Monthly variation of unfinished nursing care at the US Army Burn Center.

OBJECTIVE: To describe the monthly variation in the prevalence and patterns of unfinished nursing care and to determine the relationships between the system of nursing care and unfinished nursing care at the US Army Burn Center. METHODS: This was a repeated measures, descriptive study. For one week per month for six months, all nurses providing direct patient care on two inpatient burn units (intensive care and progressive care) were asked to complete an anonymous paper survey, which contained the Perceived Implicit Rationing of Nursing Care instrument, to estimate the prevalence of unfinished nursing care on their unit. Unit administrative data also were collected from the unit nursing leaders each month. Descriptive statistics and multilevel modeling were used in the analysis. RESULTS: Most (80.5%) eligible nurses participated at least once; 46.6% participated three or more times. A high proportion (85.7-100%) of nurses left at least one element of care unfinished; the mean number of activities left unfinished over each 7 shift period per nurse was 16.2. Only nursing care hours provided by float staff significantly predicted nurse estimates of unfinished nursing care, ß=.008, SE=.001, p<.05. CONCLUSIONS: The prevalence of unfinished nursing care at the US Army Burn Center was high and generally consistent with other studies of unfinished nursing care in non-burn settings. The inability to meet the demand for nursing care, as evidenced by the presence of unfinished nursing care, may be the result of a limited surge capacity. Implications for research, policy, and practice were discussed.

Resource scarcity drives lethal aggression among prehistoric hunter-gatherers in central California.

The origin of human violence and warfare is controversial, and some scholars contend that intergroup conflict was rare until the emergence of sedentary foraging and complex sociopolitical organization, whereas others assert that violence was common and of considerable antiquity among small-scale societies. Here we consider two alternative explanations for the evolution of human violence: (i) individuals resort to violence when benefits outweigh potential costs, which is likely in resource poor environments, or (ii) participation in violence increases when there is coercion from leaders in complex societies leading to group level benefits. To test these hypotheses, we evaluate the relative importance of resource scarcity vs. sociopolitical complexity by evaluating spatial variation in three macro datasets from central California: (i) an extensive bioarchaeological record dating from 1,530 to 230 cal BP recording rates of blunt and sharp force skeletal trauma on thousands of burials, (ii) quantitative scores of sociopolitical complexity recorded ethnographically, and (iii) mean net primary productivity (NPP) from a remotely sensed global dataset. Results reveal that sharp force trauma, the most common form of violence in the record, is better predicted by resource scarcity than relative sociopolitical complexity. Blunt force cranial trauma shows no correlation with NPP or political complexity and may reflect a different form of close contact violence. This study provides no support for the position that violence originated with the development of more complex hunter-gatherer adaptations in the fairly recent past. Instead, findings show that individuals are prone to violence in times and places of resource scarcity.

Unfinished nursing care: An important performance measure for nursing care systems.

Performance measurement is a core administrative function and an essential component of organizational quality programs. The prevalence of performance measurement initiatives increased significantly after the release of the Institute of Medicine series on quality. Nursing performance measures are limited in their scope, resulting in an underrepresentation of process measures. Development of performance indicators that reflect how effectively organizational units actually transform nursing resources into nursing services should be a high priority. Unfinished nursing care is a nursing process performance measure that reflects the complexity of the nursing care environment and can be useful in comparing process performance across systems and organizations. Unfinished nursing care is congruent with many of the National Quality Forum requirements for endorsement and warrants further refinement as an important nurse-sensitive performance measure.

A Descriptive Analysis of Implicit Rationing of Nursing Care: Frequency and Patterns in Texas.

The frequency and patterns of implicit rationing of nursing care in the United States are not known. The purpose of this study was to examine the phenomenon of implicit rationing among nurses in Texas. Implicit rationing was measured using a 31-item survey instrument adapted from the parent instrument originating in Switzerland. Some degree of rationing on at least one of the nursing care activities was reported by almost all of the respondents and most rationed multiple activities. Rationing preference patterns favor completion of activities directed to meet immediate physiological needs over other activities. If the relationships documented in other countries between implicit rationing and adverse patient outcomes are also present in the United States, then implicit rationing may serve as an important quality indicator.

Unfinished nursing care, missed care, and implicitly rationed care: State of the science review.

OBJECTIVES: The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions. METHODS: A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author). RESULTS: Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave. DISCUSSION & CONCLUSIONS: Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies.

Validation of the Perceived Implicit Rationing of Nursing Care (PIRNCA) instrument.

BACKGROUND: An inverse relationship between implicit rationing and quality patient outcomes has been demonstrated in European hospitals, but this relationship has not been explored in the United States. OBJECTIVE: To evaluate the psychometric properties of a new measure of implicit rationing, the Perceived Implicit Rationing of Nursing Care (PIRNCA). METHOD: A cross-sectional survey design with a stratified random sample of 226 medical surgical nurses was used to evaluate the PIRNCA. The internal structure was evaluated using exploratory factor analysis. Pearson correlations were used to assess the associations between implicit rationing and three related constructs: work environment, overall job satisfaction, and quality of care. RESULTS: A single-factor solution explaining 55% of the total variance and excellent reliability, Cronbach's alpha = 0.97, was supported for the PIRNCA. Moderate inverse relationships with related constructs provided evidence of concurrent validity: work environment (-0.44), overall job satisfaction (-0.48), and quality of care (-0.56). The majority of nurses (97%) reported rationing at least one of the 30 care activities listed; however, mean scores reflected a low frequency ("rarely") of rationing overall. CONCLUSION: The phenomenon of implicit rationing is experienced by nurses in U.S. hospitals, and the PIRNCA instrument is a valid and reliable measure of this phenomenon.

Economic theory and nursing administration research--is this a good combination?

TOPIC: Economic theory is used to describe and explain decision making in the context of scarce resources. PURPOSE: This paper presents two applications of economic theory to the delivery of nursing services in acute care hospitals and evaluates its usefulness in guiding nursing administration research. SOURCES OF INFORMATION: The description of economic theory and the proposed applications for nursing are based on current nursing, healthcare, and economic literature. Evaluation of the potential usefulness of economic theory in guiding nursing administration research is based on the criteria of significance and testability as described by Fawcett and Downs. CONCLUSIONS: While economic theory can be very useful in explaining how decisions about nursing time allocation and nursing care production are made, it will not address the issue of how they should be made. Normative theories and ethical frameworks also must be incorporated in the decision-making process around these issues. Economic theory and nursing administration are a good fit when balanced with the values and goals of nursing.