Unfinished nursing care in four central European countries

Abstract Aim The main aim of the research was to describe and compare unfinished nursing care in selected European countries. Background The high prevalence of unfinished nursing care reported in recently published studies, as well as its connection to negative effects on nurse and patient outcomes, has made unfinished care an important phenomenon and a quality indicator for nursing activities. Methods A cross‐sectional descriptive study was undertaken. Unfinished nursing care was measured using the Perceived Implicit Rationing of Nursing Care questionnaire (PIRNCA). The sample included 1,353 nurses from four European countries (Croatia, the Czech Republic, Poland and Slovakia). Results The percentage of nurses leaving one or more nursing activities unfinished ranged from 95.2% (Slovakia) to 97.8% (Czech Republic). Mean item scores on the 31 items of the PIRNCA in the total sample ranged from 1.13 to 1.92. Unfinished care was significantly associated with the type of hospital and quality of care. Conclusion The research results confirmed the prevalence of unfinished nursing care in the countries surveyed. Implications for Nursing Management The results are a useful tool for enabling nurse managers to look deeper into nurse staffing and other organizational issues that may influence patient safety and quality of care.


| INTRODUC TI ON
The number of scientific papers related to unfinished nursing care has increased significantly over the last decade, with several extensive reviews concluding that unfinished nursing care is a problem worldwide (Jones, Hamilton, & Murry, 2015;Papastavrou, Andreou, & Efstathiou, 2014b). Research into unfinished care has increased interest in the phenomenon since it was first recognized under the term "nursing care left undone" in Canada, England, Germany, the United States and Scotland (Aiken et al., 2001). In Switzerland, the concept has been introduced as "implicit care rationing" (Schubert et al., 2008). Several other terms have been used in Europe, for instance, "bedside rationing" and "care left undone" (Ausserhofer et al., 2014;Papastavrou, Andreou, Tsangari, & Merkouris, 2014a). For this study, we chose the term "unfinished nursing care" as an umbrella term (Jones et al., 2015). ing outflow of nurses out of the health system are the main concerns across these four countries (Marć, Bartosiewicz, Burzyńska, Chmiel, & Januszewicz, 2019). In addition, in the Czech Republic and Slovakia the tendency of healthcare providers to substitute registered nurses with practical nurses may influence the provided nursing care.
According to OECD statistics (OECD, 2019), there are eight nurses/per 1,000 people in the Czech Republic, 5.2 nurses/per 1,000 people in Poland and 5.7 nurses/per 1,000 people in Slovakia (OECD, 2019). In Croatia, there are 5.8 nurses/1,000 inhabitants (OECD, 2017). All have fewer nurses than the EU average (8.4).
There are serious concerns about possible decreases in these numbers over the coming years.
When these countries entered the European Union (EU), they had to contend with nursing education reforms in accordance with the EU requirements. Before the EU accession, nurses from the central and eastern European countries had been educated in secondary vocational training (after 8-year primary school education) at specialized high schools (Kalauz, Orlic-Sumić, & Simunec, 2008;Simunovic et al., 2010;Ślusarska, Zarzycka, Dobrowolska, Marcinowicz, & Nowicki, 2018;Tóthová & Sedláková, 2008). Secondary vocational nursing schools in the Czech Republic and Slovakia no longer offer the general nurse study programme. However, some nurses trained in these schools before 2004 in Czech Republic and Slovakia still work at hospitals, as general nurses. Today, there are still students who graduate from secondary nursing schools, but they are trained as "practical nurses" with lower competencies than general nurses.
These days qualified nurses are required to have a bachelor degree at university or diploma at higher education institutions in all four surveyed countries (after 12 years of general education). In Poland, since 2004 bridging studies-intended for nurses graduating from secondary medical schools/colleges-have become very popular as a supplementary to bachelor degrees (Ślusarska et al., 2018). A dual entry system operates in Croatia, with nursing students able to become nurses after completing vocational school (general care nurse), or a bachelor degree at university (Kalauz et al., 2008). The present status of Croatian nursing education is contentious (Simunovic et al., 2010), and study at vocational school is for 5 years: 2 years of general education and 3 years of nursing (Simunovic et al., 2010).
Croatian nurses' competencies after vocational education and bachelor degree programme are almost the same which create confusion in nurses' practice and lead to dissatisfaction (Simunovic et al., 2010).

| BACKG ROU N D
There are a number of published conceptual analyses and conceptual frameworks related to the concept of rationed/missed/ unfinished nursing care (Bail & Grealish, 2016;Hessels, Flynn, Cimiotti, Cadmus, Gershon, 2015;Kalisch, Landstrom, & Hinshaw, 2009;Lucero, Lake, & Aiken, 2009;Schubert, Glass, Clarke, Schaffert-Witvliet, & De Geest, 2007). For this study, the conceptual framework of unfinished nursing care described by Jones et al. (2015) and Jones, Willis, Amorim-Lopes, Drach-Zahavy, RANCARE Consortium COST, (2019) was chosen. Unfinished care in this conceptual model is a component of the process of care between organizational system structures and outcomes/ effects. Organizational variables, nursing work environment, care philosophy, and nurse and patient variables are considered as antecedents (Jones et al., 2015). They are also factors that influence clinical judgment, decision-making, setting of priorities and triage processes in nursing practice (Schubert et al., 2013(Schubert et al., , 2007. The model suggests that unfinished care is directly related to patient and nurse outcomes. In this study, we wanted to explore associations between unfinished care and selected nurse outcomes (i.e. job satisfaction and intention to leave) and patient outcome (nurse-assessed quality of care). The results of the RN4CAST study involving 12 European countries (Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden and Switzerland) indicate that all these countries have had to deal with the problem of nursing care quality, patient safety, job satisfaction and burnout (Aiken et al., 2012). According to Ausserhofer et al. (2014), unfinished nursing care might play an important role in nurse outcomes (job satisfaction, burnout and intention to leave). Unfinished nursing care has previously been linked to a decrease in job satisfaction (Bekker, Coetzee, Klopper, & Ellis, 2015;Jones, 2014;Kalisch, Tschannen, & Lee, 2011) and an increase in nurse intention to leave (Tschannen, Kalisch, & Lee, 2010). In addition, the frequency of unfinished care is increasingly being considered an indicator in the assessment of quality of care (Recio-Saucedo et al., 2018). Associations between unfinished care and overall quality of care have been documented before (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014;Jones, 2014;Sochalski, 2004;Zúñiga et al., 2015).

| AIM
The main aim of the research was to describe and compare unfinished nursing care in four Central European countries (Croatia, the Czech Republic, Poland and Slovakia). A secondary aim was to explore the relationships between selected variables and unfinished nursing care.

| Design
A cross-sectional descriptive study was undertaken.

| Sample
The research sample included 1,353 nurses from four European countries (306 nurses from the Czech Republic, 356 nurses from Slovakia, 253 nurses from Poland and 438 nurses from Croatia).
The target population was nurses from acute care departments employed in acute care hospitals in the public or private sector in Central European countries (Croatia, the Czech Republic, Poland and Slovakia). Only fully qualified nurses were included in the survey.
Inclusion criteria were nurses from acute care departments with at least 1 year of experience; nurses engaged in direct patient care; and nurses with an understanding of the national languages. Exclusion criteria were nurses in managerial positions, home care nurses and practical nurses (formerly nurse assistants).
Since the population of nurses is large (around 270,000 nurses in Poland, 90,000 nurses in Czech Republic, approximately 40,000 nurses in Croatia and in Slovakia), we set the sample size at a minimum of 196 nurses from each country. This sample gives the study a margin of error of ±7% (confidence interval 95%) in determining the prevalence of unfinished nursing care. Online sample size calculator (Qualtrics ® ) was used.
In Slovakia, the questionnaires were distributed to all nurses from 16 selected departments of eight acute care hospitals (six private and two public) with at least 100 beds. The response rate for Slovak nurses was 82.38%. In the Czech Republic, the questionnaires were distributed to nurses from 26 selected departments of eight hospitals (three private and five public) with more than 100 beds. The response rate for Czech nurses was 70.18%. In Croatia, the sample consisted of nurses working in four university hospitals. The questionnaires were distributed to nurses from 17 selected departments. The response rate for Croatian nurses was 73%. In Poland, the sample consisted of nurses from a university hospital. The response rate for Polish nurses was 79%.

| Data collection
Data collection was carried out from April 2018 to November 2018.
A pencil and paper questionnaire was administered at a single point in time. The questionnaires were distributed to hospital nurses during day shifts by a team coordinated by the principal researchers in each country. Nurses had three-four weeks to complete the questionnaires.

| Research instruments
For the purpose of the study, the following instruments were used: demographic data sheet; the PIRNCA questionnaire (Jones, 2014); and questions regarding job satisfaction, intention to leave and overall quality of care.
Demographic data included: personal (age, education, specialisation); employment (unit, professional experience, work experience in current workplace, work hours, absent days or shifts, hours of overtime, perceived adequacy of staffing, leaving intentions-the last five items were adopted from the MISSCARE Survey (Kalisch et al., 2009)); and organizational variables (hospital size and type).

| Unfinished nursing care
Unfinished nursing care is "a problem of time scarcity that precipitates the process of implicit rationing through clinical priority setting among nursing staff resulting in the outcome of care left undone" (Jones et al., 2015).
Unfinished nursing care was measured using the PIRNCA questionnaire (Perceived Implicit Rationing of Nursing Care), an inventory of 31 nursing activities (Jones, 2014). Nurses were asked to rate how often they were unable to complete each of the 31 activities for patients on their previous seven shifts: "never" = 1, "rarely" = 2, "sometimes" = 3 and "often" = 4 (Van Fosson, 2017). In the original study (Jones, 2014), the reliability of the PIRNCA was high (0.97).
In our study, the PIRNCA was scored in two ways: a count of dichotomized occurrences for a specific cut-off point (percentage of nurse rationing greater than "never") and the arithmetic mean score across all inventory items (a mean composite score; Jones, Gemenihardt, Thomson, & Hamilton, 2016; Van Fosson, 2017).

| Overall job satisfaction
Nurses' job satisfaction is "the nurses' positive feeling response to the work conditions that meet his or her desired needs as the result of their evaluation of the value or equity in their work experience" (Liu, Aungsuroch, & Yunibhand, 2015).
Overall job satisfaction (OJS) was assessed on an 11-point scale (0-"It is terrible" to 10-"I love it"), using the single item: "Considering all aspects of your job, as well as your own values, ideals and goals, how satisfied are you with your current nursing job?" (Kramer & Schmalenberg, 2004;Schmalenberg & Kramer, 2008).

| Nurse-assessed quality of patient care on unit
Quality of care is "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Institute of Medicine, 1990).
Overall quality of patient care experience was measured on an 11-point scale (0-"dangerously low" to 10-"very high quality") using the single item (Kramer & Schmalenberg, 2004;Schmalenberg & Kramer, 2008): "Circle the number that indicates the usual quality of care provided to patients on your unit."

| Intention to leave
Intention to leave is anticipation to leave the current position of nurse (Tschannen et al., 2010).
Nurses' intention to leave their organization was measured according to the study by Yamaguchi, Inoue, Harada, and Oike (2016).
Respondents were asked one question: "How do you see your working life in the future?" Response options were on a scale from 1 to 4 (1 = "I would like to continue working at my current workplace", 4 = "I would like to change my unit/organization").
Participants' intention to leave their profession was measured using one item: "How do you see your career as a nurse in the future?" Response options were on a scale from 1 to 4 (1 = "I want to continue working as a nurse", 4 = "I don't want to continue working as a nurse"), with a higher score indicating a stronger intention to leave the profession.

| Translation and validation of the PIRNCA
Permission to translate and use the PIRNCA questionnaire was obtained from the author of the original questionnaire (Jones, 2014) prior to data collection. The PIRNCA instrument was translated from English into the four national languages (Croatian, Czech, Polish and Slovak) using forward-backward translation.
However, psychometric procedures for each language version (Czech, Slovak, Polish and Croatian) included reliability analysis and construct validity evaluation. The final versions of each language version had to be tested by the same procedures that had been used on the original instrument (Jones, 2014). The structure of each language version was studied using exploratory factor analysis (EFA), since the PIRNCA is a one-dimensional inventory.
For factor extraction and interpretation of factor loadings, principal component analysis (PCA) with varimax rotation was applied.
First, the data were subjected to unforced factor analysis. Second, EFA with forced one-factor solution was performed, since it was used in the original US sample (Jones, 2014). Factorability of each version was tested by the correlation matrix, communalities, Kaiser-Meyer-Olkin (KMO) measure and Bartlett's sphericity test (Jones, 2014). All assumptions for the performance of the EFA were met, and therefore, PCA with pairwise exclusion for missing data was applied for factor extraction and interpretation of factor loadings and assessment of the dimensionality of each version.

| Concurrent validity and relations with other variables
In the Czech version, negative non-significant correlations were noted between the PIRNCA composite score and both overall job satisfaction (r = −.03; p = .70) and quality of care (r = −.06; p = .38).
Negative, moderate and significant correlations were found between the PIRNCA composite score and both overall job satisfaction   Table 1 presents the characteristics of the nurses participating in the study. Most respondents were female (94.7%), and more than one half of the nurses had at least a bachelor degree. The majority of the respondents reported working rotating shifts. Only 9.9% of the nurses reported staffing as adequate 100% of the time.

| Frequencies and patterns of unfinished nursing care
Mean item scores of the 31 items in the total sample (Table 2) ranged from 1.13 to 1.92 (less than "rarely" to "rarely"). Patterns of unfinished care were analysed by dichotomized PIRNCA scoring (percentage of nurses with a frequency rating higher than never; Jones, 2014;Jones et al., 2015). Dichotomized scoring showed that a high percentage of nurses reported that they left one or more nursing care activities unfinished. The percentage of nurses leaving one or more care activities unfinished was high and ranged from 95.2% Item-level rationing frequencies ranged from 23.6% to 61.6% (Table 3). The areas of care most frequently left unfinished were consistent based on mean scale responses and dichotomized responses.
The care interventions most frequently unfinished were identified as emotional or psychological support to a patient or family; timely response to requests; patient education; and important conversations with another member of a patient's multidisciplinary team (Tables   2 and 3). Significant differences in all 31 activities of the PIRNCA and in overall mean score were found between countries (Table 2).
Considerable differences between participating countries were also observed in the percentage of nurses with a frequency higher than never (

| Factors contributing to unfinished nursing care
Unfinished care correlated significantly with overall job satisfaction, nurse-assessed quality of patient care on unit, intention to leave the actual workplace and perceived adequacy of staffing. Correlations were low and moderate (Table 4).
To establish the relationship between nurse, hospital and unit variables and unfinished nursing care, stepwise multiple regression analyses were performed (variables were selected according to the results of correlation analyses). Unfinished care was predicted by six variables (Table 5), explaining a total of 31% of the variance. Type of hospital and nurse-assessed quality of patient care significantly predicted unfinished nursing care. The higher the nurse-assessed quality of patient care reported, the less significant the extent of nursing care left unfinished.
Nurses from university hospitals reported more unfinished care than nurses from general hospitals. In addition, nurses reporting an intention to leave their workplace reported more unfinished care than nurses with no intention of leaving (Table 6).

| D ISCUSS I ON
This is the first multinational study describing and comparing the  (Mazzotta, 2016).
The high level of unfinished care reported by nurses from university hospitals in this study is an important finding. Similar results were reported in an Icelandic study (Bragadóttir, Kalisch, & Tryggvadóttir, 2017 (Blackman et al., 2018). We can only hypothesize about the reasons for the differences in unfinished care between countries. One possibility might be the various types of hospital in the countries included. The Polish and Croation samples included nurses from university hospitals (potentially with dual roles), and in these cases, more unfinished nursing care were reported. The Czech and Slovak samples included nurses from both university as well as private hospitals. The clinical significance of differences between countries remains undetermined (Jones et al., 2015).
In a previous study using the MISSCARE survey, Czech and Slovak nurses reported a significant amount of unfinished nursing care (Zeleníková, Gurková, & Jarošová, 2019). Nurses from Slovakia reported more unfinished care than nurses from the Czech Republic.
These results are consistent with those of the present study.
Comparable studies have not previously been carried out in either Croatia or Poland, where unfinished nursing care was thus being studied for the first time.
The instrument used for measuring unfinished care, the PIRNCA, was developed in the USA and has not been used (translated and validated) in European countries before. European countries have, for the most part, used the BERNCA (Dhaini et al., 2017;Papastavrou, Andreou, Tsangari, et al., 2014a;Schubert et al., 2008;Zúñiga et al., 2015) or MISSCARE Surveys (Ausserhofer et al., 2014;Bragadóttir, Kalisch, Smáradóttir, & Jónsdóttir, 2015;Bragadóttir et al., 2017;Palese et al., 2015;Papastavrou, Charalambous, Vryonides, Eleftheriou, & Merkouris, 2016;Sist et al., 2017;Zeleníková et al., 2019). This is the first European study reporting results of unfinished care measured using the PIRNCA. All national versions of the PIRNCA (Croatian, Czech, Polish and Slovak) showed good reliability and unidimensional factor structure and can be used for future research. The instrument can also be used by managers for evaluating care, organizational characteristics and safety issues in these countries.
The lowest overall PIRNCA score was seen in the Czech sam- In a Swiss study (Zúñiga et al., 2015), nurses reported better quality of care when the amount of unfinished care was lower. Jones et al. (2015), in their review, found the strongest association to be between perceived adequacy of staffing and unfinished care.
The negative impact of unfinished care on intention to leave, and on job satisfaction, has been reported by the authors of several reviews (Jones et al., 2015;Papastavrou, Andreou, & Efstathiou, 2014b). There are also serious concerns about job satisfaction as a key contributor to quality of care and nurse turnover (Lu, Zhao, & While, 2019). Further research is needed to fully understand the association between unfinished nursing care, job satisfaction, intention to leave and quality of care.

| LIMITATI ON S OF THE S TUDY
The study has several limitations. The first is that it used an instrument which was not developed for the target languages or cultures and developer of the instrument was not included in back translation process. Content validity was not evaluated. The second limitation is its use of a non-randomized sample of nurses. The third limitation is its use of single-item questions for measuring overall job satisfaction, quality of care and intention to leave. The final limitation is the use of a cross-sectional study design, which did not allow us to arrive at firm conclusions regarding causality of predictors. Boldface text indicates percentage of nurses from participating countries with a frequency rating higher than never (percentages are counted from the whole sample).

| CON CLUS ION
The research results confirmed a high prevalence of unfinished nursing care in the four selected European countries (Croatia, the Czech Republic, Poland and Slovakia). In this study, type of hospital and quality of care most significantly predicted the prevalence of unfinished care.

| IMPLI C ATI ON S FOR N UR S ING MANAG EMENT
The results of this study point to certain aspects of nursing care which are more frequently left unfinished than others. Most of the unfinished nursing care tasks were time-consuming nursing activities. Its findings have implications for nurse managers. The significance of prioritizing basic nursing care is obvious, and our results indicate the nursing care activities that nurse managers need to address. Since employment and organizational characteristics were among the predictors of unfinished care, nurse managers can concentrate on how to manage these predictors, which can influence the quality of care provided to patients. Improving staffing as well as using technologies could be effective in preventing unfinished nursing care.