Increasing implicit rationing of care in nursing homes: A time-series cross-sectional analysis

Implicit rationing of nursing care is a socio-ecological problem where care workers, due to lack of resources, have to leave necessary nursing care activities undone. Cross-sectional studies on implicit rationing of nursing home care revealed associations with organizational and work environment characteristics. However, little is known on how implicit rationing of nursing care varies over time in nursing homes. This study's purpose was to describe changes in levels and patterns of implicit rationing of nursing care in Swiss nursing homes over time, while accounting for key explanatory factors related to organizational, work environment, and individual characteristics. Time-series cross-sectional analysis. Nursing homes in Switzerland. A convenience sample of 47 nursing homes and 3269 care workers from all educational levels participating in two multicenter cross-sectional studies (the Swiss Nursing Home Human Resources Project) conducted in 2013 and 2018. To quantify implicit rationing of nursing care, care workers' data were collected via the nursing home version of the Basel Extent of Rationing of Nursing Care instrument. To control for leadership ability, staffing and resource adequacy, we used the Nursing Work Index–Practice Environment Scale. Objective measures including turnover, staffing and skill mix levels were aggregated at the nursing home level. Our analyses included multiple linear mixed models, using time as a fixed effect and nursing home as a random effect. We found overall increases of rationing of care activities over the five-year period studied, with documentation and social activities most rationed at both measurement points (overall coefficients varied between 0.11 and 0.23, as well as the 95%-confidence intervals between 0.05 and 0.30). Moreover, a considerable increase in rationing of activities of daily living (coefficient of 0.47 in 2013 and 0.63 in 2018) was observed. Alongside long-term deterioration of staff resources, increases in rationing of nursing care are a worrying development, particularly given their potential negative impacts both on residents and on care workers. To assess nursing home care quality and to determine adequate staffing levels and skill mixes, policy makers and nursing home managers should consider regular monitoring of rationing of nursing care. Time-series cross-sectional analysis reveals increasing rationing of nursing care activities in Swiss nursing homes from 2013 to 2018.