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CROATIAN ADAPTATION AND VALIDATION OF THE PERCEIVED IMPLICIT RATIONING OF NURSING CARE (PIRNCA) QUESTIONNAIRE: A CROSS-SECTIONAL STUDY

SUMMARY The aim was to perform adaptation and validation of the Perceived Implicit Rationing of Nursing Care. Implicit delaying of nursing care is an intermediate step, linking nurses with the quality of outcomes for patients and nurses, and it is the result of prioritization of health care measures within the assigned group of patients cared for by nurses. The Perceived Implicit Rationing of Nursing Care instrument is a tool used to assess the rationing of care in nursing practice. Study participants were nurses working at hospital wards in 4 university hospitals in the Republic of Croatia. The questionnaire was filled-in by 438 nurses. Data were collected between April and November 2018. After principal axis factoring, a single factor solution based on the correlation matrix was adopted. The measured construct is one-dimensional, and the extracted factor explains 47.2% of its variance. Additionally, the reliability of the whole questionnaire was determined by using the internal consistency coefficient Cronbach alpha on the Perceived Implicit Rationing of Nursing Care with 31 of 0.96 particles, which is extremely high internal consistency reliability. In conclusion, the study found a high level of reliability and validity of the translated Perceived Implicit Rationing of Nursing Care questionnaire, fully comparable to that of the original. The questionnaire can be used to assess the phenomenon of implicit care rationing in Croatian hospitals.


Introduction
In recent decades, cost reduction strategies, as well as an increase in the scope of health care services deliv-ered have been a trend in health systems around the world 1,2 . Despite the benefits of such a trend in terms of increasing access to health care for all, there is a significant negative impact on the nurses' work environment. There is growing evidence linking a reduced number of employed nurses to patient mortality, complications related to inappropriate care, reduced job satisfaction, and burnout at the workplace 3 . The mechanism through which a nurse's work environment con-tributes to adverse outcomes for both patients and nurses has not been adequately researched. Implicit delaying of nursing care is an intermediate step, linking nurses with the quality of outcomes for patients and nurses, and it is the result of prioritization of health care measures within the assigned group of patients cared for by nurses. These measures are related to assessment of the need for health care, identification of problems, planning of health care, implementation of interventions and evaluation of what has been implemented, as well as the condition of patients in accordance with the above. Thus, nursing consists of providing all kinds of nursing interventions in the health care system required by the individual, either sick or healthy, to an extent depending on the condition of the individual 4 . Unfortunately, an increasing number of studies in the field of nursing conducted in recent years has shown the presence of the phenomenon of missed or delayed nursing care, especially when it comes to hospitalized patients [5][6][7][8][9][10] . In the literature, this phenomenon has different names such as uneven care 11 , unfinished nursing care 12 , missed nursing care interventions 13 , implicitly rationed nursing care 14 , unfinished task of nursing care 15 , or unmet nursing care needs 16 . All these designations describe a situation where patients were not provided with enough care and attention needed, which consequently means that the whole nursing care process had negative outcomes for the patient 17 . The authors of this text have chosen the designation implicitly rationed nursing care as the term best suited for the Croatian language and the research instrument. The Perceived Implicit Rationing of Nursing CAre (PIRNCA) instrument is a tool used to assess the rationing of care in nursing practice. Schubert et al. were the first to address the phenomenon of implicit rationing of care in a study conducted in Switzerland in 2007, aiming at mapping the level of care in Swiss acute care facilities 18 . They also explained the concept of care rationing and created a new tool (Basel Extent Rationing of Nursing CAre, BERNCA) for measurement of this phenomenon in practice 18 . In 2014, Jones adopted this instrument in the USA and presented the new PIRNCA questionnaire validated by surgical nurses 19 . Nursing care rationing occurs when resources are insufficient (usually due to the lack of staff or lack of necessary materials), or when not all conditions for the provision of safe nursing care to patients are available 9,13,15 . The alloca-tion of resources relates to general resources that have implications for work and the material resources needed to provide care to patients. As far as the resource allocation is concerned, there are two types of care rationing, explicit (external) or implicit (tacit). Explicit rationing is usually connected with the economy of health care systems and deals with cost reduction. It is measured as the number of omitted or delayed interventions which should have been performed. Jones describes delaying of care in the context of decisionmaking processes at certain levels in the health care system [19][20][21] . Numerous factors related to the employer (hospital characteristics: financial limits, number of patient beds), employees (skills, expertise, level of education) and patients (type of disease, severity, comorbidities) contribute to delay or incompletion of health care interventions 5,6,8,13,22 . As the first aspect, Jones identified macro level decisions that are political in nature and fall within the competence of the government and health care authorities in a particular country 19 . Decisions made at the middle level are the responsibility of health care institutions as part of the organizational aspects of the system, including allocation of financial resources. Lastly, decisions that are made at the micro level usually involve actual health care professionals who are responsible for their provision. Decisions made at the macro and middle levels are administrative and political in nature and are therefore considered explicit. In contrast, decisions made at the micro level are directly related to patients and depend on the experiences and considerations of the specific situation assessed by individually responsible health care professionals and are therefore considered a form of implicit rationing of care 19,20 . As a result of such decisions, nurses are forced to give priority to tasks that may result in adverse patient outcomes or reduced quality of care provided 14 . In their study, Kalankova et al. mention areas of care that nurses are rationing most often, such as emotional support, patient or family training, keeping nursing records, communication with the patient, and basic activities such as turning or feeding patients 17 .
Worryingly, studies to date have shown a detrimental impact of rationed nursing care on treatment and health care outcomes, including higher mortality rates, increase in falls, pressure ulcers during hospitalization, and more reported nosocomial infections, as well as lower patient and nurse satisfaction 10,14,23 . As-sessment of nursing care also affects staff satisfaction. Kalisch et al. found that nurses who reported more rationed health care were less satisfied with their job 24 . Also, Bekker et al. report that the highest degree of job dissatisfaction was recorded in jobs with delayed nursing tasks 26 . Zeleniková et al. showed that rationed care was linked to the overall level of job satisfaction and the intention of nurses to leave their actual job 27 . In nursing, several instruments have been developed to measure rationed nursing care in different countries and contexts but none of them was available in Croatian and therefore could not be used to reliably assess this problem in Croatian hospitals 14,19,27 . The purpose of this study was therefore development of the Croatian version of the PIRNCA questionnaire.

Participants
The participants were nurses working on hospital wards at four university hospitals in the Republic of Croatia. Nurses were asked to participate voluntarily. The questionnaire was filled-in by 438 nurses who signed informed consent forms. The study was approved by Ethics Committees of all four institutions. Research group followed all ethical principles of Hel- sinki Declaration. Data were collected between April 2018 and November 2018. The inclusion criteria were as follows: nurses with at least one year of service, and nurses working in direct patient care. Exclusion criteria were as follows: nurses on leading positions, and nurses working for less than a year.

Instrument
The PIRNCA questionnaire consists of 31 statements related to nursing procedures (assessment, problem identification, care planning, implementation of procedures, and evaluation of care) necessary to achieve the desired outcomes in nursing. The answers are based on the respondents' last 7 shifts. Answers are marked on You could not assist a patient in urinating or defecating in a timely manner (e.g., bed pan, wheelchair with bed pan, trip to the restroom) nor you could delegate the task. 0.736 You were unable to perform further follow up on changes in the patient's status, take note of unanswered requests for intervention (including assessment and referrals) or unclear orders. 0.734 You were unable to help a patient achieve physical comfort (e.g., timely application of pain relief medication, adjusting room temperature, back rub) nor you could delegate the task. 0.724 You were unable to educate the patient or his/her family when you deemed it necessary. 0.721 You were unable to document all the assessment and monitoring activities.
0.720 You were unable to adequately prepare the patient for therapy, tests, or procedures. 0.720 You were unable to adequately evaluate the plan of care (applying critical thinking) in order to establish appropriateness and/or effectiveness of interventions and to enter the necessary changes as noted. 0.711 You were unable to provide adequate assistance during food or fluid intake to patients who are incapable of eating or drinking independently, nor you could delegate the task. 0.708 You were unable to change the entry point for intravenous therapy, tubing and/or dressings in the time frame as prescribed by the doctor/according to standards or as you considered appropriate. 0.702 You were unable to adequately supervise or perform follow up on delegated activities. 0.701 You were unable to adequately review the patient's multidisciplinary documentation in order to inform yourself on the patient. 0.697 the following scale: "never", "rarely", "sometimes" and "often", with the option of answering "not needed" if a certain procedure was not needed during their shift.

Translation of the questionnaire
The PIRNCA questionnaire was translated into Croatian. Then it was back translated into English by a translator who is a native English speaker. The translations were then compared to the original questionnaire. The translations were assessed by two experts in the field of nursing care. Three adjustments were made and approved by the author of the questionnaire: the words "error" and "mistake" were translated into Croatian as "greška", and the term "non-surgical" was trans-lated as "interni" (ward). The term "care" was translated as "skrb".

Data analysis
The analysis was performed using IBM SPSS 25.0 (IBM Statistics for Windows, Version 25.0., IBM Corp., Armonk, NY, USA). The exploratory factor analysis was conducted using the principal axis factoring method to determine the factor structure of the questionnaire. The reliability of the questionnaire was calculated on the basis of the internal consistency coefficient, Cronbach alpha, and the competitive validity of the PIRNCA questionnaire was verified by Pearson's two-measure correlation coefficient, assessment of the level of quality of nursing care, and overall job satisfaction.

Results
The study was conducted on 438 nurses at four university hospitals in the Republic of Croatia. Table 1 shows participant characteristics, and Table 2 shows characteristics of the participant workplace.
Principal axis factoring was used to check the factoring structure of the instrument. The Bartlett sphericity test (χ 2 =10595.266, df=465, p<0.001) and Kaiser-Meyer-Olkin indicator (KMO measure of sampling adequacy: 0.953) are measures that show that

Item
Factor loading You could not assist in patient mobility nor you could delegate the task. 0.696 You were unable to follow recommended guidelines for safe patient relocation (e.g., using equipment to lift and/or assistance from other staff ). 0.695 You were unable to document in a detailed manner all the nursing care you provided. 0.676 You were unable to provide the level of emotional or psychological support to the patient (or their family) that you deemed necessary. 0.673 You were unable to adhere to guidelines for infection control (e.g., hand hygiene, aseptic technique, isolation   Table 3. In the first step of factor analysis, 5 factors were extracted, of which 4 factors had values of characteristic roots above 1 (eigenvalues >1), but with only 1 factor with a remarkably high eigenvalue of 14.772, and the next factor with an eigenvalue of 2.005, which means that all subsequent factors except for the first factor explain little additional variance of the latent factor (all four factors together explain 61% of the factor variance). Also, according to the scattering diagram (so-called scree test), it could be concluded that only 1 factor explains most of the variance, so a single factor solution was finally adopted for the final Principal Axis Factoring analysis without rotation, with a forced number of factors. You were unable to adequately evaluate the plan of care (applying critical thinking) in order to establish appropriateness and/or effectiveness of interventions and to enter the necessary changes as noted. 0.701 0.962 Table 4. Continued A single factor solution based on the correlation matrix shows that the factor explains 47.2% of the variance. All factor saturations of individual questionnaire particles are above the minimum limit value of 0.30 and are ordered according to their size. Factor saturations range from 0.48 to 0.78, and there are no particles with a saturation less than 0.30. The particle with the lowest saturation is "You could not have an important conversation with an external agency about the care of a patient or the conversation was delayed" (0.48) and the extracted factor explains the smallest part of the variance of this particle. Table 4 shows correlations of individual particles with the total result, as well as changes in the Cronbach alpha coefficient in case a particle is omitted from the questionnaire. The correlations of particles with the to-tal score are relatively high, i.e., 12 of them are above 0.70, and the added 14 are above 0.60. The total correlation range is between 0.47 and 0.76. The same particle linked to the lowest factor saturation has the lowest correlation with the total result, and by removing it from the questionnaire, the reliability of Cronbach alpha would be 0.96, i.e., the value of the currently determined coefficient. Namely, the reliability of the entire questionnaire was determined using the Cronbach alpha internal consistency coefficient on PIRNCA with 31 particles of 0.96, which is an extremely high reliability of the internal consistency type.
The correlation of the total score on the PIRNCA questionnaire with the assessment of the quality level is r=-0.38, p<0.001, which means that there is a negative relationship between the perceived implicit rationing of nursing care, with a low measure of association. Regarding total job satisfaction, r=-0.43, p<0.001, lower perceived satisfaction was associated with a higher score on the PIRNCA questionnaire, with a low measure of association.

Discussion
The aim of this study was to validate the Croatian version of the PIRNCA questionnaire. Compared to the original version, the Croatian version of the PIRN-CA questionnaire was adjusted in such a way that the terms "error" and "mistake" were both translated as "greška", and the term "care" was translated as "skrb". Also, the names of the nurses' wards were adjusted to match the names in our health care system.
Factor analysis determined that all preconditions for factor extraction were met and based on exploratory analysis using the principal axis factoring, a single factor solution was accepted, which explains 47.2% of the factor variance.
Jones also had 3 extracted factors in the first factoring solution, but the author decided to opt for a single factor solution that explained 55% of the variance 19,20 .
In our study, Cronbach alpha was 0.96, showing high reliability. This refers to the reliability of internal consistency, so it can be concluded that the particles that make up the questionnaire are very homogeneous according to their object of measurement. This can be compared with Jones 19,20 , whose Cronbach alpha was 0.97, as well as with Uchmanowicz and Gotlib 22 , whose Cronbach alpha was 0.95. It can be concluded that the reliability of the adapted questionnaire is satisfactorily high and comparable to the original version. However, it should be noted that there is one "problematic" particle, i.e., "You could not have an important conversation with an external agency about the care of a patient or the conversation was delayed". It is problematic because it has exceptionally low correlation with the questionnaire in total and also has the smallest factor saturation, but the results show that its omission would not achieve greater result homogeneity and the Cronbach alpha coefficient would remain unchanged, so the particle was retained. Thus, the entire questionnaire becomes comparable to the applications of the questionnaire in other countries.
Jones cites the timeliness of response to a request, emotional and psychological support and talking to the patient as the nursing procedures that are most often missed 19 . Uchmanowicz and Gotlib 22 report that the most common missed nursing procedures were patient/family training and emotional support. Friganović et al. report on timeliness of response to a request as the nursing procedure that is most often missed 23 .
Kalisch and Williams determined that nurses who reported on rationed health care were less satisfied with their job 28 . Also, Bekker et al. report that the highest degree of job dissatisfaction was recorded in jobs with incomplete nursing tasks 26 . Zeleniková et al. showed that rationed care was linked to overall job satisfaction and the intention of nurses to leave their actual job 27 .
Jones states that the correlation between PIRNCA results and nurses' assessment of quality of care is r=-0.492, p<0.005, while the assessment of job satisfaction is r=-0.375, p<0.001. Uchmanowicz et al. had the same results 20,[29][30][31] . This means that the higher the level of nursing care quality assessment and job satisfaction assessment, the lower is the level of missed care.
In order to verify the validity of the adapted instrument, this study also found that the total scores on the PIRNCA questionnaire were negatively correlated with the assessment of the quality level (r=-0.38, p<0.001), which means that there is a negative relationship between the perceived implicit rationing of nursing care and the quality of care, although this correlation has a low measure of association. Regarding total job satisfaction (r=-0.43, p<0.001), lower perceived satisfaction was associated with a higher degree of care rationing (also with a low measure of associa-tion). The results are in accordance with the cited literature and testify to the discriminatory validity of the Croatian version of the PIRNCA questionnaire.

Conclusion
The purpose of this study was to translate and validate the PIRNCA questionnaire. Study results showed the Croatian version of the PIRNCA questionnaire to be a reliable tool for the measurement of nursing care rationing in Croatian hospitals. It is our belief that more research using the above questionnaire is needed and that this research will enable outcome improvements in nursing practice.