Implicit rationing of nursing care among patiens in Lebaneese hospitals (RATIONAL) - A longitudinal research study on the variations, trends, predictors and outcomes of rationed nursing care.

Suzanne Dhaini 

Dietmar Ausserhofer
Michael Simon

Ort der Datenerhebung
– 2 lebanese acute care hospitals

2018 bis 2021

Maintaining and improvingthe quality of nursing care and patient safety have been the focus of health services researchers over the last decade. Recent studies show an association between implicit rationing of nursing care, i.e., nursing care that is either partially or fully omitted due to a lack of resources, and negative patient and nurse outcomes.

Rationale: Existing studies on rationing of care used cross-sectional design correlating aspects of nurses’ work environment and rationing of care. However, previous studies did not investigate the relationship between organizational factors, implicit rationing of care, and patient and nurse outcomes over time. The different time frames used to collect nurses` perceptions about rationing of care do not allow the assessment of trends and variation within- and between- units on a shift level and over time. It is crucial to gain thorough understanding of how nurses’ rationing of nursing care activities prevails on a shift-level basis and over time within and between units.


Aims: The purpose of the proposed RATIONAL project is (1) to establish a within-units baseline measure of rationing of care activities on medical, surgical and paediatric units by shift (day, evening, night shifts) and over 90 days; (2) to explore between-units variations of the extent and types of rationed activities across shifts and time; (3) to explore key self-perceived work environment factors (e.g. workload; staffing adequacy) in relation to rationing of care; and (4) to explore the associations of implicit rationing of care, work environment factors, with nurse (i.e. health) and patient (i.e. mortality, infections) outcomes on a shift level and over a 3 months time period.

Design / Methode
Single center longitudinal observational study .The proposed study will include 9 medical, surgical and paediatric units in 1 teaching hospital in Lebanon. Nurses working on medical, surgical, and paediatric units and who meet the inclusion criteria will be surveyed. We expect to collect a maximum of 2,700 responses from 185 registered nurses working on 9 units over three months.

Erwarteter Nutzen / Relevanz
RATIONAL will be one of the first longitudinal studies on implicit rationing of care and measuring this concept on a shift-level, contributing to the understanding of its variations and patterns. It will help us gain a better understanding on when nursing care activities are rationed (e.g. shift effect, weekend effect) to make better predictions on required nurse staffing levels. The proposed study will help us identify areas for improvement of quality of nursing care and inform future quality improvement and research projects.


  1. Dhaini SR, Simon M, Ausserhofer D, Abed Al Ahad M, Elbejjani M, Dumit N, Huijer HA. Trends and variability of implicit rationing of care across time and shifts in an acute care hospital: a longitudinal study.J Nurs Manag. 2020 Nov;28(8):1861-1872. doi: 10.1111/jonm.13035
  2. Abed Al Ahad M, Elbejjani M, Simon M, Ausserhofer D, Abu-Saad Huijer H, Dhaini SR. Variability, shift-specific workloads and rationed care predictors of work satisfaction among Registered nurses providing acute care: A longitudinal study. Nurs Open. 2022 Mar;9(2):1190-1199. doi: 10.1002/nop2.1160. Epub 2021 Dec 15.