Dear Editor,

Contextual rationing of nursing care is a reality that flies in the face of ethical, managerial, and organizational policy expectations of provision of full care. Referred to as covert rationing, missed or unfinished care, care rationing is perceived to be an outcome of extraordinary demands placed on nurses (Scott et al., 2019). Care rationing occurs when nurses fail to or cannot provide certain care due to time, staffing, or skill constraints (Zhu et al., 2019).

Relevant currently, a landmark analysis by the Institute of Medicine (2004) reported that as demands on nursing increase due to insurance reimbursement policies, subsequent efforts of health organizations to curtail costs, and changes in staffing, ripple effects include increased acuity of patients, decreased length of hospital stays, increased readmissions, increased care coordination and documentation, redesigned work, inadequately trained staff, and turnover.

Empirical research with nurses demonstrates that care rationing occurs with patient instability and complexity with no leeway for unanticipated events such as admits/discharges or care needs, high patient loads, time accessing needed resources, nursing or auxiliary staff shortage, inadequately oriented staff needing assistance, high turnover, organizational lack of support, and nurse burnout (Chiappinotto & Palese, 2022). Missed care may include emotional support to patients, adequate surveillance, education, and/or planning of care (White et al., 2019).

Mandal et al. (2020) and Chaboyer et al. (2021) noted that rationing care correlates with poor patient care, decreased patient and nurse satisfaction, higher adverse events, longer stays, and readmissions. A recent meta-analysis corroborates adverse events to include falls, falls with severe injuries, nosocomial infections, medication errors, pressure injuries, suicide, and mortality. These events could occur due to simple omissions such as hand hygiene, education, monitoring, or repositioning (Kalankova et al., 2020). Care rationing has devastating consequences and is an ethical dilemma.

The American Nurses Association (2015) Code of Ethics, Provision 3, states that “the nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 9). Provision 6 reiterates patient safety and emphasizes that “the nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care” (American Nurses Association, 2015, p. 23). Mandal et al. (2020) identified care rationing as antagonistic to ethical nursing and professional health. Nurses perceive their ethical standards for safety being compromised by financial concerns and unrealistic workloads and as leading to depersonalization or resignation (Harvey et al., 2020).

While some may argue that cost curtailment and redesigning work are inevitable parts of adapting and staying financially viable, the stakes are high. While nurses should improve care prioritization, changes are crucial in organizational approaches and recognition that time for better nursing care is the wise approach leading to patient satisfaction, safety, decreased readmissions, and financial viability. Staffing algorithms must consider patient complexity and unanticipated events. Nurses must be supported in providing quality care and be a part of policy making. Moral apathy does not belong in healthcare.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretative statements.
https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

Chaboyer, W., Harbeck, E., Lee, B. O., & Grealish, L. (2021). Missed nursing care: An overview of reviews. The Kaohsiung Journal of Medical Sciences, 37(2), 82-91.
https://doi.org/10.1002/kjm2.12308

Chiappinotto, S., & Palese, A. (2022). Unfinished nursing care reasons as perceived by nurses at different levels of nursing services: Findings of a qualitative study. Journal of Nursing Management, 30(7), 3393-3405. https://doi.org/10.1111/jonm.13800

Harvey, C., Thompson, S., Otis, E., & Willis, E. (2020). Nurses’ views on workload, care rationing and work environments. Journal of Nursing Management, 28(4), 912-918.

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. https://doi.org/10.17226/10851.

Kalánková, D., Kirwan, M., Bartoníčková, D., Cubelo, F., Žiaková, K., & Kurucová, R. (2020). Missed, rationed or unfinished nursing care: A scoping review of patient outcomes. Journal of Nursing Management, 28(8), 1783-1797. https://doi.org/ 10.1111/jonm.12978

Mandal, L., Seethalakshmi, A., & Rajendrababu, A. (2020). Rationing of nursing care, a deviation from holistic nursing: A systematic review. Nursing Philosophy, 21(1), e12257.

Scott, P. A., Harvey, C., Felzmann, H., Suhonen, R., Habermann, M., Halvorsen, K., Christiansen, K., Toffoli, L., & Papastavrou, E. (2019). Resource allocation and rationing in nursing care: A discussion paper. Nursing Ethics, 26(5), 1528-1539.

White, E. M., Aiken, L. H., & McHugh, M. D. (2019). Registered nurse burnout, job dissatisfaction, and missed care in nursing homes. Journal of the American Geriatrics Society, 67(10), 2065-2071.

Zhu, X., Zheng, J., Liu, K., & You, L. (2019). Rationing of nursing care and its relationship with nurse staffing and patient outcomes: The mediation effect tested by structural equation modeling. International Journal of Environmental Research and Public Health, 16(10), 1672-1683.