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Nursing Research

Rationing of Nursing Care Within Professional Environmental

Constraints: A Correlational Study
Evridiki Papastavrou, Panayiota Andreou, Haritini Tsangari, Maria Schubert and
Sabina De Geest
Clin Nurs Res 2014 23: 314 originally published online 3 January 2013
DOI: 10.1177/1054773812469543

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Article
Clinical Nursing Research

Rationing of Nursing
2014, V
  ol. 23(3) 314­–335
© The Author(s) 2012
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DOI: 10.1177/1054773812469543
Environmental cnr.sagepub.com

Constraints: A
Correlational Study

Evridiki Papastavrou, PhD, RN1,

Panayiota Andreou, MSc, PhDc, CPsych1,
Haritini Tsangari, PhD2,
Maria Schubert, PhD, RN3, and
Sabina De Geest, PhD, RN, FAAN, FRCN4

Abstract
The purpose of this study was to examine rationing of nursing care and
the possible relationship between nurses’ perceptions of their professional
practice environment and care rationing. A total of 393 nurses from medical
and surgical units participated in the study. Data were collected using the
Basel Extent of Rationing of Nursing Care (BERNCA) instrument and the
Revised Professional Practice Environment (RPPE) Scale. The highest level
of rationing was reported for “reviewing of patient documentation” (M =
1.15, SD = 0.94; 31.2% sometimes or often) followed by “oral and dental
hygiene” (M = 1.06, SD = 0.94; 31.5% sometimes or often) and “coping with
the delayed response of physicians” (M = 1.04, SD = 0.96; 30% sometimes or
often). Regression analyses showed that teamwork, leadership and autonomy,

1
Cyprus University of Technology, Limassol, Cyprus
2
University of Nicosia, Nicosia, Cyprus
3
University Hospital Zurich, Zurich, Switzerland
4
University of Basel, Basel, Switzerland

Corresponding Author:
Evridiki Papastavrou, PhD, RN, Department of Nursing, School of Health Sciences, Cyprus
University of Technology,Vragadinos 15, 3041, 3rd Floor, Office 311, Limassol, Cyprus.
Email: e.papastavrou@cut.ac.cy

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Papastavrou et al. 315

and communication about patients accounted in total 18.4% of the variance

in rationing. In regard to application, the association between the practice
environment and rationing suggests improvements in certain aspects that
could minimize rationing.

Keywords
care rationing, missed nursing care, professional practice environment

Background
Nursing scope of practice involves a wide range of responsibilities aiming to
ensure quality of care and patient safety. It is widely accepted that nurses
have the greatest amount of direct contact with patients and they provide
most of the care within the health care system (Aiken & Cheung, 2008).
Consequently, the volume and quality of nursing care has significant impli-
cations for the quality and safety of the entire health care system (Jones &
Yoder, 2010). This fundamental mission of the profession has been chal-
lenged recently by public accounts reporting cases of poor care and mistrust,
blaming nurse leadership and hospitals’ culture for allowing unacceptable
care to become the norm (Care Quality Commission, 2011).
There is also research evidence revealing that important elements of care
are being missed on a regular basis and may contribute to poor patient out-
comes and compromised patient safety (e.g., Lucero, Lake, & Aiken, 2009;
Schubert, Clarke, Glass, Schaffert-Witvliet, & De Geest, 2009; Sochalski,
2004). To cope with the scarcity of resources, time, low staffing, and patients’
needs, some nurses report a tendency to develop minimalistic standards of
care, rather than aiming at good or excellent care practice in their work, lead-
ing to limited patient care (Nortvedt et al., 2008). There are times when
nurses find it impossible to fulfill all nursing requirements or choose not to
complete all aspects of care, and in these circumstances they may reduce,
delay, or simply omit care (Kalisch, Landstrom, & Hinshaw, 2009).
Research studies have also established links between the level of rationing
and the work environment, arguing that nurses are kept from the bedside by
a variety of constraints, for example, lack of support, system insufficiencies,
and organizational failures (Rochefort & Clarke, 2010; Schubert et al., 2008;
Sochalski, 2004).
Although much of the debate around rationing is centered on macro
allocation, which refers to government policy and funding decision mak-
ing (Bourgeault et al., 2001), there is increasing pressure to focus on

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316 Clinical Nursing Research 23(3)

microallocation, or implicit rationing, that occurs at the patients’ bedside.

However, there is scarcity of research on what factors could be related to
and potentially influence nurses’ decisions, and how their decisions influ-
ence patient and nurses’ outcome. There is also a limited number of instru-
ments measuring rationing and those available have not been widely
applied yet so as to increase their robustness in time. Based on the princi-
ple of patient safety, an implied zero tolerance to nursing care rationing, in
line with patient safety movement, and the fact that some environmental
factors could be modifiable, this study aimed to investigate the association
between the work environment and rationing of nursing care.
This study builds on the conceptual framework developed by Schubert et
al. (2008) in which implicit rationing of nursing care is defined as “the with-
holding or failure to carry out necessary nursing tasks due to inadequate
time, staffing level and skill-mix” and that rationing may be influenced by
organizational attributes and the nurse practice environment. Rationing is
also regarded as an end product of clinical decision making and critical judg-
ment when nursing resources are too scarce to provide all the necessary care
to all patients. Nurses are then forced to ration their attention across patients,
minimize or omit certain duties, thereby increasing the risk of adverse
patient outcomes. This process is influenced by the nurses’ and patients’
characteristics as well as by environmental characteristics, such as team-
work, leadership, nurses’ autonomy and responsibility, the philosophy of
care, as well as the amount of available time and resources, such as staff,
skill mix, and equipment (Hendry & Walker, 2004; Kalisch et al., 2009;
Morin & Leblanc, 2005).
An alternative terminology was introduced, that of “missed care,” defined
as “any aspect of required patient care that is omitted or delayed” (Kalisch
et al., 2009). For the purposes of this study, the terms rationing and missed
care are used synonymously. Another group of researchers have looked at
rationing from an ethical and philosophical perspective, highlighting the
principles of justice, equality of care, and value considerations in the deci-
sion-making processes (Halvorsen, Førde, & Nortvedt, 2008, 2009; Nortvedt
et al., 2008). Despite the methodological differences, the diverse approaches,
and the broader policy-level context of most studies, literature provides con-
siderable agreement on the aspects of care being rationed: Nursing staff tend
to focus on biomedical and clinical tasks with less attention to basic human
needs. The aspects of care being rationed include fundamental elements of
care, such as ambulation, hygiene, feeding, surveillance, patient teaching,
and discharge planning as well as care documentation (Bittner & Gravlin,
2009; Kalisch, 2006; Morin & Leblanc, 2005). Nurses on medical–surgical

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Papastavrou et al. 317

wards spend more time in supporting activities than providing patient care
(Storfjell, Ohlson, Omoike, Fitzpatrick, & Wetasin, 2009) and focus on medi-
cal needs that are specific and visible while neglecting essential aspects of
patient care (Kalisch, 2006; Tønnessen, Nortvedt, & Førde, 2011).
In addition, more comprehensive needs and elements of care, such as
empathetic listening and communication, may be jeopardized due to lack of
time and a subjective focus on what the most urgent medical treatment is
(Halvorsen, Slettebø, et al., 2008; Slettebø et al., 2010; Tønnessen, Førde,
& Nortvedt, 2009). In some cases, nurses define appropriate care based on
administrative decisions, and formalities entail dominance of the legal
aspects rather than the patient’s individual need for care (Tønnessen et al.,
2011).
When rationing is viewed as an outcome variable influenced by charac-
teristics of the work environment, most studies identified factors, such as
teamwork (Kalisch & Lee, 2010), nurse staffing and resource adequacy,
lack of time, and training as all being related to specific aspects of care not
addressed by nurses (Rochefort & Clarke, 2010; West, Barron, & Reeves,
2005). Investigating the impact of rationing on patient outcomes (Schubert
et al., 2008; Schubert et al., 2009) showed that implicit rationing was asso-
ciated with factors, such as patient mortality, nurse reports on patient falls,
nosocomial infections, and pressure ulcers; it has also been linked with
patient satisfaction levels. Other authors have evaluated the quality of nurs-
ing care on the basis of care deficiencies showing that quality care ratings
by nurses and patient safety were significantly related to the rates of unfin-
ished care (Lucero et al., 2009; Rochefort & Clarke, 2010; Sochalski,
2004). Similarly, nurses reported the impact of rationing at an individual
level, such as low job and occupational satisfaction, intention to leave, and
turnover (Kalisch, Tschanen, & Lee, 2011; Tschannen, Kalisch, & Lee,
2010).
The aims of the study were to explore the level and aspects of rationing of
nursing care, and the potential relationship between nurses’ perception of
their professional practice environment and rationing.

Method
Design and Setting

This is a descriptive, correlational, cross-sectional multicentre study using

nurse survey data from nurses working in all the public general hospitals of
the country.

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318 Clinical Nursing Research 23(3)

Participants
Nurses were recruited via convenience sampling from the surgical and inter-
nal medicine departments from all the public general hospitals of the country.
The inclusion criteria were as follows: Nurses had to be (a) registered
according to the national legislation, which is in line (or harmonized) with
the EU Directives regarding mutual recognition of professional qualifica-
tions in Europe (Directive 2005/36/EC); (b) actively involved in direct
patient care; and (c) willing to participate in the study. Power analysis indi-
cated that the minimum number of participants to get a power of 99% (α =
.05) was 318 nurses.

Data Collection and Ethical Considerations

The data were collected over a 9-month period in 2010 and 2011. The ques-
tionnaires were anonymous; nurses were informed in writing about the pur-
pose of the study, including its voluntary nature, with a guarantee of the
confidentiality of the data. Return of the questionnaire was considered as
informed consent. The nurses were given the questionnaires, with a sealed
envelope at their work place; they were returned into a box that was placed
and left for 2 weeks at the ward office. The study was approved by the
National Bioethics Committee (ΕΕΒΚ ΕΠ 2010.01.21), and permission to
access the hospital facilities was granted by the Ministry of Health and the
administrators of each participating hospital separately.

Measures and Variables

The participating nurses completed two questionnaires: the Basel Extent of
Rationing of Nursing Care (BERNCA; Schubert, Glass, Clarke, Schaffert-
Witvliet, & De Geest, 2007) and the Revised Professional Practice
Environment (RPPE; Erickson, 2007).
The BERNCA Questionnaire. Two instruments were identified in the litera-
ture exploring rationing of nursing care. The first is the U.S.-developed
MISSCARE SURVEY with two parts: measuring missed care and the rea-
sons for missed care (Kalisch & Williams, 2009). The second instrument is
the BERNCA Questionnaire (Schubert et al., 2007), which was used for the
current study as it was developed within a European context that is closer to
the organization of care in the country under study.
The BERNCA questionnaire is a validated scale assessing implicit ration-
ing addressing areas, such as activities of daily living, care and support,

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Papastavrou et al. 319

rehabilitation, surveillance, and security. It comprises 20 negatively phrased

questions on a list of tasks related to the above areas, and nurses need to indi-
cate how often they were not able to perform these in the past 7 days they
have been working. Responses are marked on a 4-point Likert-type scale and
rationing score is obtained from the average sum of all items (range: 0-3).
The reliability of the instrument was measured using Cronbach’s alpha,
where a value of .93 indicated high internal consistency (Schubert et al.,
2007). The construct validity was confirmed with exploratory factor analysis;
the results indicated a one-factor solution, which confirmed the instruments’
one-dimensional internal structure (Schubert et al., 2007).
The RPPE scale. The evaluation of the nurse environment characteristics
was based on the RPPE scale, a 39-item validated instrument focusing on
dimensions related to the professional environment of clinical practice. Other
measures, such as the Nurse Work Environment Index–Revised (Aiken &
Patrician, 2000), address similar concepts but include more items and deal
with additional areas related to the working environment rather than profes-
sional practice only. The participants are asked to indicate on a 4-point Likert-
type scale their agreement to statements and descriptions of their working
environment with no reference to a particular time frame. The scale com-
prises eight subscales on Handling Disagreement and Conflict (9 items);
Internal Work Motivation (8 items); Control Over Practice (5 items); Leader-
ship and Autonomy in Clinical Practice (5 items); Staff Relationships With
physicians (2 items); Teamwork (4 items); Cultural Sensitivity (3 items);
Communication About Patients (3 items). The score of each subscale is based
on its corresponding mean item scores. The construct validity of the scale
was assessed by comparing whether the eight components of the scale derived
from a sample could be validated with a second sample, both drawn from the
same population. The results confirmed the original conceptually derived
model’s structure. Cronbach’s alpha coefficients for the eight RPPE sub-
scales ranged from .80 to .88 (Erickson, Duffy, Ditomassi, & Jones, 2009).
Low scores on the BERNCA suggest low levels of rationing whereas low
scores on the RPPE suggest low evaluation of the various aspects of the
professional practice environment. Nurse characteristics, such as gender,
age, educational level, employment status, and number of years of experi-
ence in nursing were measured based on questionnaire items developed for
this study.
The adaptation procedure of the instruments in the Greek language. The
RPPE scale has been translated into several languages and used in interna-
tional studies (Papastavrou et al., 2011). The BERNCA questionnaire was

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320 Clinical Nursing Research 23(3)

translated following the guidelines of MAPI for translating and validating

health research instruments for cross-cultural use (MAPI Institute, 2009).
Initially, the underlying concepts of each item of the original instrument
were clarified among the research team. The second step consisted of for-
ward translations of the instrument from English into Greek by two inde-
pendent bilingual health professional translators. After the two forward
translations, to establish semantic equivalence, the research team had rec-
onciliation meetings to reach consensus and in the third step, the best Greek
version of the instrument was back translated by another translator that was
discussed by the research team. The fourth step included pilot testing the
Greek version of the instruments using two parallel procedures: (a) a cogni-
tive debriefing, aiming to assess the clarity, intelligibility, appropriateness,
and cultural relevance of the target language version to the target popula-
tion and (b) a clinician’s review approach, used to obtain input from experts
regarding the translation as to the domain-specific terminology of the
instrument and to incorporate feedback from potential clinical users of the
instrument. As part of this fourth step, the Greek version of the instrument
was pilot tested among a sample of 10 participants. Any comments made by
the participants regarding the wording of the scale were considered by the
research team and included where appropriate in the final version of the
instrument.

Data Analysis
Statistical analysis was performed at the individual level unless specified
otherwise. Descriptive statistics such as percentages, means, and standard
deviations were used to describe the sample characteristics, rationing of
nursing care (BERNCA scale measuring the frequency of the activities
being rationed), and perception of professional practice environment (RPPE
scale measuring the level of agreement with each environment-related
dimension). For descriptive purposes, the BERNCA scale was classified
into two categories, based on a grouping of the response options, namely no
rationing/rarely, and sometimes/often. Similarly, the RPPE Scale was
grouped into agree/strongly agree and disagree/strongly disagree. Rationing
scores were highly skewed and nonparametric tests were used to explore the
relationship with the professional practice environment. Hierarchical mul-
tiple regression analysis (forward method) was used to assess the contribu-
tion of the significant professional practice environment subscales (as
independent variables) toward rationing of nursing care (as dependent

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Papastavrou et al. 321

variable) while accounting for the sociodemographic characteristics.

Missing data on the RPPE scale was handled based on the guidelines of the
scale, that is, if a case had more than 10% of missing data across the scale
items then the case was removed from any subsequent analysis. There were
18 cases that were dropped because of missing data on the RPPE scale.
There were no corresponding guidelines for the BERNCA scale. The current
study used listwise analysis, that is, cases were included if they had data on
all BERNCA scale items for the specific analysis. The level of significance
level was set at .05. Data were analyzed using SPSS 18.0 for Windows
(SPSS Inc., Chicago, IL).

Results
Demographics

A total of 715 questionnaires were distributed because the response rate was
expected to be low according to other studies in this country (Kalogirou,
Lambrinou, Middleton, & Sourtzi, 2012). In all, 433 questionnaires were
returned (response rate 60.6%) and 393 questionnaires were considered eli-
gible for analysis. For the statistical analyses involving the BERNCA and the
RPPE scales and the sociodemographic variables, the sample was reduced to
N = 356 because of missing data. The sample covered all the regions of the
country, and it was as representative as possible of the research population.
All the sociodemographic characteristics appear in Table 1. Although the
majority of nurse participants were female (71%), the number of male nurses
is quite high compared with the number of male nurses in other countries
(Suhonen et al., 2011). The average age of the participants was less than 35
years, which reflects the age of the overall nurse population of the country.
Approximately, a quarter of the nurse participants possessed a university
degree in nursing (24%), and on average had more than 10 years of profes-
sional experience (M = 11.41 years).

Reliability of the Instruments

The Cronbach’s reliability coefficient for the BERNCA was .91 and for the
RPPE was .89. For the individual RPPE factors, Cronbach’s alpha were as
follows: Handling Disagreement and Conflict .60, Internal Work Motivation
.84, Control Over Practice .77, Leadership and Autonomy in Clinical
Practice .78, Staff Relationships With Physicians .74, Teamwork .76,
Cultural Sensitivity .80, and Communication About Patients .58.

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322 Clinical Nursing Research 23(3)

Table 1. Nurse Characteristics.

Demographic variables n (%) Mean SD

Response rate 393 (55)  
Age (in years) range  
 21-59 34.06 9.41
Gender  
 Females 278 (71)  
 Males 115 (29)  
Education  
  Nursing school diploma (3 years) 293 (74.5)  
  University degree (4 years) 93 (24)  
  Master’s degree 2 (0.5)  
Employment  
 Permanent 301 (77)  
 Temporary 85 (22)  
Experience in nursing (in years) 11.41 9.27
Experience in current department 5.32 5.47
(in years)
Place of work  
  Internal medicine ward 156 (40)  
  Surgical ward 211 (54)  

Aspects of Nursing Care Rationing

The average number of tasks reported being rationed were 11.14 (SD = 5.20).
Mann–Whitney test indicated that rationing in surgical departments was
lower (median = 0.68) than in medical wards (median = 0.85), U = 18.97,
z = 2.77, p = .006. The overall mean value of rationing at the individual level
was 0.83 (SD = 0.52, median = 0.75, range = 0-3).
The highest mean level of rationing, compared with the other tasks, was
measured for the item “reviewing of patient documentation at the beginning
of the shift” (M = 1.15, SD = 0.94) with 31.2% of the respondents reporting
this occurring as sometimes or often. This was followed by the item “oral and
dental hygiene for the patient” (M = 1.06, SD = 0.94; 31.5% reported occur-
ring sometimes or often), “coping with the delayed response of physicians”
(M = 1.04, SD = 0.96; 30% reported occurring sometimes or often), and the
“emotional or psychological support” (M = 1.03, SD = 0.88; 29% reported
occurring sometimes or often). The lowest was observed for bathing and skin

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Papastavrou et al. 323

care (M = 0.61, SD = 0.81; 13.9% reported occurring sometimes or often). All

the results are presented in Table 2.

The Professional Practice Environment

The overall mean of the RPPE scale was 2.76 (SD = 0.32, median = 2.76,
range = 1.28-3.69). Correlations among RPPE factors ranged from 0.034 to
0.594. As Table 3 shows, mean ratings fell within the middle, and the least
values were for Control Over Practice. In other words, the majority of nurses
felt there was no sufficient control over practice for good patient care
(95.2%), and that disagreement and conflict at their working place was not
dealt with (84.5%). Nonetheless, nurses rated their self-generated motivation
for work highly (77.6%) as well as their interaction with doctors (75.3%).
The association between rationing of nursing care and professional practice
environment. Kendall’s tau correlation coefficient between the two instru-
ments showed significant but low correlation between five of eight factors of
the professional environment investigated and rationing with, that is Internal
Work Motivation (τ = −0.191), Leadership and Autonomy (τ = −0.221), Staff
Relations With Physicians (τ = −0.186), Teamwork (τ = −0.263), and Com-
munication About Patients (τ = −0.286), with all p values <.001 (see Table 4).
The regression model included the five significant RPPE subscales to
rationing, namely Internal Work Motivation, Leadership and Autonomy,
Staff Relations With Physicians, Teamwork, and Communication About
Patients, and sociodemographic variables, namely age, gender, and educa-
tion. Experience in nursing at the current department and work experience
overall were excluded because of multicollinearity with age (r = .68 and .95,
respectively).
As indicated in Table 5, the RPPE factors accounted for 18.4% of the vari-
ance in rationing with Teamwork, Leadership and Autonomy, and
Communication About Patients being significant compared with the rest of
the RPPE factors. Teamwork explained most of the variance at 13.3%, fol-
lowed by Leadership and Autonomy at 3.5%. None of the sociodemographic
variables increased variance explanation. An increase of a standard deviation
in teamwork (0.57) was associated with reduction of a 0.22 standard devia-
tion in rationing. Thus, for every 0.57 increase in teamwork score, there was
a reduction of 0.17 in rationing (95% confidence Interval [CI] = −0.31,
−0.10). Similarly, a 0.57 increase in leadership and autonomy and a 0.48
increase in communication about patients was associated with a reduction of
0.08 in rationing (95% CI = −0.24, −0.04 and −0.31,−0.05, respectively).

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324 Clinical Nursing Research 23(3)

Table 2. Rationing of Nursing Care (Range: 0-3)a.

Never; n Rarely; n Sometimes–
Question Mean (SD) (%) (%) often; n (%)

1. Activities of daily living  

  1a. Bathing/ skin care 0.61 (0.81) 221 (56.8) 114 (29.3) 54 (13.9)
  1b. Perform oral or dental 1.06 (0.94) 129 (33.3) 136 (35.1) 122 (31.5)
hygiene for the patient
  1c. Eating 0.66 (0.80) 178 (51.6) 121 (35.1) 46 (13.4)
  1d. Mobilizing/ changing position 0.73 (0.84) 186 (47.9) 135 (34.8) 68 (17.3)
  1e. Managing body waste (urine, 0.62 (0.85) 222 (57.2) 111 (28.6) 55 (14.2)
stool, vomit)
  1f. Changing bed linen 0.89 (0.99) 173 (44.5) 126 (32.4) 90 (23.1)
2. Caring—Support  
  2a. Emotional or psychological 1.03 (0.88) 122 (31.3) 155 (39.7) 113 (29.0)
support
  2b. Conversation with patients 0.99 (0.87) 129 (33.1) 157 (40.3) 104 (26.6)
or their families
3. Rehabilitation—Instruction—  
Education
  3a. Toilet training 0.64 (0.85) 220 (56.4) 108 (27.7) 62 (15.9)
  3b. Activating/rehabilitating care 0.85 (0.85) 155 (39.8) 155 (39.8) 79 (20.3)
  3c. Education of patients 0.77 (0.80) 171 (44.0) 147 (37.8) 71 (18.2)
  3d. Preparation for hospital 0.62 (0.77) 208 (53.5) 126 (32.4) 55 (14.1)
discharge
4. Monitoring—Safety  
  4a. Adequate monitoring of 0.83 (0.78) 143 (37.0) 180 (46.5) 64 (16.6)
patients’ vital signs
  4b. Adequate monitoring of 0.70 (0.93) 221 (57.1) 87 (22.5) 79 (20.4)
confused/impaired patients
  4c. Coping with the delayed 1.04 (0.96) 134 (35.0) 134 (35.0) 115 (30.0)
response of physicians
  4d. Respond promptly to patient 0.79 (0.92) 192 (49.6) 106 (27.4) 89 (23.0)
calls
  4e. Adequate hand hygiene 0.70 (0.83) 196 (50.8) 123 (31.9) 67 (17.4)
5. Documentation  
  5a. Reviewing of patient 1.15 (0.94) 104 (26.8) 163 (42.0) 121 (31.2)
documentation at the
beginning of the shift
  5b. Formulate/update patient 0.94 (0.84) 130 (33.7) 166 (43.0) 90 (23.4)
care plans
  5c. Documentation of 0.87 (0.83) 145 (37.5) 166 (42.9) 76 (19.6)
performed nursing care

Note: Entries in boldface indicate activities with the highest level of rationing.
a. Rationing level: 0 = Never/no rationing; 1 = Rarely; 2 = Sometimes; 3 = Often.

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Papastavrou et al. 325

Table 3. The Professional Practice Environment Subscales (Range: 1-4)a.

Strongly Disagree— Agree—strongly

Variables Mean (SD) disagree; n (%) agree; n (%)
Handling 2.61 (0.36) 332 (84.5) 61 (15.5)
disagreement and
conflict
Internal work 3.21 (0.46) 88 (22.4) 305 (77.6)
motivation
Control over 2.03 (0.54) 374 (95.2) 19 (4.8)
practice
Leadership & 2.80 (0.57) 214 (54.5) 179 (45.5)
autonomy in
clinical practice
Staff relationships 2.92 (0.60) 97 (24.7) 296 (75.3)
with physicians
Teamwork 2.80 (0.57) 209 (53.2) 184 (46.8)
Cultural sensitivity 2.70 (0.64) 198 (50.4) 195 (49.6)
Communication 2.94 (0.48) 147 (37.4) 246 (62.6)
about patients
a. Agreement level: 1 = Strongly disagree; 2 = Disagree; 3 = Agree; 4 = Strongly disagree.

Table 4. Correlations Between the Revised Professional Practice Environment

(RPPE) Subscales and Rationing.
RPPE total and subscales

RPPE Internal Control Leadership Staff relations

total Handling work over and with Cultural Communication
  scale disagreement motivation practice autonomy physicians Teamwork sensitivity about patients

Rationing −0.234* −0.042 −0.191* −0.076 −0.221* −0.186* −0.263* −0.008 −0.286*

*p < .001.

Discussion
The results of the study provided evidence about the level of nursing care
rationing and the elements of nursing care omitted or not carried out. Nurses’
perceptions about their professional environment were not very positive and
some aspects were correlated negatively with rationing of nursing care. An
increase in ratings of certain environment dimensions, such as Teamwork,

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326 Clinical Nursing Research 23(3)

Table 5. Multiple Regressions of the Environmental Factors on Rationing.

Variance
b SE b β inflation factor
Model 1  
 Constant 1.775 0.130  
 Teamwork −0.339 0.046 −0.365* 1.000
Model 2  
 Constant 2.089 0.151  
 Teamwork −0.263 0.049 −0.283* 1.195
  Leadership and autonomy −0.189 0.049 −0.204* 1.195
in clinical practice
Model 3  
 Constant 2.312 0.171  
 Teamwork −0.203 0.053 −0.218* 1.448
  Leadership and autonomy −0.143 0.051 −0.154** 1.348
in clinical practice
  Communication about −0.177 0.066 −0.160** 1.565
patients
Note: R2 = .133 for Model 1; ΔR2 = .035 for Model 2 (p < .001); ΔR2 = .016 for Model 3 (p < .01).
*p < .001. **p < .01.

Leadership and Autonomy, and Communication About Patients was also

associated with a decreased level of rationing.

Rationing of Necessary Nursing Care

The reported overall mean rationing level of 0.83 indicates that nurses on
average were rarely unable to provide the necessary nursing tasks listed in
the BERNCA, and this finding is in line with previous research (Schubert
et al, 2008). One explanation may be attributed to the problems in reporting
care deficits. Some authors argue that nurses are not willing to report omitted
care because of feelings of guilt and powerless to correct the situation
(Kalisch, 2006) or are fearful about the repercussions, retribution, and blame
(Attree, 2007). Kalisch et al. (2009) compared the underreporting of missed
care as similar to the tradition of hiding patient errors that the current patient
safety movement aims to correct. Another explanation is that before they
withhold a necessary nursing measure, nurses use first other strategies such
as providing care in a lower quality in order to save time or by prolonging

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Papastavrou et al. 327

the time interval between two measures. Therefore, certain nursing tasks may
not actually be omitted, but they are not carried out properly.

Aspects of Rationing in Nursing Care

One third of the study participants reported having inadequate time to review
patient documentation at the beginning of their shift and formulate or update
patient care plans. Nursing documentation is an essential component of care
that provides evidence of nurses’ management, the patient response, and
evaluation of care. Although nursing documentation defines the performance
of nursing practice and is essential for patient safety, there is evidence that
nurses are not using patient documentation effectively (Jefferies, Johnson, &
Griffiths, 2010). In the rationing literature, our results are consistent with
previous research (Lucero et al., 2009; Schubert et al., 2007) supporting
documentation failures, such as incomplete intake and output documents
(Kalisch, 2006) and raising concerns regarding the assessment of the
patients’ condition before the implementation of any intervention.
Oral or dental hygiene was another nursing task most frequently omitted
in this study. Also in other studies, this task was frequently withheld (Bittner
& Gravlin, 2009; Gravlin & Phoenix Bittner, 2010; Lucero et al., 2009), a
low priority was given to oral care by nurses, and a gap between practices and
policy was shown (Costello & Coyne, 2008; Feider, Mitchell, & Bridges,
2010; Southern, 2007).
Another area frequently rationed in this study was caring and support as
assessed by the BERNCA questionnaire. This aspect of care is clearly defined
in the National Law for the Protection of Patients’ Rights stating that patients
and their families have the right to receive respectful treatment according to
their cultural values as well as continuous psychological support (Patients’
Rights Act 2005, section 1(I), part 2, article 5). Supporting patient and their
families and providing psychological support is also an important aspect of
caring. Furthermore, the empirical evidence shows a link between emotional
or psychological support and positive patient outcomes in critically ill
patients, which underlines the relevance of this nursing care aspect
(Papathanassoglou, 2010). However, there are indications that nurses do not
consistently conduct an assessment of the patients’ psychosocial needs
(Kalisch, 2006; West et al., 2005). Reasons for this might be that psychoso-
cial support often appears as peripheral or even outside the nurses’ primary
responsibilities, which mainly focus on biomedical tasks (Nortvedt et al.,
2008). Hendry and Walker (2004) suggest that patient needs may be classi-
fied as high, intermediate, and low priority: low priority needs require

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328 Clinical Nursing Research 23(3)

minimal support, they can be left until later, and may include psychological
and physiological dimensions.
Relatively high rationing levels were reported in the area of “monitoring
and safety” and the tasks “monitor the patients’ vital signs,” “adequately
monitor confused or impaired patients,” and “respond promptly to patients’
calls.” There is evidence indicating a link between neglecting monitoring
confused patients and higher complications, injuries, mortality, and morbid-
ity rates in this group (Cacchione, 2002; DeCrane, Culp, & Wakefield, 2011;
Ouimet, Kavanagh, Gottfried, & Skrobik, 2007). In addition, not responding
promptly to patient calls was strongly criticized in the Care Quality
Commission (2011). In order to ensure patient safety and a well-functioning
24-hour monitoring system provided by the nurses, interventions are required
to monitor and reduce the rationing levels in this area.

The Professional Practice Environment

There is a lot of discussion around nursing work environment, it’s’ complexi-
ties, and the impact on outcomes for patients. A worrying finding of the current
study is that nurses’ perceptions of their professional practice environment are
still not encouraging and are similar to the findings of a previous international
project (Papastavrou et al., 2011). Among the seven countries that participated
in the latter study, nurses from this country had the lowest scores in Leadership
and Autonomy in clinical practice (M = 2.53, p < .001). In this study, the sub-
scales Teamwork (M = 2.80, SD = 0.57) and Communication About Patients
(M = 2.94, SD = 0.48) had relatively low scores but higher when compared
with the international study (M = 2.61, SD = 0.44 and M = 2.79, SD = 0.52,
respectively). Other researchers who used the same instrument in Finland also
reported higher scores of the practice environment compared with this study,
and significant correlations with the support of patient individuality as well as
the perceptions of individuality in care provided (Charalambous, Katajisto,
Välimäki, Leino-Kilpi, & Suhonen, 2010).

Relationship Between Professional Practice

Environment and Rationing of Nursing Care
The results have shown that a 1-point increase in the three environmental
subscales Leadership and Autonomy in Clinical Practice, Teamwork, and
Communication About Patients were significantly associated with a lower
rationing level. These significant associations also remain after during the
second step the demographic were added. Similar findings are reported in

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Papastavrou et al. 329

other studies using the same or similar methodologies (Rochefort & Clarke,
2010; Schubert et al., 2008; Schubert et al., 2007).
Teamwork among health care providers explained much of the variance
in rationing; this aspect of the nursing work environment is essential for
patient safety and some studies have provided a link between teamwork and
patient outcomes (Kalisch, Curley, & Stefanov, 2007). The relation of team-
work to missed nursing care was explored in two studies (Kalisch et al.,
2009; Kalisch & Lee, 2010). The significant association between the prac-
tice environment dimension “teamwork” and rationing found in our study is
also in line with Kalisch and Lee’s (2010) work who found an important
association between better teamwork and lower levels of missed nursing
care after accounting for individual nurse characteristics. Although the
aforementioned studies are based in different sociocultural and organiza-
tional contexts, the findings support the contribution of teamwork in care-
rationing decisions.
There is very little literature exploring Leadership and Autonomy in
Clinical Practice and rationing, as examined in this study. A plausible expla-
nation for their association may be related to the amount of decisional auton-
omy that nurses possess in assigning care hours when asked to prioritize the
treatment and diagnostic dimensions of care (Morin & Leblanc, 2005;
Nortvedt et al., 2008).
Although the statistical correlation of the professional environment sub-
scales and implicit rationing is low, the clinical significance is important as
other studies have shown; even low levels of rationing are strongly associated
with deteriorating patient outcomes, and rationing was found as a strong
independent predictor of those outcomes (Schubert et al., 2008; Schubert
et al., 2009).

Limitations of the Study

Rationing of nursing care is a sensitive issue and nurses are not always will-
ing to report cases of work undone (Attree, 2007; Kalisch, 2006), which may
partly explain the relatively low response rate. However, studies examining
response rates in the assessment of clinical nurses work environment report
that 40% is considered acceptable (Kramer, Schmalenberg, Brewer, Verran,
& Keller-Unger, 2009). Second, the use of self-completed questionnaires
may have led to self-report bias (as nurses may have been reluctant to make
an honest report of rationing during their clinical practice; Polit, Beck, &
Hungler, 2001). Third, the questions of the BERNCA Scale are negatively
phrased (e.g., “how often you could not assist a patient” or “you could not

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330 Clinical Nursing Research 23(3)

monitor a patient”), which could have been difficult to understand. In addi-

tion, there are tasks that are not applicable to certain nurse subgroups; thus,
data could yield a higher percentage indicating “never” as there was not a not
applicable reply option. There is a revised version of the scale underway that
incorporates this option that was not available at the time of data collection
(Schubert, 2010, personal communication). Furthermore, the correlational
nature of the data did not allow making inferences for the causality of vari-
ables. Regarding the RPPE instrument, two subscales, namely Handling
Disagreement and Conflict and Communication About Patients, had low
internal consistency scores. However, similar findings were also found in
other work (Charalambous et al., 2010; Papastavrou et al., 2012) based on
similar nursing samples.
Despite these limitations, the results of this study are consistent with stud-
ies conducted in different health care systems, organizational contexts, and
diverse cultural backgrounds (Kalisch & Lee, 2010; Schubert et al., 2008).

Conclusion and Application

The findings of this study are in line with previous research, which suggests
that rationing of nursing care is a newly identified organizational variable
influenced by teamwork and other practice environment factors (Kalisch &
Lee, 2010; Schubert et al., 2008). Identifying the type of and reasons for
care being missed or omitted, and the predictors of rationing will facilitate
hospital organizations to develop care environments in which patient recov-
ery is not compromised. Given that previous studies have shown that even
low levels of rationing are strongly associated with deteriorating patient
outcomes, investing on factors that may reduce nursing care rationing are
worthwhile.
However, rationing of care is a phenomenon that has not been thoroughly
investigated in nursing. Additional studies are needed to determine the valid-
ity of these findings, explore the conditions under which care is rationed, and
to develop a deeper understanding of this phenomenon and its relationship
with quality care and patient outcomes.
There are several implications for practice arising from the results of this
study. Their importance lies in the association of rationing with certain envi-
ronmental factors that can be modified and changed. The findings point to the
need for a continuous assessment of the level and areas of rationing and pro-
vide data to nursing management for transforming the work environment so
as to facilitate the development of a safe care environment. This study also
provides evidence as to the importance of teamwork among nurses who work

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Papastavrou et al. 331

together to provide all necessary care to patients and points to a need to

address the barriers to teamwork, educating staff in how to be effective team
members, as well as encouraging leadership training and enhancing nurses’
autonomy in decision making. The third aspect is related to Communication
About Patients and its role with rationing; more attention needs to be focused
on this area and the methods needed to implement it, such as the use of elec-
tronic health records or structured patient documentation systems that have
been developed and used for many years to facilitate information dissemina-
tion (Björvell, Wredling, & Thorell-Ekstrand, 2003; Gunningberg, Fogelberg-
Dahm, & Ehrenberg, 2009). Finally, explicitly and openly discussed rationing
issues may facilitate a better understanding of the causes and impacts for both
the patients and nurses.

Acknowledgments
The authors would like to thank Jeanette Ives Erickson (Vice President) and Dorothy
Jones (Director) of the Yvonne Munn Center for Nursing Research, Massachusetts
General Hospital for their permission to use the Revised Professional Practice
Environment. The authors are grateful to the nurses who participated in the study and
Maria Evangelou for the language checking.

Authors’ Note
Written permission to use the BERNCA instrument and the RPPE scale was obtained.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This study was funded by the Cyprus
University of Technology.

References
Aiken, L. H., & Cheung, R. (2008). Nurse workforce challenges in the United States:
Implications for policy (OECD Health Working Papers No. 35). Paris, France:
Organisation for Economic Co-operation and Development.
Aiken, L. H., & Patrician, P. A. (2000). Measuring organizational traits of hospitals:
The revised Nursing Work Index. Nursing Research, 49, 146-153.
Attree, M. (2007). Factors influencing nurses’ decisions to raise concerns about care
quality. Journal of Nursing Management, 15, 392-402.

Downloaded from cnr.sagepub.com at UCSF LIBRARY & CKM on August 14, 2014
332 Clinical Nursing Research 23(3)

Bittner, N. P., & Gravlin, G. (2009). Critical thinking, delegation, and missed care in
nursing practice. Journal of Nursing Administration, 39, 142-146.
Björvell, C., Wredling, R., & Thorell-Ekstrand, I. (2003). Prerequisites and conse-
quences of nursing documentation in patient records as perceived by a group of
registered nurses. Journal of Clinical Nursing, 12, 206-214.
Bourgeault, I. L., Armstrong, P., Armstrong, H., Choiniere, J., Lexchin, J.,
Mykhalovskiy, E., & White, J. (2001). Everyday experiences of implicit ration-
ing: Comparing the voices of nurses in California and British Columbia. Sociol-
ogy of Health & Illness, 23, 633-653.
Cacchione, P. Z. (2002). Four acute confusion assessment instruments: Reliability and
validity for use in long-term care facilities. Journal of Gerontological Nursing,
28, 12-19.
Care Quality Commission. (2011). National overview: Dignity and nutrition inspec-
tion programme: National overview, HSMC policy paper (Policy Paper). New-
castle upon Tyne, England: Author.
Charalambous, A., Katajisto, J., Välimäki, M., Leino-Kilpi, H., & Suhonen, R.
(2010). Individualised care and the professional practice environment: Nurses’
perceptions. International Nursing Review, 57, 500-507.
Costello, T., & Coyne, I. (2008). Nurses’ knowledge of mouth care practices. British
Journal of Nursing, 17, 264-268.
DeCrane, S. K., Culp, K. R., & Wakefield, B. (2011). Twelve-month mortality among
delirium subtypes. Clinical Nursing Research, 20, 404-421.
Erickson, J. I. (2007). The MGH Revised Professional Practice Environment (RPPE)
scale. Boston: Massachusetts General Hospital.
Erickson, J. I., Duffy, M. E., Ditomassi, M., & Jones, D. (2009). Psychometric evalu-
ation of the Revised Professional Practice Environment (RPPE) scale. Journal of
Nursing Administration, 39, 236-243.
Feider, L. L., Mitchell, P., & Bridges, E. (2010). Oral care practices for orally intu-
bated critically ill adults. American Journal of Critical Care, 19, 175-183.
Gravlin, G., & Phoenix Bittner, N. (2010). Nurses’ and nursing assistants’ reports of
missed care and delegation. Journal of Nursing Administration, 40, 329-335.
Gunningberg, L., Fogelberg-Dahm, M., & Ehrenberg, A. (2009). Improved quality
and comprehensiveness in nursing documentation of pressure ulcers after imple-
menting an electronic health record in hospital care. Journal of Clinical Nursing,
18, 1557-1564.
Halvorsen, K., Førde, R., & Nortvedt, P. (2008). Professional challenges of bedside
rationing in intensive care. Nursing Ethics, 15, 715-728.
Halvorsen, K., Førde, R., & Nortvedt, P. (2009). The principle of justice in patient
priorities in the intensive care unit: The role of significant others. Journal of Medi-
cal Ethics, 35, 483-487.

Downloaded from cnr.sagepub.com at UCSF LIBRARY & CKM on August 14, 2014
Papastavrou et al. 333

Halvorsen, K., Slettebø, Å., Nortvedt, P., Pedersen, R., Kirkevold, M., Nordhaug, M.,
& Brinchmann, B. S. (2008). Priority dilemmas in dialysis: The impact of old age.
Journal of Medical Ethics, 34, 585-589.
Hendry, C., & Walker, A. (2004). Priority setting in clinical nursing practice: Litera-
ture review. Journal of Advanced Nursing, 47, 427-436.
Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta-study of the essentials of qual-
ity nursing documentation. International Journal of Nursing Practice, 16, 112-124.
Jones, T. L., & Yoder, L. (2010). Economic theory and nursing administration
Research—Is this a good combination? Nursing Forum, 45, 40-53. doi:10.1111/
j.1744-6198.2009.00160.x
Kalisch, B., Tschanen, D., & Lee, H. (2011). Does missed nursing care predict job
satisfaction? Journal of Healthcare Management, 56, 117-131.
Kalisch, B. J. (2006). Missed nursing care: A qualitative study. Journal of Nursing
Care Quality, 21, 306-313.
Kalisch, B. J., Curley, M., & Stefanov, S. (2007). An intervention to enhance nursing
staff teamwork and engagement. Journal of Nursing Administration, 37, 77.
Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A
concept analysis. Journal of Advanced Nursing, 65, 1509-1517.
Kalisch, B. J., & Lee, K. H. (2010). The impact of teamwork on missed nursing care.
Nursing Outlook, 58, 233-241. doi:10.1016/j.outlook.2010.06.004
Kalisch, B. J., & Williams, R. A. (2009). Development and psychometric testing of a tool
to measure missed nursing care. Journal of Nursing Administration, 39, 211-219.
Kalogirou, F., Lambrinou, E., Middleton, N., & Sourtzi, P. (2012). Cypriot nurses’
knowledge of heart failure self-management principles. European Journal of Car-
diovascular Nursing. Advance online publication. doi:10.1177/1474515112440367
Kramer, M., Schmalenberg, C., Brewer, B. B., Verran, J. A., & Keller-Unger, J.
(2009). Accurate assessment of clinical nurses’ work environments: Response rate
needed. Research in Nursing & Health, 32, 229-240.
Lucero, R. J., Lake, E. T., & Aiken, L. H. (2009). Variations in nursing care qual-
ity across hospitals. Journal of Advanced Nursing, 65, 2299-2310. doi:10.1111/
j.1365-2648.2009.05090.x
MAPI Institute (2009). Linguistic validation—methodology. Retrieved from http://
www.mapi-institute.com/linguistic-validation/methodology
Morin, D., & Leblanc, N. (2005). Less money, less care: How nurses in long-term
care allocate hours of needed care in a context of chronic shortage. International
Journal of Nursing Practice, 11, 214-220.
Nortvedt, P., Pedersen, R., Grothe, K., Nordhaug, M., Kirkevold, M., Slettebo, A., &
Andersen, B. (2008). Clinical prioritisations of healthcare for the aged: Profes-
sional roles. Journal of Medical Ethics, 34, 332-335.
Ouimet, S., Kavanagh, B. P., Gottfried, S. B., & Skrobik, Y. (2007). Incidence, risk
factors and consequences of ICU delirium. Intensive Care Medicine, 33, 66-73.

Downloaded from cnr.sagepub.com at UCSF LIBRARY & CKM on August 14, 2014
334 Clinical Nursing Research 23(3)

Papastavrou, E., Efstathiou, G., Acaroglu, R., Da Luz, M. D. A., Berg, A.,
Idvall, E., & Suhonen, R. (2011). A seven country comparison of nurses’ percep-
tions of their professional practice environment. Journal of Nursing Management.
Advance online publication. doi:10.1111/j.1365-2834.2011.01289.x
Papastavrou, E., Efstathiou, G., Tsangari, H. H., Suhonen, R., Leino-Kilpi, H.,
Patiraki, E., & Merkouris, A. (2012). A cross-cultural study of the concept of
caring through behaviours: Patients’ and nurses’ perspectives in six different EU
countries. Journal of Advanced Nursing, 68, 1026-1037.
Papathanassoglou, E. D. E. (2010). Psychological support and outcomes for ICU
patients. Nursing in Critical Care, 15, 118-128.
Polit, D., Beck, C., & Hungler, B. (2001). Essentials of nursing research methods,
appraisal, and utilization (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Rochefort, C. M., & Clarke, S. P. (2010). Nurses’ work environments, care rationing,
job outcomes, and quality of care on neonatal units. Journal of Advanced Nursing,
66, 2213-2224.
Schubert, M., Clarke, S. P., Glass, T. R., Schaffert-Witvliet, B., & De Geest, S. (2009).
Identifying thresholds for relationships between impacts of rationing of nursing
care and nurse-and patient-reported outcomes in swiss hospitals: A correlational
study. International Journal of Nursing Studies, 46, 884-893. doi:10.1016/j.
ijnurstu.2008.10.008
Schubert, M., Glass, T. R., Clarke, S. P., Aiken, L. H., Schaffert-Witvliet, B.,
Sloane, D. M., & De Geest, S. (2008). Rationing of nursing care and its rela-
tionship to patient outcomes: The swiss extension of the international hospital
outcomes study. International Journal for Quality in Health Care, 20, 227-237.
doi:10.1093/intqhc/mzn017
Schubert, M., Glass, T. R., Clarke, S. P., Schaffert-Witvliet, B., & De Geest, S. (2007).
Validation of the basel extent of rationing of nursing care instrument. Nursing
Research, 55, 416-424.
Slettebø, Å., Kirkevold, M., Andersen, B., Pedersen, R., Halvorsen, K.,
Nordhaug, M., & Nortvedt, P. (2010). Clinical prioritizations and contextual con-
straints in nursing homes ? A qualitative study. Scandinavian Journal of Caring
Sciences, 24, 533-540. doi:10.1111/j.1471-6712.2009.00745.x
Sochalski, J. (2004). Is more better? The relationship between nurse staffing and the
quality of nursing care in hospitals. Medical Care, 42, II-67-II-73.
Southern, H. (2007). Oral care in cancer nursing: Nurses’ knowledge and education.
Journal of Advanced Nursing, 57, 631-638.
Storfjell, J. L., Ohlson, S., Omoike, O., Fitzpatrick, T., & Wetasin, K. (2009). Non-
value-added time: The million dollar nursing opportunity. Journal of Nursing
Administration, 39, 38-45.
Suhonen, R., Efstathiou, G., Tsangari, H., Jarosova, D., Leino-Kilpi, H., Patiraki, E.,
& Papastavrou, E. (2011). Patients’ and nurses’ perceptions of individualised care:

Downloaded from cnr.sagepub.com at UCSF LIBRARY & CKM on August 14, 2014
Papastavrou et al. 335

An international comparative study. Journal of Clinical Nursing. Advance online

publication. doi:10.1111/j.1365-2702.2011.03833.x
Tønnessen, S., Førde, R., & Nortvedt, P. (2009). Fair nursing care when resources
are limited: The role of patients and family members in norwegian home-based
services. Policy, Politics, & Nursing Practice, 10, 276-284.
Tønnessen, S., Nortvedt, P., & Førde, R. (2011). Rationing home-based nursing care:
Professional ethical implications. Nursing Ethics, 18, 386-396. doi:10.1177/
0969733011398099
Tschannen, D., Kalisch, B. J., & Lee, K. H. (2010). Missed nursing care: The impact
on intention to leave and turnover. Canadian Journal of Nursing Research, 42(4),
22-39.
West, E., Barron, D. N., & Reeves, R. (2005). Overcoming the barriers to patient-
centred care: Time, tools and training. Journal of Clinical Nursing, 14, 435-443.
doi:10.1111/j.1365-2702.2004.01091.x

Legislation
Directive 2005/36/EC. (2005). Directive 2005/36/EC of the European Parliament and
of the Council of September 7, 2005 on the recognition of professional qualifica-
tions. Retrieved from http://ec.europa.eu/internal_market/qualifications/policy_
developments/legislation_en.htm
Patients’ Rights Act. (2005). (Republic of Cyprus), section 1(I), part 2, article 5
(no 3943, 1.I. 2005).

Author Biographies
Evridiki Papastavrou, PhD, RN, is an assistant professor at the School of Health
Sciences, Department of Nursing, Cyprus University of Technology, Cyprus.

Panayiota Andreou, MSc, PhDc, CPsych, is a research associate at the School of

Health Sciences, Department of Nursing, Cyprus University of Technology, Cyprus.

Haritini Tsangari, PhD, is a statistician and an associate professor at the Department

of Economics and Finance, School of Business, University of Nicosia, Cyprus.

Maria Schubert, PhD, RN, is a clinical nurse scientist and Head Team of the Patient
Safety Centre of Clinical Nursing Science, Nursing Department of the University
Hospital Zurich, Switzerland.

Sabina De Geest, PhD, RN, FAAN, FRCN, is a professor of nursing and Director at
Institute of Nursing Science Faculty of Medicine of the University of Basel,
Switzerland.

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