Abstract

Background

In recent years, the healthcare industry has experienced a significant shift toward an awareness of the need for improving patient safety and quality of care. Patient safety is a critical aspect of healthcare and is essential in maintaining the well-being of patients [1,2]. However, RONC has become a common problem in healthcare institutions, affecting the quality of patient care and the safety of patients [3,4]. RONC refers to the intentional withholding or delay in provision of nursing care essential to maintaining the health and well-being of patients. This can lead to various adverse events, including medication errors, falls, pressure ulcers, and other complications.

The conceptual model of missed nursing care developed by Kalisch et al clearly states that structural factors that contribute to missed care include resources in the work environment, including material resources, teamwork, and team communication [5]. In a situation where any element is missing or not fully met, this will result in a delay or omission of care. It has been postulated that the most important factors influencing the omission of nursing care are staffing of the ward and lack of teamwork. The Kalisch concept, which considers the omission or lack of nursing care, emphasizes that this is a common threat that generates medical errors that directly affect patient safety. In addition, Schubert et al used a model to show that rationing of care is directly related to patient outcomes. In addition, research on rationing is intended to be a starting point for developing specific organizational strategies and standards of nursing practice necessary to achieve desired outcomes and patient safety [6]. Several studies have investigated the relationship between RONC and patient safety[7,8]. Missed nursing care is a result of many other factors of the nursing staff’s professional functioning, including low job satisfaction, high stress levels, an increase in staff turnover, a rise in job absenteeism, and the risk of burnout [9–11]. Nursing care is rationed based on psychological variables, including life satisfaction and life orientation. Low life satisfaction and a more negative outlook on life have been proven to be associated with a higher incidence of missing nursing care [12,13] Several strategies have suggested the need to address the problem of nursing care rationing and its impact on patient safety. One such strategy is implementation of workload management tools that enable nurses to prioritize care activities and identify patients who require immediate attention. Another strategy is improvement of staffing levels, which can reduce workload and prevent rationing of care [14]. The literature suggests that the discussion of appropriate nurse staffing levels and the measurement of workload is an area of considerable research that has been ongoing for several decades and continues to be assessed and evaluated. Despite the literature available on nurse workload and staffing requirements, there is still no specific method or tool to assess their impact on quality-of-care outcomes, patients, and staff. The issue is still relevant and continues to be included in new studies. It is now suggested that it would be optimal to review the available tools and to consider and develop a way to use them optimally, taking into account costs and consequences [15]. In addition, providing nurses with adequate resources, such as medical equipment and training, can improve their ability to provide safe and high-quality care. In addition to this fostering a positive work environment with opportunities for professional development and support for staff well-being, it can contribute to a reduction rationing and an improvement in patient safety [1,13]. Finally, developing a culture of transparency and open communication can facilitate the reporting and resolution of incidents related to rationing and improve the overall quality and safety of care.

Despite all this information and suggestions, it is still essential to address the growing ethical concerns of nursing care rationing and patient safety. Therefore, it is necessary to explore the factors that contribute to RONC and how it impacts patient safety. A systematic review of the literature on the topic will provide an in-depth analysis of the research conducted in this field, identifying the key factors that contribute to nursing care rationing and how it affects patient safety. This evaluation will offer helpful insights into the subject’s present level of research and make suggestions for further study and application.

Material and Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [16,17]. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (registration number: CRD42020201395).

Results

The search strategy for this systematic review involved multiple databases, including Academic Search Ultimate, CINAHL Complete, ERIC, MEDLINE, International Pharmaceutical Abstracts, and Health Source: Nursing/Academic Edition. A total of 1344 records were identified in the first phase, and after the removal of duplicates records, 401 unique papers were analyzed. The second phase involved rejecting 275 records based on title, keywords, and abstract analysis, resulting in 126 papers eligible for comprehensive analysis. From these, 113 records were excluded after a full-text analysis, resulting in 13 full-text papers eligible for detailed examination. Additionally, a manual search was conducted on various search engines and using citations identified manually in the selected articles that were not in the original query results. This step aimed to ensure that relevant papers that met the scope of the review were included. We finally included and analyzed 15 full-text papers. Figure 1 provides a flow diagram that reports the outcomes obtained in each phase, and Table 2 presents all the articles selected and analyzed.

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Figure 1

PRISMA 2020 flow diagram

Discussion

The literature shows that restricting nursing care has a detrimental effect on patient safety. The level of missing nurse care was found to be greater on medical-surgical and telemetry units than on specialized units, which is consistent with earlier studies. The level of RONC was positively associated with nurses’ self-perceived overwork, but patient-to-nurse ratios were not.

The literature suggests there is an urgent need for nurse leaders to take action to address the issue of RONC. The results of previous studies also indicate that cross-cultural comparisons allow for the examination of differences and similarities in safety dimensions across countries [22]. A study found that areas with potential for implementing strategies for improvement in 4 countries studied were staffing, non-punitive response to errors, and teamwork across hospital units [20].

Studies indicate that higher prevalence of understaffed nursing care is associated with more negative perceptions of patient safety [25]. Implicit RONC was also the most reliable predictor of patient satisfaction, nurse-reported prescription mistakes, bloodstream infections, and pneumonia. Higher levels of implicit RONC led to a significant decrease in the odds of patient satisfaction and a significant increase in the odds of nurse-reported medication errors, bloodstream infections, and pneumonia after controlling for major organizational variables and hierarchical data structure [2].

The findings imply that general medical/surgical units should monitor nursing care levels, as this could support the identification of any imbalances in the “work system,” such as insufficient nurse staffing or a lack of a skill mix to meet patients’ needs [26]. It may be possible for nurse managers to use measures to keep rationing at a level where patient safety is not compromised by identifying the thresholds at which it begins to negatively affect patient outcomes.

Throughout the course of the 10 years covered by the studies we included in this review, there was an overall increase in the rationing of care activities, with social and documentation activities showing the greatest rationing at both assessment periods. Moreover, a large rise in rationing of daily living activities was seen. The increased rates of RONC and long-term deterioration of staff resources are a troubling development, especially considering their potential detrimental effects on residents and caregivers [21]. Policy makers and nursing home management should consider routinely monitoring RONC to evaluate the quality of nursing home care and determine the proper staffing levels and skill combinations.

The studies we reviewed offer compelling evidence of the detrimental effects of nursing care rationing on patient safety. The results suggest that the issue of RONC needs to be urgently addressed by nurse leaders [22]. Regular monitoring of the RONC may help detect imbalances in the “work system,” such as inadequate nurse staffing or skill mix levels to meet patients’ needs, allowing nurse managers to implement interventions to maintain rationing at a level that mitigates any risk to patient safety.

Finally, we would like to emphasize the importance of the socio-ecological domain in the rationing of care. Jones et al [30] emphasized that the rationing of care as a global phenomenon is a complex socio-ecological problem that requires constant interdisciplinary exchange and consolidation of knowledge. Rationing of care is constantly juxtaposed with the problem of allocating social resources and ensuring quality health care for all. The authors point out that the sustainable development of care rationing requires cooperation on many levels, from computer science and engineering to psychology and ethics, for optimal understanding of unfinished care. Collaboration across many disciplines is necessary, and it seems crucial to recognize the activities that are being undertaken. These activities can be carried out in an additive (multidisciplinary), synthetic, and harmonized (interdisciplinarity) or integrated and transcendent (transdisciplinarity) interdisciplinary way [31]. Gidden’s proposed structure, covering both the social system and social psychology, despite its limitations and criticism, can constructively lead to a more comprehensive and unified theory [30].

Conclusions

The results and conclusions from the studies we reviewed indicate that rationing of nursing care is a widespread issue in healthcare settings across different countries and specialties. The amount of nursing care that was missing is consistent with other research, with greater levels observed in medical-surgical and telemetry units, and higher levels of rationing were negatively associated with staffing/resources, job satisfaction, and collegial nurse-physician interactions.

The present review also indicates that higher levels of implicit rationing of nursing care are associated with significant decreases in patient satisfaction and significant increases in the odds of nurse-reported medication errors, bloodstream infections, and pneumonia. Determining the levels at which rationing begins to have a negative impact on patient outcomes may allow nurse managers to introduce interventions to keep rationing at a level where patient safety is not jeopardized. The variability in rationing activities was found to be associated with nurses’ self-perceived workload.

Implications

The present study highlights the need for urgent nurse leader action and future research to address the issue of nursing care rationing and to improve patient outcomes. Nursing homes, hospitals, and other healthcare settings need to consider regular monitoring of rationing of nursing care to assess nursing home care quality and determine adequate staffing levels and skill mixes. Additionally, employers should develop implementation programs for young workers to avoid burnout and invest in factors increasing nurses’ satisfaction, such as improving workplace culture. The links among organizational and environmental factors, care rationing, and patient satisfaction must also be confirmed by additional research.

Availability of Data and Materials

All relevant data are included in this article. If necessary, it is possible to contact the corresponding author to obtain additional materials.

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