Protocol for a Systematic Review of Rationing of Nursing Care

Introduction

Since the last two decades nurse researchers across the world have been studying the concept of “Rationing of care.” The findings of these studies suggest that nursing care rationing is widespread ^1-3. However, the levels of rationing reported across studies showed inconsistency ^4,5. As a concept, “rationing of care” is considered to be relatively new as most of the researches done in this area were in the last decade although sporadic researches on nurses missing and leaving care undone were being studied earlier. A secondary analysis of nursing survey data collected in 1998 have recorded that a very high percentage of nurses left necessary nursing works undone when reported in hospitals across five countries.⁶ There have been studies in the past that have tentatively thrown light on specific aspects of nursing care being omitted or missed.^6-9 However, it was Dr Beatrice Kalisch of USA who was the first to study this concept of care rationing within the perspective of “Nursing care” ² Since then many researchers have studied the concept in the context of “Patient safety” & “quality of care” and have called it as “Missed care” in nursing.^3,10,11-14 Independent to their works but somewhat during the same time nurse researchers from European countries were studying the same phenomena and called it “Implicit Rationing of nursing care”. They studied the phenomena within the framework of nursing workload and decision making.^1,5,15,16 Researchers from the Scandinavian countries have also studied the phenomena of nursing care rationing but from the perspective of ethics and justice of care & called it as “prioritization of care”^17-21.Whatsoever may it be named but the commonality of all these researches lie in the ground that rationing have been linked with two very important aspect of health care, namely “quality of nursing care” and “patient's safety and satisfaction”.

The existing systematic review on this topic by Papastavrou is more than five years old.²² This review will build upon that research systematically consolidating the level of rationing, aspects of rationing, factors influencing rationing and its impact on nurses and patients across countries. Thus the evidence synthesis of this review will help to understand “rationing of nursing care” & identify evidence gap. This review will further help to inform policies and programmes pertaining to nursing and patient care.

Conceptual definition of rationing of nursing care

Dr Schubert has studied rationing within the conceptual framework of nurses' decision making and has defined it as “the withholding of or failure to carry out necessary nursing measures for patients due to lack of nursing resources such as staffing, skill mix, or time”.¹This framework places environmental components like availability of time and resources as pivotal factors influencing nurses doing rationing of care.¹

Dr Kalisch studied the phenomena within the conceptual framework of patient safety and errors of omission. She called it “missed care” in nursing and indicated it being influenced by both external as well internal factors like individual nurses' beliefs, habits and decision making.

“Prioritization” and “Priority setting” are some other terms used by researchers who focused on the nurses' organization of their work in order to maximize patient outcomes.

“Unmet nursing care needs ”and “unfinished care” are other terms used by researchers for “Rationing of nursing care” and have served as Quality indicators for nursing care. ^{4, 23} for ease of reference this review will be using the term “rationing of nursing care” throughout the text. The others terms will be used while discussing the corresponding literature.

The review will attempt to answer questions regarding:

1. Levels of “Rationing of nursing care”

2. Aspects of nursing tasks that are being rationed

3. Reasons that influence rationing of nursing care

4. Potential effect of rationing on Nurses and patients

Methods

Preferred Reporting Items for Systematic reviews and Meta analysis protocol-P 2015 (PRISMA) guidelines were used to prepare the protocol of the review.²⁴ This protocol is already registered with PROSPERO International Prospective register for systematic reviews (CRD 42018088679).

Search strategy: Search of literature for this systematic review will follow three steps without any restriction on the date of publication.

• Initially only MEDLINE and CINAHL plus will be searched with the keywords. The titles and the abstracts from the above search will be analysed looking for additional keywords.

• In the second step a detailed search will be conducted with all identified keywords in the following databases namely, Psyc Info, Web of Science, EMBASE in addition to CINAHL plus and MEDLINE.

• In the last step searching of the references of all selected studies will be carried out to look for more researches.

Inclusion criteria

Studies should meet the following criteria to become eligible to be included in the review.

1. Researches published only in peer reviewed journals

2. Available in electronic databases

3. Study design: only quantitative studies will be included in the review

4. Intervention: Studies that explicitly deal with rationing of nursing care as the main variable will be included in the review.

5. Population: Studies must have samples including nurses of any level and experience across all genders, age, race, country or religion.

6. Settings: Conducted in an acute or chronic care clinical setting

7. Outcomes: Studies will be included if they describe either or all of the following variables

   1. Level of rationing,

   2. Aspects of rationing,

   3. Factors influencing rationing,

   4. Rationing and its effect on patients or/and nurses.

8. Language: English only articles

   1. Studies that have used the terms “missed care”,

      “Unfinished nursing care”, “Unmet nursing care needs” will be included even if they do not explicit the definition of “rationing of nursing care.”

Exclusion criteria

1. Studies that have used mixed samples of nurses with other health care providers will be excluded.

2. Conference abstracts, books & grey literature will be excluded

Results

The findings of the studies will be grouped under each review question and presented in the same order as the review questions are mentioned in the protocol. A descriptive synthesis will be carried out and will be presented as a narrative summary in a tabular form under each research question. Both narrative description as well as statistical findings of studies will be used in the summaries. This review will not be pooling statistical findings of various studies for Meta analysis.

Discussions

Rationing of nursing care is in direct contradiction to Holistic nursing thus creating a dent in “quality nursing care”. Therefore an up to date evidence synthesis on “rationing of care” will help the nursing community to identify the commonality & differences in the levels, aspects, reasons and effects of rationing across studies done in various parts of the world and at different times. Moreover this review will be able to discuss the methodological strength and limitations of the various studies in researching “Rationing in care”.

Conclusion

This review will help the nursing community in general and individual nurses in particular to understand the extent and effect of “rationing of nursing care”. It will also help in policy decisions for practice and will identify gaps in the existing literature and suggest areas for further research.