating, drinking, elimination and mobilization less often than documentation of care and the social care of nursing homes residents. Statistically significant factors related to implicit rationing of care were the perception of lower staffing resources, teamwork and safety climate, and higher work stressors. Unit staffing and turnover levels were not related to rationing activities. Conclusions: Improving teamwork and reducing work stressors could possibly lead to less implicit rationing of nursing care. Further research on the relationship of implicit rationing of nursing care and resident and care worker outcomes in nursing homes is requested.
Original languageEnglish
Pages (from-to)1463-1474
JournalInternational Journal of Nursing Studies
Issue number9
Publication statusPublished - Sept 2015


  • Missed care
  • Nursing care left undone
  • Nursing home
  • Omitted care
  • Rationing of care
  • Staffing
  • Teamwork
  • Turnover
  • Work stressors

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