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Anteayer Journal of Advanced Nursing

The “8050 issueˮ of social withdrawal and poverty in Japan’s super‐aged society

Abstract

Japan is now a super‐aged society, and the older population is estimated to reach 39.9% in 2060 (Cabinet Office, 2016). Long‐term care insurance was launched in 2000 to support the older population in community‐settings. Presently, many parents in their 80s who are receiving pensions are supporting their single children in their 50s who have experienced social withdrawal and been unemployed since their youth. This situation, commonly called the ‘8050 issue’, is increasing in Japan (Ministry of Health, Labour, and Welfare, 2019).

Issue Information

Journal of Advanced Nursing, Volume 76, Issue 5, May 2020.

Exploring the recruitment of men into the nursing profession in the United Kingdom

Abstract

To explore the gendered nature of the nursing working force To consider current initiatives and programmes to encourage men to enter the nursing profession. To understand some of the barriers to recruiting men into the nursing profession.

Benefits of a transtheoretical model‐based program on exercise adherence in older adults with knee osteoarthritis: a cluster randomized controlled trial

Abstract

Aims

Benefits of a transtheoretical model‐based exercise program on exercise adherence (primary outcome) and secondary outcomes (self‐efficacy, decisional balance, knee osteoarthritis symptoms and physical function) were assessed among older adults with knee osteoarthritis.

Design

A two‐arm, superiority, assessor‐blinded, cluster randomized trial with randomization at the community level.

Methods

Participants were recruited from 14 communities in Beijing between April and October 2018 (N = 189). The intervention was a 24‐week transtheoretical model‐based exercise program and the control group underwent a non‐theory‐based exercise program. Exercise adherence was collected every four weeks and secondary outcomes were measured at baseline, 12 and 24 weeks. An independent t‐test and repeated measures ANOVA were the main statistical tests.

Results

Most participants were women (92.5%), married (81.4%), with high‐school education (36.0%), with both knees affected (50.3%) and did not make use of a walker (93.8%). There were no significant differences between groups in any of the outcome measures at baseline. Repeated measures ANOVA indicated that there was a significant difference in the trend of adherence scores between the two groups from 0 to 24 weeks. The independent t‐test showed that scores in the intervention group were significantly better than in the control group at 16 weeks, 20 weeks and 24 weeks. Improvements in the intervention group were also significantly greater in all secondary outcomes than in the control group.

Conclusion

A theory‐based exercise program could improve exercise adherence, self‐efficacy, decisional balance, knee osteoarthritis symptoms and physical functioning in older adults with knee osteoarthritis.

Impact

The 24‐week theory‐based exercise program could improve exercise adherence, self‐efficacy, decisional balance, symptoms of knee osteoarthritis and physical functioning in older adults with knee osteoarthritis. The theory‐based exercise program could help older adults with knee osteoarthritis to improve their symptoms and knee function.

Barriers and facilitators to seasonal influenza vaccination uptake among nurses: A mixed methods study

Abstract

Aim

To identify the barriers and facilitators to seasonal influenza vaccination uptake among nurses.

Background

Seasonal influenza causes significant mortality and morbidity among older people and high risk groups. Vaccinating nurses against influenza is an essential public health measure to reduce the burden of disease. Yet despite annual recommendations, nurses’ influenza vaccine uptake rates remain low.

Design

An explanatory sequential mixed methods study design.

Data Sources

Qualified nurses attending mandatory training in two large acute hospitals in Ireland.

Methods

A paper‐based questionnaire assessing nurses’ knowledge, risk perception, health beliefs and influenza vaccination practices was distributed to a convenience sample of qualified nurses (N = 462) between September 2017 and February 2018. A self‐selected sample of thirty five nurses who completed the questionnaire participated in five focus groups to explore in depth the barriers and facilitating factors associated with their vaccination practices between September 2018 and October 2018. The questionnaire data were analysed statistically and thematic analysis was applied to the qualitative data. The quantitative and qualitative findings were integrated using the Pillar Integration Process.

Results

Seven themes emerged: (a) the influence of nurses’ knowledge on vaccine uptake; (b) dissemination of information; (c) vaccine fears and concerns; (d) protection, risk and vulnerability: self and others; (e) influencers; (f) accessibility; and (g) organisational pressure.

Conclusion

Achieving high vaccine uptake rates among nurses through voluntary vaccination programmes remains a challenge. Multi‐faceted influenza campaigns based on the HBM should be prioritised to address dissemination of evidence based information, accessibility and external cues to action.

Impact

Low influenza vaccine uptake among nurses compromises patient safety and contributes to a significant burden on health services. This study identified factors associated with vaccine practices among nurses and will inform the development of specific tailored interventions for nurses.

Hospital response to the COVID‐19 outbreak: the experience in Shanghai, China

Abstract

On 20th January 2020, the first COVID‐19 case was reported in Shanghai, China. As of 12th March 2020, 344 cases with laboratory‐confirmed COVID‐19 infection have been detected in Shanghai, of which three died, 321 patients are discharged, 20 patients still receive ongoing treatments (Shanghai Municipal Health Commission, 2020).

Nursing and the Novel Coronavirus: Risks and Responsibilities in a Global Outbreak

Abstract

In December of 2019, reports emerged of pneumonia clusters of unknown cause at health facilities in Wuhan, China. These cases were linked to a wet animal wholesale market in the region and, after extensive epidemiologic investigation, led to identification of a novel coronavirus (COVID‐19). COVID‐19 is among a family of viruses—called coronaviruses—that can affect both humans and animals (Zhu et al., 2020).

First Responder’s Care Package on management of road traffic accident victims of Udupi: Study Protocol

Abstract

Aim

To evaluate the effectiveness of ‘First Responder's Care Package’ on knowledge and skill on the management of road traffic accident victims. The outcomes relate to the quality of First Responder's care by autorickshaw drivers.

Methods

Autorickshaw drivers (N = 1,040) will be assessed to identify the impediments and knowledge to provide the first responder's care to Road Traffic Accident victims following which, 150 autorickshaw drivers will be selected based on a cut‐off knowledge score to train half of them using workshops. Drivers below 55 years and willing to participate will be recruited and drivers with serious health issues, hemophobia and who cannot read English or Kannada will be excluded. Randomized controlled trial with repeated measures design will be adopted. Funding for the research is by the Indian Council of Medical Research and it is registered in the Clinical Trial Registry of India.

Discussion

Road traffic accidents are responsible for 85% of the total global mortality and 90% of the ‘Disability Adjusted Life Years’ in the developing countries amounting to an annual loss of $65 billion to $100billion. India's rate of road traffic accident deaths is high and post‐crash care is not addressed efficiently by any agencies in India. Autorickshaw drivers could be ideal candidates for teaching the first responder's care package in India as they are a constant presence on the roads and reach all the main roads and small lanes of the country.

Impact

The research will add to knowledge on quality of First Responder's care provided to accident victims. If the intervention is found to be fruitful for the accident victims of the locality, it can be recommended to be implemented all over the state.

CO‐design of a patient and family‐initiated escalation of care intervention to detect and refer patient deterioration: Research protocol

Abstract

Aim

To co‐design a patient and family‐initiated intervention to improve the detection and escalation of patient deterioration on acute adult hospital wards in Northern Ireland and the Republic of Ireland.

Design

The design is a collective case study approach in an acute hospital in Northern Ireland and the Republic of Ireland using an adapted co‐design approach and Medical Research Council framework guidelines.

Methods

Data will be collected from key stakeholders (patients, relatives and healthcare professionals) using individual and focus group interviews and a review of patients’ records. This will inform the development of a co‐designed intervention and implementation strategy. The developed prototype will be further refined and optimised following a feedback session with stakeholders from each hospital site. This study was funded in February 2018 and Research Ethics Committee approval was granted in March 2019.

Discussion

This study will contribute to the growing knowledge base in relation to the interventions that improve the escalation of patient deterioration. It will also contribute to the intelligence, evidence and understanding of the role of patient and family participation in the detection and referral of clinical deterioration in acute adult hospital settings.

Impact.

There is an ongoing need to introduce systems or mechanisms in acute care hospital settings which allow patient or family members to have a greater role in escalating care when they are concerned regarding patient deterioration. To date there is limited evidence of rigorous studies examining this area and this study will use stakeholder engagement and involvement to co‐design an intervention which will provide patients and families with a mechanism to address concerns which can be tested in practice.

Visual art therapy as a treatment option for cognitive decline among older adults. A systematic review and meta‐analysis

Abstract

Aims

To investigate the effects of visual art therapy on cognitive and psychological outcomes and explore the crucial design characteristics of visual art therapy that might be associated with greater cognitive benefits among older adults.

Design

Systematic review and meta‐analysis.

Data sources.

Peer reviewed articles were searched from Medline, EMBASE, Global Health, Cochrane Library, Ovid Nursing database, PsycINFO, British Nursing Index and CINAHL Complete from inception of the databases to September 2019.

Review methods.

This review and meta‐analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. The Cochrane risk of bias tool was used to examine the risk of bias of the studies. Narrative synthesis and quantitative meta‐analysis were performed.

Result

Twelve articles published between 2004 – 2019 involving 831 participants were identified. Visual art therapy significantly improved global cognitive function compared with different control groups (Hedges’ g = 0.348 (95%CI = 0.026–0.671), p = .034, I 2 = 66.570%). Visual art therapy also demonstrated psychological benefits in reducing depressive symptoms and anxiety. By systematic comparison of the intervention designs, it seems that those with greater cognitive benefit involved a higher level of creativity and optimized the use of essential components including art‐education, reminiscence, art‐processing, cognitive evaluation, art‐crafts/modelling and socialization.

Conclusion

Visual art therapy could be effective in improving cognitive functions and the associated psychological symptoms. Therefore, it can be adopted as an effective non‐pharmacological intervention for preventing cognitive decline and dementia.

Impact

This review answers the key question regarding the pooled effect of visual art therapy as non‐pharmacological therapy on preventing or managing dementia. In addition, it informs on the design characteristics of an effective visual art therapy for implementing among older adults. This research will have an impact on the gerontological care and support the evidence regarding non‐pharmacological approaches to prevent and manage dementia.

Nativity Status and Workplace Discrimination in Registered Nurses: Testing the Mediating Role of Psychosocial Work Characteristics

Abstract

Aim

To examine: 1) whether nativity status was associated with workplace discrimination, 2) whether this association was mediated through psychosocial work characteristics (job strain, job demands and job control) among registered female nurses.

Design

Cross‐sectional survey with a self‐report questionnaire was conducted.

Methods

A random sample of 610 native Registered Nurses and a total sample of 188 foreign‐born Registered Nurses working in Finland were used. Data were collected between September ‐ November of 2017 and analyzed using a counterfactual approach in the causal mediation framework.

Results

After adjusting for several potential confounders, foreign‐born nurses scored higher on workplace discrimination than native nurses. Approximately 20% of the association between nativity status and workplace discrimination was mediated through job control. Job demands and job strain were unlikely to mediate this association.

Conclusion

The study provides further evidence that migrant status is associated with a higher risk of workplace discrimination among nurses. Lower levels of control over one's own job may partly contribute to the higher risk of workplace discrimination in foreign‐born women nurses.

Impact

Our study addresses the relationship between nativity status and workplace discrimination among female nurses and its mediating factors. The findings suggest that health care organization leaders need to be aware of the increased risk of workplace discrimination among migrant nurses. Moreover, health care organizations need to consider psychosocial work characteristics, including job control, in the efforts aimed to prevent and reduce discrimination against their foreign‐born employees.

Umbrella review of family‐focused care interventions supporting families where a family member has a long‐term condition

Abstract

Aim

To summarise reviews of family‐focused care interventions that support families with a family member with a long‐term condition across the life course.

Design

Umbrella review.

Data sources

Medline (1946‐ 2019), Cochrane Data Base of Systematic Reviews (2019), Database of Abstracts of Reviews of Effect and EMBASE (1947‐ 2019), CINAHL (1981‐2019), Health Technology Assessment Database (2019) and PsycInfo (1806‐2019).

Review Methods

All authors independently undertook title/abstract screening, data extraction and quality appraisal on a cluster of papers, working in groups of two or three to reach a consensus. The AMSTAR tool was used to appraise the quality of the studies and descriptive syntheses were undertaken.

Results

Fifteen reviews met the selection criteria. Overall family‐focussed care and associated terms were poorly defined. Typically interventions were educational or psychological therapy/counselling with the goal of empowering individuals to manage their condition. There is some evidence that family‐focused care interventions can improve clinical/biological health measures and self‐care outcomes such as treatment adherence. Multi‐component psychosocial interventions that include cognitive‐behavioral therapy, skills training, education and support and are focused on wider family members appear to improve family relationships and martial functioning.

Conclusion

Long‐term conditions have an impact on individual and family health and well‐being, yet the impact of family‐focused care interventions on family outcomes was overall inconclusive. A better understanding of how family‐focused care interventions improve the health and well‐being of individuals and their families is needed to promote the inclusion of family‐focused care into practice.

Impact

Supporting people with a long‐term condition is a key health and social care priority. Family‐focused care interventions have potential to improve the health and well‐being of individuals and families but there is a need to evaluate their clinical and cost effectiveness. The findings from this review could be used by funding bodies when commissioning research for long‐term conditions.

Does Ethical Leadership Boost Nurses’ Patient‐Oriented Organizational Citizenship Behaviors? A cross‐sectional study

Abstract

Aims

To examine the relationships between perceived ethical leadership, perceived interactional justice climate and patient‐oriented organizational citizenship behavior.

Design

A cross‐sectional non‐experimental design was employed.

Methods

The convenience sampling was adopted. Data were collected in July and August, 2018. A total of 738 nurses were recruited from eight Chinese hospitals. The survey included instrument scales of ethical leadership, interactional justice climate and patient‐oriented organizational citizenship behavior. SPSS version 22 was used to compute means, standard deviations and intercorrelations. The partial least squares structural equation modeling was chosen to estimate the path coefficients of the relationships.

Results

Relationships among perceived ethical leadership, perceived interactional justice climate and organizational citizenship behaviors were statistically significant. Perceived interactional justice climate mediated the relationship between perceived ethical leadership and nurses’ organizational citizenship behaviors.

Conclusions

Ethical leadership is related to interactional justice climate, which in turn, increases nurses’ organizational citizenship behavior. Nurse leaders are encouraged to exhibit ethical behaviors and to create justice climate. Ethical leadership scale can be used to select, train and evaluate the nurse supervisors and managers.

Impact

Hospital administrators are encouraged to recruit and promote those with both moral compass and leadership potential to nursing leadership positions. Nursing managers should create a justice climate in their hospitals. Hospital administrators could use ethical leadership scale to develop ethical leadership training programs.

Social Construction of Biopsychosocial and Medical Experiences of Women with Polycystic Ovary Syndrome

Abstract

Aim

To explore the perceived biopsychosocial and medical experiences of women with polycystic ovary syndrome, as presented in stories written by women on a social support website.

Design

Qualitative descriptive using low inference content analysis, guided by the social construction of illness theoretical framework.

Methods

In July 2018, 95 of 379 website stories were randomly selected. The stories were analyzed, ending in September 2018.

Results

Three major themes aligning with framework constructs were identified: Biopsychosocial struggles and management: “I can’t even look in the mirror without wanting to cry,” Sociocultural navigation: “I feel all alone and no one understands me.” and Healthcare encounters: “I don’t feel like I’m getting the help I need”. These themes revealed that PCOS has biological and experiential components, which exist independently of each other and hold social and cultural meanings.

Conclusion

Care for women with PCOS should be multidisciplinary, multidimensional and multi‐level to ameliorate biopsychosocial issues. Provider (physicians, nurse practitioners, physician assistants) education about PCOS is necessary to enhance timely diagnosis and implement individualized treatment strategies. Non‐advanced practice nurses are in a unique position to have an impact on patient satisfaction and clinical outcomes by providing and reinforcing patient education, coordinating management processes, counseling via telephone or in‐person appointments and facilitating referrals to ancillary providers. Evidence‐based and accessible psychosocial supports and interventions will lead to improved self‐esteem and effective coping skills, as well as reduced stigma‐related stress. Lastly, policy changes are warranted to address access to care, health insurance inequities and inadequate funding for PCOS‐related research.

Impact

Increased awareness of PCOS and its biopsychosocial aspects will aid providers with timely diagnosis and meaningful treatment plans. Women with PCOS will gain acknowledgment, acceptance and insight toward healthcare and self‐management.

The digital patient journey solution for patients undergoing elective hip and knee arthroplasty: Protocol for a pragmatic randomized controlled trial

Abstract

Aim

To describe a randomized controlled trial (RCT) protocol that will evaluate the effectiveness of a digital patient journey (DPJ) solution in improving the outcomes of patients undergoing total hip and knee arthroplasty.

Background

There is an urgent need for novel technologies to ensure sustainability, improve patient experience, and empower patients in their own care by providing information, support, and control.

Design

A pragmatic RCT with two parallel arms.

Methods

The participants randomized assigned to the intervention arm (N = 33) will receive access to the DPJ solution. The participants in the control arm (N = 33) will receive conventional care, which is provided face to face by using paper‐based methods. The group allocations will be blinded from the study nurse during the recruitment and baseline measures, as well as from the outcome assessors. Patients with total hip arthroplasty will be followed up for 8–12 weeks, whereas patients with total knee arthroplasty will be followed up for 6–8 weeks. The primary outcome is health‐related quality of life, measured by the EuroQol EQ‐5D‐5L scale. Secondary outcomes include functional recovery, pain, patient experience, and self‐efficacy. The first results are expected to be submitted for publication in 2020.

Impact

This study will provide information on the health effects and cost benefits of using the DPJ solution to support a patient's preparation for surgery and postdischarge surgical care. If the DPJ solution is found to be effective, its implementation into clinical practice could lead to further improvements in patient outcomes. If the DPJ solution is found to be cost effective for the hospital, it could be used to improve hospital resource efficiency.

A systematic review of activities undertaken by the unregulated nursing assistant

Abstract

Aim

to identify activities performed by nursing assistants in acute and primary healthcare.

Design

Systematic review.

Data Sources

The databases MedLine/PubMed, ProQuest and Google Scholar were searched for empirical studies published in the English language between 2008 and 2018 that addressed the work of nursing assistants.

Review Methods

From an initial yield of 2,944 publications, 71 publications were retained for full text review and 20 publications included in this review. Activities undertaken by Nursing Assistants’ from eight countries were extracted and categorised into one of six categories.

Results

Over 200 activities were identified as being delegated to Nurse Assistants globally. Many of these activities are beyond the training of the Nurse Assistant and are being performed with limited Registred Nurse supervision.

Conclusion

Patient safety is at risk. Nurse Assistants’ roles vary widely, with some seeing their role as similar to that of a regulated nurse, while recognising their need for additional training.

Impact

Over 31% of activities delegated to Nurse Assistants require skill and comprehension beyond their level of training.

Patients and regulated nurses need to have confidence that Nursing Assistants responsible for care provision are appropriately trained and practicing within regulatory standards.

Development and psychometric properties of the public attitude towards vaccination scale – Health belief model

Abstract

Aim

The aim of this study was to develop and psychometrically evaluate the Public Attitude Towards Vaccination Scale – Health Belief Model.

Design

A methodological and prospective psychometric study.

Method

A three‐phase construct was used to develop the Public Attitude Towards Vaccination Scale – Health Belief Model and to determine its psychometric properties: (1) creation of the item pool/conceptualization; (2) evaluation of the items; and (3) psychometric evaluation. This scale was tested using the construct validity (exploratory and confirmatory factor analyses) and the reliability analysis. A psychometric assessment of the scale was conducted with 586 individuals. Data were collected between January ‐ April 2018.

Results

Items of the scale were obtained by appraising the literature concerning vaccination and the other Health Belief Model scale and conducting interviews with mothers. The content validity ratio of this scale calculated according to experts’ opinions ranged between 0.769 and 1.00. According to the exploratory factor analysis, there were five factors with an eigenvalue higher than 1 in the scale. These five factors accounted for 68.9% of the total variance. In confirmatory factor analysis, values of fit indices were excellent or acceptable. This scale had high internal consistency and test–retest reliability.

Conclusion

This study successfully developed the Public Attitude Towards Vaccination Scale – Health Belief Model. In addition to researchers, this scale can be used by nurses while providing counselling for people with vaccine hesitancy/refusal.

Impact

This measurement tool can be used to understand and address ‘vaccine hesitancy’ by researchers. The results of the research using this measurement tool will provide valuable information to policymakers for preventing vaccine hesitancy. The validity and reliability of this scale can easily be conducted in different languages.

A systematic review of the effects of character strengths‐based intervention on the psychological well‐being of patients suffering from chronic illnesses

Abstract

Aims

To identify and evaluate available evidence on the effectiveness of character strengths‐based intervention on the psychological well‐being of patients with chronic illnesses.

Design

A systematic review with meta‐analysis.

Data sources

Six electronic databases, including PubMed, EMBASE, EBSCO (CINAHL® and MEDLINE), Web of Science and PsycINFO, were searched from inception to December 2018.

Review methods

The quality appraisal of evidence and summary of studies were undertaken following Joanna Briggs Institute critical appraisal checklists and the standard guidelines of Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. Meta‐analysis was conducted according to Cochrane methods using RevMan 5.1.

Results

Clinical studies on the character strengths‐based intervention for patients with chronic illnesses are limited. Eight studies involving 692 patients were identified and critically appraised in this review. Meta‐analysis results for three comparable studies indicated that character strengths‐based intervention was effective in improving the self‐esteem of patients with chronic illnesses and it significantly enhanced their general self‐efficacy and reduced their depression.

Conclusions

The findings support the effectiveness of character strengths‐based intervention on improving the psychological well‐being of patients with chronic illnesses. However, caution is needed in interpreting these results due to limited studies and heterogeneity across studies. Further research is needed to provide strong evidence on the applicability of the intervention in clinical practice.

Impact

This rigorous review provided current evidence on using character strengths‐based intervention to improve the psychological well‐being of patients with chronic illnesses. character strengths‐based intervention provides a creative approach for patients because it may help improve their well‐being, happiness, self‐esteem and self‐efficacy, as well as reduce depression and mental symptoms. Studies in different groups of patients suffering from chronic illnesses are recommended in the future. The character strengths‐based intervention should be replicated in various inpatient facilities and include a larger and a more ethnically and socioeconomically diverse sample.

The effects of therapeutic activity kits in emergency department patients with dementia: Study protocol for a pragmatic randomized control trial

Abstract

Aim

To determine the effectiveness of therapeutic activity kits on health service use and treatment delivered in the emergency department (ED) in patients with pre‐morbid dementia.

Design

Pragmatic randomized control trial with equal parallel groups.

Methods

Participants with dementia will be randomly assigned to the control group (N = 56) or the intervention group (N = 56). The intervention group will be given access to a therapeutic activity kit containing several different activities and sensory stimuli to engage the person with dementia during their ED stay in addition to usual care, and the control group will be given usual care only. A research nurse will observe participants at 30–60‐min intervals throughout their ED stay for responsive behaviours, one‐on‐one nursing, and the use of chemical and physical restraint. This study has received Research Ethics Committee approval from the institutional review board and funding from the Rosemary Bryant Foundation (May 2019).

Discussion

Emergency departments are busy and noisy environments and can be intimidating and disorientating for patients with dementia, which can result in responsive behaviours. Responsive behaviours are often managed with restrictive interventions, such as chemical or physical restraint, or with constant bedside nursing (one‐on‐one nursing) to ensure patient safety. Alternatively, non‐restrictive and non‐pharmacological interventions that divert or occupy the attention of patients such as those contained in the therapeutic activity kit can be considered as a more person‐centred strategy. Therapeutic activity kits have been reported as feasible for the use in ED; however, there is limited quality evidence at present to support the implementation of such interventions in the ED.

Impact

If this study is successful, it will demonstrate that a therapeutic activity kit containing activities (puzzles, colouring, music, and tactile activities) is inexpensive, easily implemented intervention that can prevent this patient group from demonstrating unsafe behaviours and requiring one‐on‐one nursing and restraints.

Psychometric testing of perceived implicit rationing of nursing care (PIRNCA)

Abstract

Aims

To evaluate the psychometric properties of the Perceived Implicit Rationing of Nursing Care (PIRNCA) instrument and to report the prevalence of rationed care at university and faculty hospitals.

Design

A cross‐sectional study.

Methods

The study was carried out at two university and five faculty hospitals in the Slovak Republic. Participants were 895 Registered Nurses recruited by the purposive sampling method between December 2017 and July 2018. Data were collected using the PIRNCA instrument. Construct validity and reliability of the instrument were tested.

Results

The prevalence of rationed care at university and faculty hospitals was identified as being 42.1 %. Furthermore, 87.6 % of nurses reported rationing one or more nursing care activities. Using both statistical methods when evaluating the PIRNCA resulted in the confirmation that the tool is valid and reliable.

Conclusion

Rationed care is a common phenomenon at university and faculty hospitals. The PIRNCA is a suitable instrument to measure the phenomenon in adult acute care units because of its high reliability and validity. We recommend using the instrument in different contexts, not only for specific conditions that were presented for this study.

Impact

Rationed care at university and faculty hospitals has never been reported. Psychometric properties of the instrument that measures nurses' perception of rationed care have never been evaluated by using different approaches. The most frequently rationed nursing care activities are those that nurses are competent to initiate on the basis of their knowledge and skills – the independent ones. The PIRNCA is a valid and reliable instrument. Hospital management can use the instrument to explore the prevalence of rationed care, followed by the application of prevention strategies. Our findings represent the base for further exploration of rationed care using the PIRNCA.

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